Consensus Document of the International Union of Angiology (IUA)-2013. Current concept on the management of arterio-venous management.

Arterio-venous malformations (AVMs) are congenital vascular malformations (CVMs) that result from birth defects involving the vessels of both arterial and venous origins, resulting in direct communications between the different size vessels or a meshwork of primitive reticular networks of dysplastic minute vessels which have failed to mature to become 'capillary' vessels termed "nidus". These lesions are defined by shunting of high velocity, low resistance flow from the arterial vasculature into the venous system in a variety of fistulous conditions. A systematic classification system developed by various groups of experts (Hamburg classification, ISSVA classification, Schobinger classification, angiographic classification of AVMs,) has resulted in a better understanding of the biology and natural history of these lesions and improved management of CVMs and AVMs. The Hamburg classification, based on the embryological differentiation between extratruncular and truncular type of lesions, allows the determination of the potential of progression and recurrence of these lesions. The majority of all AVMs are extra-truncular lesions with persistent proliferative potential, whereas truncular AVM lesions are exceedingly rare. Regardless of the type, AV shunting may ultimately result in significant anatomical, pathophysiological and hemodynamic consequences. Therefore, despite their relative rarity (10-20% of all CVMs), AVMs remain the most challenging and potentially limb or life-threatening form of vascular anomalies. The initial diagnosis and assessment may be facilitated by non- to minimally invasive investigations such as duplex ultrasound, magnetic resonance imaging (MRI), MR angiography (MRA), computerized tomography (CT) and CT angiography (CTA). Arteriography remains the diagnostic gold standard, and is required for planning subsequent treatment. A multidisciplinary team approach should be utilized to integrate surgical and non-surgical interventions for optimum care. Currently available treatments are associated with significant risk of complications and morbidity. However, an early aggressive approach to elimiate the nidus (if present) may be undertaken if the benefits exceed the risks. Trans-arterial coil embolization or ligation of feeding arteries where the nidus is left intact, are incorrect approaches and may result in proliferation of the lesion. Furthermore, such procedures would prevent future endovascular access to the lesions via the arterial route. Surgically inaccessible, infiltrating, extra-truncular AVMs can be treated with endovascular therapy as an independent modality. Among various embolo-sclerotherapy agents, ethanol sclerotherapy produces the best long term outcomes with minimum recurrence. However, this procedure requires extensive training and sufficient experience to minimize complications and associated morbidity. For the surgically accessible lesions, surgical resection may be the treatment of choice with a chance of optimal control. Preoperative sclerotherapy or embolization may supplement the subsequent surgical excision by reducing the morbidity (e.g. operative bleeding) and defining the lesion borders. Such a combined approach may provide an excellent potential for a curative result. Conclusion. AVMs are high flow congenital vascular malformations that may occur in any part of the body. The clinical presentation depends on the extent and size of the lesion and can range from an asymptomatic birthmark to congestive heart failure. Detailed investigations including duplex ultrasound, MRI/MRA and CT/CTA are required to develop an appropriate treatment plan. Appropriate management is best achieved via a multi-disciplinary approach and interventions should be undertaken by appropriately trained physicians.

Women's health: time for a redefinition.

Traditionally, women's health has been defined in mainly biologic terms. The various contexts within which women's health can be considered have been ignored, and many people have been unable to recognize the need for such a clinical entity as "women's health" in the first place. It is time for a change in attitudes and approaches. We need a more inclusive definition of women's health, one that takes into account social, cultural, spiritual, emotional and physical aspects of well-being. Case histories that have recently received media attention and statistics on the impact of poverty and violence on women also show how urgently a redefinition of "women's health" is needed. Regardless of whether "women's health" will always have to be viewed as a separate discipline or whether it can be brought within mainstream medical practice, it is clear that, by altering their perception of women's health and of the problems unique to women, physicians can improve both health care and medical education to the benefit of all members of our society.

[Surgical treatment of post-thrombotic syndrome]. / Traitement chirurgical syndrome post-thrombotique.

The authors present the study of the surgical treatment of the post-thrombotic syndrome, with the different methods related to this type of pathology. The personal classification carried out by the authors (RS) includes the different pathologies and their syndromes. In the non recanalized PTS, the authors use the Palma technique (17) with temporary arteriovenous fistula, with the Siano Quiros technique (24). In the case of avalvular recanalized PTS, the authors use the Queral technique (37) using a venous by-pass, the Kistner technique (36), a personal technique consisting in an intraluminal valvuloplasty at the level of the femoral and popliteal veins.

[Klippel-Trenaunay syndrome]. / Syndrome de Klippel Trenaunay.

This study is based on the development of the surgical treatment of Klippel-Trenaunay's syndrome by means of an original technique which consists in the separation of the arterial system from the deep veinous system which we call: "Regional segmental skeletization". Moreover, it dries up the superficial veinous areas affected by the varices. A bibliographical and clinical review of the 120 cases studied is also carried out.

Premenstrual syndrome: approaches to diagnosis and treatment.

There has been much confusion in the literature over the definition, diagnosis and treatment of premenstrual syndrome (PMS). This article discusses definitions of PMS, incidence, etiology and symptomatology. Diagnosis depends on the timing of symptoms rather than the type. Symptoms commonly occur during the late premenstruum; at ovulation and during the premenstruum; or at ovulation, gradually increasing in severity throughout the luteal phase. To diagnose PMS, three consecutive menstrual cycles must be charted, the symptoms must be limited to the luteal phase, and there must be a complete absence of symptoms for at least one week in the postmenstruum. Rational treatment programs for mild, moderate and severe PMS are proposed. The role of progesterone in treatment is discussed.

Alternative birthing.

This paper deals with the concept of alternative birthing. The reasons for home births versus hospital births are discussed. A general model of an alternative birthing centre (ABC) is described. Some concepts common to alternative birthing are discussed, followed by a discussion of problems involved in initiating an alternative birthing centre. The article concludes that hospital-based alternative birthing centres are an ideal vehicle for modern healthy obstetrics.

Basal cell epithelioma of the vulva.

A case of basal cell epithelioma of the vulva is reported. Basal cell epitheliomata of the vulva are less rare than commonly thought. They are easily misdiagnosed and the proper treatment may thus be delayed.