Persistent incompetent truncal veins should not be treated immediately.

BACKGROUND: The traditional attitude for the treatment of chronic venous disorder is to systematically treat incompetent truncal veins. We wanted to evaluate the outcomes of not treating all incompetent truncal veins with regard to our experience of focusing the treatment to the varicose tributaries. METHODS: Retrospective study on all procedures of surgical treatment consecutively performed for varicose veins by single phlebectomy with preservation of a refluxing great saphenous vein (GSV), according to the principles of the ambulatory selective varices ablation under local anesthesia (ASVAL) during four years of practice. The clinical and hemodynamic outcomes have been evaluated at eight days, one year, and once a year. RESULTS: We have included 1212 lower limbs (LLs) that underwent consecutive ASVAL procedures in 816 patients (611 women and 205 men) aged between 19 and 93 years (mean age 53.7 years). The CEAP Class C classification was C0-C1 = 0%; C2 = 85.6%; C3 = 5.4%; C4 = 7.8%; C5 = 0.7%; C6 = 0.7%. Symptoms were present in 854 cases (70.5%). A thrombosis of the GSV was diagnosed at eight days postoperative in 13 cases (1.1%). A total of 1010 LLs were followed after the first postoperative year (mean follow-up of 44.5 months). A secondary major procedure was done in 30 cases during the follow-up: a striping of the GSV in nine cases and a redo phlebectomy in 21 cases. The cumulative incidence of a persistent or recurrent GSV reflux, of a varicose recurrence, and of secondary major procedure at five years after life table analysis was 33.8%, 13%, and 4.5%, respectively. A GSV reflux extended above plus below the knee and multiple connections of the varicose tributaries to the GSV at the calf were associated with a varicose recurrence (respectively 66.7% versus 55.3% p < 0.05 and 46.7% versus 12.8% p < 0.05). CONCLUSION: A treatment limited to the varicose tributaries by phlebectomy is safe and efficient at midterm with preservation of the main veins of the superficial venous system. It can be performed in a large group of patients thanks to a proper exclusion of cases with advanced chronic venous disorder. Therefore, the systematic treatment of an incompetent truncal vein is not relevant in the majority of the cases.

Influence of the competence of the sapheno-femoral junction on the mode of treatment of varicose veins by surgery.

BACKGROUND: It is usually agreed that incompetence of the sapheno-femoral junction (SFJ) is the main indication for stripping or ablation of the great saphenous vein (GSV) in the treatment of varicose veins (VVs). We wanted to test this assumption in our surgical treatment of varicose veins. METHODS: Study design: retrospective study of the surgical procedures for VVs in our centre between January and October 2012 in patients with reflux in the GSV. The SFJ was considered to be incompetent when both terminal and pre-terminal valves were assessed as incompetent by duplex ultrasound duplex imaging. We compared the preoperative clinical and haemodynamic data according to the surgical procedure performed. RESULTS: We reviewed a total of 389 LLs operated on for VVs in which reflux was present in the GSV. The SFJ was incompetent preoperatively in 189 LLs (48.6%). The GSV was treated in 78 cases (20.1%) stripping in 24 cases and radiofrequency ablation (RFA) in 54 cases, while phlebectomy with preservation of the GSV (ASVAL = Ambulatory Selective Varices Ablation under Local Anaesthesia) was done in the 311 remaining cases (79.9%). Incompetence of the SFJ led to stripping or RFA of the GSV in 38.1% of the cases only. Treatment by stripping or RFA was associated with male gender (50% vs 18.9% P < 0.01 χ2), an older age (62.5 vs 53.1 yrs P < 0.01 t-test), a greater body mass index (BMI) (26.1 vs 23.8 P < 0.01 t-test), a higher frequency of CEAP Class C4 to C6 (33.3% vs 4.8% P < 0.01 χ2), a higher frequency of symptoms (94.4% vs 73.6% P < 0.01 χ2) and a greater diameter of the GSV at the thigh (8.1 vs 5.2 mm P < 0.01 t-test). At last the presence of a focal dilatation of the GSV and an extension of the reflux below the lower half of the calf were also more frequent in case of stripping or RFA (respectively 55.6% vs 10.3% and 84.6% vs 18.3% P < 0.01 χ2). CONCLUSION: An incompetent SFJ was not the only clinical feature which determined the choice for preservation or ablation of the GSV in patients with varicose veins. In our experience a greater age, a higher BMI, the presence of trophic skin changes, extension of the reflux below the knee and a more damaged GSV trunk were also taken into account in order to decide whether to ablate or to preserve the GSV.

