Current Trends in Anti-Aging Strategies.

The process of aging manifests from a highly interconnected network of biological cascades resulting in the degradation and breakdown of every living organism over time. This natural development increases risk for numerous diseases and can be debilitating. Academic and industrial investigators have long sought to impede, or potentially reverse, aging in the hopes of alleviating clinical burden, restoring functionality, and promoting longevity. Despite widespread investigation, identifying impactful therapeutics has been hindered by narrow experimental validation and the lack of rigorous study design. In this review, we explore the current understanding of the biological mechanisms of aging and how this understanding both informs and limits interpreting data from experimental models based on these mechanisms. We also discuss select therapeutic strategies that have yielded promising data in these model systems with potential clinical translation. Lastly, we propose a unifying approach needed to rigorously vet current and future therapeutics and guide evaluation toward efficacious therapies.

Evaluating dermatology education in Australia: Medical students' and junior doctors' perceptions.

BACKGROUND: Despite a high frequency of dermatological general practice and emergency department presentations, including serious and potentially fatal skin conditions, evidence suggests that undergraduate dermatological education remains sparse. Given this, there exists a need to gauge dermatology-relevant knowledge and skill in our new doctors. METHODS: An online survey was completed by final-phase medical students and junior doctors from Australian medical schools. The survey appraised self-perceived confidence of dermatology knowledge and skills, in addition to 5 knowledge-based multiple-choice questions. RESULTS: Nine hundred and forty-two eligible responses were completed. Respondents reported low confidence in identifying dermatological conditions in people with skin of colour (µ = 1.69), handing over to dermatology colleagues (µ = 2.00) and in diagnosing and managing acute/emergency dermatology conditions (µ = 1.84). In contrast, participants felt most confident in counselling sun-protective behaviours (µ = 3.95) and suturing small wounds (µ = 3.43). 76.4% of respondents had not undertaken any dermatology placement, and 70.9% had never been formally assessed in dermatology. Those who received dermatology placement had a significantly higher aggregated self-reported confidence (p < 0.0001) and answered significantly more MCQs correctly (p = 0.0419). Those who had been formally assessed had a significantly higher self-reported confidence (p < 0.001) and answered significantly more MCQs correctly (p = 0.007). CONCLUSION: Final-phase medical students and junior doctors exhibit low confidence across many dermatology competencies. Participants believed they need more dermatology education, and seldom feel prepared when exposed to dermatologic pathologies. Introduction of a standardised curriculum, formal assessments and increased clinical exposure are possible solutions.

Defocused contrast sensitivity function in peripheral vision.

PURPOSE: Human peripheral detection performance is affected by optical factors such as defocus and higher order aberrations. From optical theory, we would expect defocus to produce local depressions (notches) in the contrast sensitivity function (CSF). However, such notches have not been observed in peripheral vision, and it is unknown whether human peripheral vision can detect local depressions (notches) in the CSF, such as those produced by monochromatic defocus when all monochromatic ocular aberrations are corrected. The purpose of the study was to identify such notches. METHODS: Participants were three adult emmetropes. Following full adaptive optics correction, on-axis and 20° nasal visual field detection CSFs in monochromatic light were measured for the right eye with a 7 mm diameter pupil, both without and with ±2 D defocus, and with separate determinations for horizontal and vertical gratings. Defocused CSFs were compared with predictions based on theoretical modulation transfer functions. RESULTS: Notches in the monochromatic defocused CSFs were identified for peripheral vision at optically predicted spatial frequencies with other monochromatic ocular aberrations corrected, provided that there was adequate spatial frequency sampling. The spatial frequencies of notches were similar to those predicted from optical theory, but their depths (0.3 to 0.9 log unit) were smaller than predicted. CONCLUSION: With fine spatial frequency sampling, notches were identified in defocused monochromatic CSFs when all other monochromatic ocular aberrations were corrected, both on-axis and at 20° eccentricity. Unless recognised as such, notches may contribute to noise in through-focus detection measurements of peripheral visual performance.