Patterns of reflux in the great saphenous vein system.

OBJECTIVE: To report the patterns of reflux in the great saphenous vein as well as to investigate the correlations between patterns of reflux, the demographics and the clinical findings in the population studied. METHODS: A total of 1882 limbs were assessed by duplex ultrasound examination in 1449 patients (348 men and 1101 women). Ages ranged from 21 to 94 years (mean 51.8). The presence of symptoms of venous disease (aching, heaviness, night cramps, swelling, itching, burning, tingling and throbbing) and clinical signs were recorded. RESULTS: Varicose veins without saphenous reflux occurred at a younger age (43 versus 55.6 years P < 0.05). The presence of incompetence at the saphenofemoral junction occurred in older patients (58.5 versus 54.1 years P < 0.05). Venous reflux to the ankle also occurred in older patients (mean 64.0 years P < 0.05). Saphenous vein reflux without clinical varices was associated with more advanced signs (C4-C6: 20.3% P < 0.05). A younger age was associated with less advanced signs (C0-C2:49.4 versus C4-C6: 60.1 years P < 0.05). Presence of symptoms was associated with advancing patient age (51.1 versus 49.1 years P < 0.05). CONCLUSIONS: A significant correlation between the extent of great saphenous vein reflux and the patient age and the clinical stage of SVI has been observed in this study. The authors hypothesize that these findings support the concept of early treatment of venous insufficiency before symptomatic and physiological deterioration occurs.

Evaluación de mutaciones en los genes GJB2 y GJB6 en pacientes con sordera congénita identificados mediante screening neonatal / Evaluation of GJB2 and GJB6 gene mutation in Chilean patients with congenital deafness identified through neonatal screening

If not detected and treated early, congenital sensorineural hearing loss generates impairment in linguistic, intellectual and social development of individuals. Most congenital hearing deficits are genetic. The most common causes are mutations in GJB2 and GJB6 genes, both located on chromosome 13, encoding junction proteins that allow the transduction of sound in the inner ear. Objetive: To evaluate the presence of mutations in GJB2 and GJB6 genes in a population of children diagnosed with deafness in Complejo Hospitalario Sótero del Río since implementation of the universal newborn hearing screening program. Patients and Methods: 8 patients with congenital nonsyndromic sensorineural deafness were evaluated. Genomic DNA was extracted from oral mucosa swabs. PCR was performed to identify the 35 del G mutation in GJB2, followed by sequencing of this gene, and PCR for 2 GJB6 deletions. Results: Two patients were heterozygous for 35 del G mutation in GJB2, being their other alleles normal. Another 2 patients were heterozygous for V27I polymorphism, one of them also accompanied by p.A148A (c.444C > A) variant. A patient was found with a previously undescribed mutation (c.4360 C>T) in GJB2's intron 1, being the second allele normal. No mutations were identified in GJB6. Conclusions: In this population of children, mutations in the GJB2 gene were an identifiable cause of congenital sensorineural.

La hipoacusia neurosensorial congénita es una patología frecuente que si no es detectada y tratada oportunamente genera alteraciones en el desarrollo del niño. Desde el año 2005 se lleva a cabo en el Complejo Hospitalario Dr. Sótero del Río un programa de screening auditivo universal para la detección precoz de esta patología. La mayor parte de los déficits auditivos congénitos son genéticos. La etiología más común son las mutaciones en los genes GJB2 y GJB6, que codifican para proteínas "gap junction" que permiten la traducción del sonido en el oído interno. Objetivo: Evaluar la presencia de mutaciones de los genes GJB2 y GJB6 en una población de niños diagnosticados con hipoacusia congénita en el Complejo Hospitalario Dr. Sótero del Río a través del programa de screening auditivo universal. Pacientes y Método: Se evaluaron 8 pacientes con hipoacusia congénita neurosensorial no sindrómica. Se extrajo ADN genómico de hisopado de mucosa bucal y se realizó PCR para identificar la mutación 35 del G en GJB2, seguida de secuenciación de este gen, y PCR para 2 deleciones del gen GJB6. Resultados: Dos pacientes fueron heterocigotos para la mutación 35 del G en GJB2, siendo sus otros alelos normales. Dos fueron heterocigotos para el polimorfismo V27I; uno acompañado por la variante p.A148A (c.444 C > A). Se encontró además un paciente con una mutación no descrita anteriormente (c.4360 C>T) en el intrón 1 de GJB2, siendo su segundo alelo normal. No se identificaron mutaciones en GJB6. Conclusiones: En este grupo de niños estudiados se encontró mutaciones en el gen GJB2, causantes de sordera neurosensorial congénita.