Autofluorescence of blood and its application in biomedical and clinical research.

Autofluorescence of blood has been explored as a label free approach for detection of cell types, as well as for diagnosis and detection of infection, cancer, and other diseases. Although blood autofluorescence is used to indicate the presence of several physiological abnormalities with high sensitivity, it often lacks disease specificity due to use of a limited number of fluorophores in the detection of several abnormal conditions. In addition, the measurement of autofluorescence is sensitive to the type of sample, sample preparation, and spectroscopy method used for the measurement. Therefore, while current blood autofluorescence detection approaches may not be suitable for primary clinical diagnosis, it certainly has tremendous potential in developing methods for large scale screening that can identify high risk groups for further diagnosis using highly specific diagnostic tests. This review discusses the source of blood autofluorescence, the role of spectroscopy methods, and various applications that have used autofluorescence of blood, to explore the potential of blood autofluorescence in biomedical research and clinical applications.

Factors associated with health-related quality of life in patients with cirrhosis: a systematic review.

BACKGROUND: Patients with cirrhosis have a poor health-related quality of life (HRQoL). Recognizing factors that affect HRQoL is key in delivering patient-centred care. AIM: To identify factors most commonly associated with a poor HRQoL in adults with cirrhosis in a systematic review of the literature. METHODS: Four databases (MEDLINE, EMBASE, CENTRAL and PsycINFO) were searched from inception to March 2020, using terms related to patient-reported outcomes plus cirrhosis. Studies that analysed an association between at least one factor and HRQoL in adult patients with cirrhosis were included. Abstract and full-text screening was performed by two reviewers. Data were collected on factors evaluated in each study and the significance of their association with HRQoL. RESULTS: A total of 10647 citations were reviewed, of which 109 met eligibility criteria. 76% of the studies used a generic instrument while only 45% used liver-specific instruments. Among identified factors, demographic factors and cirrhosis aetiology were not generally associated with poor HRQoL except for poor social support. Depression, poor sleep and muscle cramps affected HRQoL in all the studies that evaluated them. Among comorbidities, frailty, falls, malnutrition and cognitive impairment were also associated with poor HRQoL in the majority of studies. Among cirrhosis-specific decompensating events, only hepatic encephalopathy (HE) was consistently associated with impairment in HRQoL (75% of studies). CONCLUSION: Many factors impact poor HRQoL in patients with cirrhosis such as depression, muscle cramps, poor sleep, falls, frailty and malnutrition. Among cirrhosis decompensating events, HE was the complication most commonly associated with a poor HRQoL.

Retrospective analysis of the efficacy and duration of botulinum toxin A injections in 30 patients with palmar hyperhidrosis.

Palmar hyperhidrosis is a common disorder characterised by excessive sweating due to hyperfunction of the sweat glands. It can be classified as primary disease, or secondary to other causes. It has a high morbidity, and a range of treatment options. Botulinum toxin injections inhibit the release of acetylcholine from the presynaptic receptors. It is an effective treatment; however, it is infrequently selected as only axillary hyperhidrosis currently attracts a Medicare subsidy. We conducted a retrospective review of 30 patients at a Sydney dermatology clinic who received botulinum toxin injections for palmar hyperhidrosis within the past 5 years. This study has the largest patient cohort with this condition in Australia. There was evidence for a median reduction in the Hyperhidrosis Disease Severity Scale, a qualitative self-reported score, as well as an increasing duration of efficacy with repeated injections. There were minimal side-effects of weakness and numbness. There is also an association between treatment of palmar disease and improvement in plantar disease, which suggests that treatment of palmar hyperhidrosis should be considered earlier and more frequently.

Embolization Techniques for Arteriovenous Malformations in Parkes-Weber Syndrome.