Lymphatic complications after varicose veins surgery: risk factors and how to avoid them.

INTRODUCTION: Lymphatic complication (LC) after varicose veins (VVs) surgery is an annoying event with a variable frequency in the literature. METHOD: Retrospective study reviewing all surgeries carried out for VVs from January 2000 to October 2010. Postoperative LC we reported: lymphatic fistula, lymphocele including the minor ones and lymphoedema. RESULTS: During the period studied, 5407 surgical procedures for VVs were performed in 3407 patients (74.7% women) with a mean age of 53.4 years. A postoperative LC occurred in 118 cases (2.2%): lymphocele on limb in 1.3%, inguinal LC (fistula or lymphocele) in 0.7% and a lymphoedema in 0.2%. The population with a LC was older (59.6 vs. 53.3 years, P < 0.05), had a higher frequency of C4-C6 (22.0% vs. 6.5%, P < 0.05), a higher incidence of obesity (31.4% vs. 5.4%, P < 0.05) and was more often treated by a redo surgery or a crossectomy stripping (48.3% vs. 13.4% and 38.1% vs. 21.8%, respectively, P < 0.05). We have observed a dramatic decrease in incidence of LC after January 2004 (1.3% vs. 5.3%, P < 0.05) corresponding to a new surgical practice for the treatment of VVs: stripping, crossectomy and redo surgery at the groin were less frequent (74.6% vs. 7.7%, 74.6% vs. 0.2% and 11.3% vs. 0.1%, respectively, P < 0.05), while isolated phlebectomy was more often performed during this period (78.4% vs. 8.4%, P < 0.05). CONCLUSION: LC after VVs surgery is not rare but frequently limited to lymphocele on limbs. Older age, more advanced clinical stage and obesity were associated with a higher frequency of LC. A mini-invasive and selective surgery has significantly reduced the occurrence of LC.

Evaluation of the pain in varicose vein surgery under tumescent local anaesthesia using sodium bicarbonate as excipient without any intravenous sedation.

OBJECTIVE: In order to simplify varicose vein surgery, we studied the possibility of tumescent local anaesthesia (TLA) using sodium bicarbonate 1.4% as excipient without any intravenous sedation. METHODS: For three months, 215 patients were included in two centres for ambulatory varicose vein surgery performed without any intravenous sedation. Clinical results and pain were evaluated according to the type and duration of surgery. RESULTS: Mean perioperative pain was evaluated at 2.7 on a visual scale (0-10). In 91% of the cases, surgery was deemed to be slightly painful. Preoperative pain was not linked to the technical means of surgery but to the psychological and organizational environment of the centre. CONCLUSIONS: In many of the cases, varicose vein surgery could be performed under TLA without any intravenous sedation. Ambulatory varicose vein surgery without any intravenous sedation could be highly cost-effective.

[Adherence to immunizations in newborns less than 1500 gr at birth and/or younger than 32 weeks, in two chilean centers]. / Adherencia a las inmunizaciones en niños nacidos con menos de 1.500 gr de peso o antes de 32 semanas de gestación, en dos centros chilenos.

UNLABELLED: Preterm neonates less than 1500 gr. or younger than 32 weeks have an increased morbidity and mortality due to infectious diseases. Immunization of these children is critical but is often incomplete and delayed. OBJECTIVES: To describe the adherence of scheduled and additional vaccines recommended in preterms less than 1500 gr. and to compare the level of compliance in two centers. PATIENTS AND METHODS: Prematures less than 1500 gr. born between January 2006 and December 2008 in a private center (HCPUC) and in a public health system (HSR) were included. Neonatal charts and follow up records were reviewed. Demographic data, diagnosis, scheduled vaccines, delays and its causes, prescription of additional vaccines were registered. RESULTS: 92 children were included in HCPUC and 246 in HSR. Among these 60-70% respectively had delayed immunizations. The reasons for these were considered not justified in almost 80% of the cases, being the primary reason oversight or lack of parental time. The use of additional vaccines is still low in both centers. CONCLUSIONS: Vaccination of prematures in Chile requires important improvements; education of healtheare personnel and parents, inclusión of modern computerized records and inclusión of new efficacious and safe vaccines in the regular immunization program with no cost to the patient.

Adherencia a las inmunizaciones en niños nacidos con menos de 1.500 gr de peso o antes de 32 semanas de gestación, en dos centros chilenos / Adherence to immunizations in newborns less than 1500 gr at birth and/or younger than 32 weeks, in two chilean centers

Preterm neonates less than 1500 gr. or younger than 32 weeks have an increased morbidity and mortality due to infectious diseases. Immunization of these children is critical but is often incomplete and delayed. Objectives: To describe the adherence of scheduled and additional vaccines recommended in preterms less than 1500 gr. and to compare the level of compliance in two centers. Patients and Methods: Prematures less than 1500 gr. born between January 2006 and December 2008 in a private center (HCPUC) and in a public health system (HSR) were included. Neonatal charts and follow up records were reviewed. Demographic data, diagnosis, scheduled vaccines, delays and its causes, prescription of additional vaccines were registered. Results: 92 children were included in HCPUC and 246 in HSR. Among these 60-70 percent respectively had delayed immunizations. The reasons for these were considered not justified in almost 80 percent of the cases, being the primary reason oversight or lack of parental time. The use of additional vaccines is still low in both centers. Conclusions: Vaccination of prematures in Chile requires important improvements; education of healtheare personnel and parents, inclusión of modern computerized records and inclusión of new efficacious and safe vaccines in the regular immunization program with no cost to the patient.

Los niños prematuros menores de 1.500 gr o de 32 semanas de gestación al nacer (RNMBPN) tienen mayor morbimortalidad por enfermedades infecciosas. La vacunación de estos niños es una medida esencial, la que, sin embargo, es subóptima. Objetivo. Describir la adherencia a las vacunas programáticas (PNI) y adicionales recomendadas en RNMBPN en dos centros y comparar su nivel de cumplimiento. Pacientes y Métodos. Se incluyeron RNMBPN nacidos entre enero 2006 y diciembre 2008 de un centro privado (HCPUC) y otro del sistema público (HSR). Se registraron a partir de fichas neonatales y de consultorio de seguimiento, datos demográficos, diagnósticos, vacunas PNI, retrasos y causas de éstos y prescripción de vacunas adicionales. Resultados. Se describen 92 niños en el HCPUC y 246 en el HSR, 60 y 70 por ciento respectivamente tienen alguna vacuna atrasada. En ambos centros las razones fueron no justificadas en 80 por ciento de los casos, siendo la razón principal olvido o falta de tiempo de los padres. El uso de vacunas adicionales es aún escaso en ambos centros. Conclusiones. La vacunación del prematuro en nuestro país requiere mejorías que incluyan educación del personal de salud y padres, mejoras en los registros e incorporación al programa de nuevas vacunas eficaces y seguras sin costo para los pacientes.

The effect of isolated phlebectomy on reflux and diameter of the great saphenous vein: a prospective study.

OBJECTIVES: To evaluate the effect of phlebectomy on venous reflux and diameter of the great saphenous vein (GSV). DESIGN: Prospective cohort study. METHOD: Patients presenting with reflux in the GSV resulting in varicose veins were included in this series. Patients were treated by phlebectomy for dilated and incompetent tributaries of the GSV with conservation of the incompetent GSV. We measured reflux duration (RD), peak reflux velocity (PRV) and the diameter of the GSV using duplex ultrasound imaging at inclusion and 1 month after surgery. PATIENTS: We included 55 limbs in 54 patients (30 women and 24 men) aged from 37 to 83 (mean age 63) years. RESULTS: Following treatment we observed a significant reduction of the mean RD (0.81 s vs. 1.5 s p < 0.01, t-test), mean PRV (120 mm s(-1) vs. 249 mm s(-1)p < 0.01, t-test) and mean diameter of the GSV (SFJ = 5.6 mm vs. 6.7 mm, p < 0.01, sub-terminal valve 4.8 mm vs. 4.4 mm p < 0.05, mid-thigh 5.0 mm vs. 4.2 mm, p < 0.01, knee 4.0 mm vs. 5.3 mm p < 0.01, mid-calf 2.7 mm vs. 4.0 mm, p < 0.01, t-test). CONCLUSIONS: We noted reduced reflux in the GSV after phlebectomy with a significant reduction in RD and PRV. Phlebectomy also led to a significant reduction in GSV diameter. These data suggest that the haemodynamics and the diameter of the SV can be improved by using a treatment focussing on the saphenous tributaries.

Classification of saphenous refluxes: implications for treatment.

OBJECTIVE: To determine the possible correlations of patient age, symptoms and signs with findings of Doppler duplex examination in limbs with varicose veins. METHODS: A total of 2275 ultrasound examinations were done on 2275 limbs of 1751 patients (421 men and 1330 women). Ages ranged from 21 to 94 years (mean 50). Symptoms of aching, heaviness, burning pain (venous neuropathy) were recorded, and signs of ankle hyperpigmentation, scars of healed ulcers and presence of open venous ulcers were noted. RESULTS: Presence of symptoms was associated with advancing patient age (50.7 vs. 48.8 years). Varicose veins without great saphenous reflux correlated with younger age (43 vs. 53.5 years). Presence of saphenofemoral junctional incompetence correlated with an older age (54.7 vs. 49.8 years), and reflux to the ankle (Hach stage IV) also correlated with older age (mean 63.7 years). A younger age was associated with less advanced signs (C0-C2: 49.1 vs. C4-C6: 60.1 years). Saphenous vein reflux without clinical varices was associated with more advanced signs (C4-C6: 21.3%). CONCLUSIONS: Ageing is associated with advancing clinical symptoms, signs and increasing multifocal reflux in limbs with venous insufficiency. These facts support the concept of early treatment of venous insufficiency before predictable deterioration occurs.

Evolución neurosensorial en recién nacidos de muy bajo peso de nacimiento a los 2 años de edad corregida / Neurosensory evaluation of very low birth weight babies at corrected 2 years old

Objetivo: El propósito de nuestro estudio fue conocer el déficit neurosensorial a los 2 años de edad corregida (EC) en niños con antecedentes de muy bajo peso de nacimiento (MBPN) en control en el policlínico de seguimiento del Servicio de Recién Nacidos del Hospital Sótero del Río, Santiago, Chile. Método y participantes: 254 RN de 268 sobrevivientes de un total de 424 RNMBPN nacidos entre 1994 a 1996 fueron seguidos prospectivamente por un equipo multidiciplinario, que realiza evaluación clínica, neurológica, auditiva y psicomotora. Del grupo en seguimiento: 181 niños, que representa el 71 por ciento del grupo, completan adecuadamente los controles. Resultados: 32 por ciento (59/181) de los niños tiene una evaluación neurosensorial anormal a los 24 meses de EC; 13 por ciento (24/181) presenta anormalidad neurosensorial severa: 6.6 por ciento (12/181) parálisis cerebral, 6 por ciento coeficiente del desarrollo mental menor de 70.3 por ciento sordera neurosensorial severa bilateral y 1 presentó ceguera. La mitad de los niños con parálisis cerebral presentan además otra secuela severa. Los factores asociados significativamente con evolución neurosensorial anormal fueron peso de nacimiento menor de 1000 g, hemorragia intraventricular grados 3 y 4, convulsiones, apneas y duptus. En análisis de regresión logística, la apnea fue significativa e independientemente asociada a evolución neurosensorial anormal

Curva de crecimiento intrauterino para prematuros entre 23 a 36 semanas de edad gestacional / Intrauterine growth curves for premature babies with a gestational age between 23 and 36 weeks

Objetivo: diseñar una curva de crecimiento intrauterino para prematuros nacidos entre las 23 y 36 semanas de edad gestacional en base a datos recopilados prospectivamente entre 1990-1998 en el Hospital Dr. Sótero del Río Santiago, Chile. Método: se incluyeron en este estudio 2.830 prematuros menores de 37 semanas con edad gestacional confiable, producto de embarazo único sin patología materna ni fetal. Se calculó peso promedio, desviación estándar, percentiles 5, 10, 25, 50, 75, 90 y 95 para cada edad gestacional. Resultados: se presenta una curva suavizada de peso para cada edad gestacional y se compara con la actualmente en uso. Conclusión: considerando el gran número de niños en el estudio esta curva es una herramienta útil para evaluar el peso de nacimiento en niños prematuros especialmente en edades gestacionales menores

Sobrevida del niño menor de 1500 gramos en Chile / Survival of newborn weighing less than 1500 grams in Chile

Se analiza la sobrevida de recien nacidos en Chile, menores de 1500 gramos de peso. Se evalúan sus complicaciones como sindrome de dificultad respiratoria; difusión broncopulmonar, hemorragia intracraneales, retinopatía y problemas sensoriales

La vitamina B12 no modifica la evolución de la anemia del prematuro / B12 vitamin does not change the evolution of the anemia in preterm babies

Se evalúa el efecto de 100 mg IM de vitamina B12 mensual por 4 veces, sobre la evolución de la anemia del prematuro, en un estudio controlado, aleatorizado y doble ciego, en 55 niños de edad gestacional menor de 33 semanas. No se encontraron diferencias clínicamente significativas en la evolución hematológica ni en el crecimiento en los dos grupos estudiados. El número de transfusiones fue significativamente menor en ambos grupos que los reportados en la literatura