BACKGROUND: Multiple high-flow arteriovenous malformations (AVMs) are the hallmark of Parkes-Weber syndrome (PWS). Surgical resection has historically shown poor outcomes with PWS. The aim of this study was to assess the management of PWS in the current era. METHODS: A retrospective review was performed from 2004 to 2017 on all patients presenting to a single institution for the management of PWS. Presentation, techniques, complications, and outcomes were reviewed. RESULTS: Fourteen patients (50% male) with PWS were seen at our institution, and mean age was 19.9 years (range, 4.7-68.8). The lower extremity was affected in 12 (86%) and the upper extremity in 2 (14%) patients. All patients presented with pain and swelling in the affected limb. Seven (50%) patients presented with ulcers, of which 3 (43%) had extensive wounds. Five (36%) patients had echocardiographic evidence of high-output cardiac failure. All patients underwent angiography with the intention to treat. Three (21%) patients were found to have diffuse arteriovenous communication with no discrete AVM nidus and thus did not undergo intervention. The remaining 11 (79%) patients underwent transcatheter embolization of the AVM's arterial inflow. Six (55%) patients required multiple or staged inflow embolization procedures, with a mean of 3.3 (range, 1-10) interventions. Thirty-two arterial embolization procedures were performed in total. n-Butyl-2-cyanoacrylate (nBCA) adhesive was used in 22 (69%), microspheres in 8 (25%), and a combination of coils and nBCA adhesive in 2 (6%) cases. Technical angiographic success was seen in all patients. Six (55%) patients also had interventions to treat the venous component of the malformation, either concomitantly or during a separate procedure. This included radiofrequency ablation in 1 (17%), coil embolization in 1 (17%), sodium tetradecyl sulfate (STS) sclerotherapy in 2 (33%), and a combination of STS, coil embolization, and vein stripping in 2 (33%) patients. Ten (91%) patients experienced a partial response and 1 (9%) patient experienced no response to treatment. No patients had a complete response, as expected with the diffuse nature of this disease. There were no periprocedural complications. Two of 3 patients with complex wounds required major amputations for gangrene, including one above-knee and one below-knee amputation at 128 months and 66 months after the index procedure, respectively. CONCLUSIONS: AVMs in PWS can be successfully treated by a transcatheter approach. Multiple interventions are usually required. Patients with extensive wounds remain at risk for loss of limb.

Major Limb Amputations in Patients with Congenital Vascular Malformations.

BACKGROUND: The need for major amputations in patients with vascular malformations is rare. This study reviews our contemporary experience with major amputations in patients with vascular malformations. METHODS: A retrospective review from April 2014 to November 2018 identified 993 patients undergoing management of a vascular malformation involving the upper or lower extremity at a tertiary center. This population was analyzed to identify those requiring either a transfemoral or transhumeral amputation. This cohort was investigated for clinical course, surgical procedures, and outcomes. RESULTS: Five patients (0.5%) underwent major amputation, including 3 transhumeral and 2 above-knee amputations. The median age was 37.8 years (interquartile range (IQR): 25.4-40.2), and 2 (40%) were male. Four (80%) patients had high-flow arteriovenous malformations, including 1 (20%) with Parkes-Weber syndrome. One (20%) patient had a low-flow venous malformation associated with Klippel-Trénaunay syndrome. All patients had malformation extending into the chest or pelvis, with the amputation being at the level of residual malformation. As such, amputation had been initially felt to be high risk because of the proximal extent of the lesions. Before amputation, a median of 11 procedures (IQR: 4-39) were performed per patient. This included 29 transarterial embolizations, 4 transvenous embolizations, 20 direct stick embolizations, 3 debulking procedures, 38 debridements, 6 skin grafts or muscle flaps, and 4 minor amputations. The median time course of treatment before amputation was 117 months (IQR: 44-171). Indications for major amputation included chronic pain and recurrent bleeding in all 5 (100%) patients, loss of function in 2 (40%), nonhealing wounds in 2 (40%), and sepsis in 1 (20%) patient. There were no perioperative deaths. The median blood loss was 1,000 mL (IQR: 650-2,750). All patients required transfusion of packed red blood cells with a mean of 1.6 units (standard deviation: 0.54). Transhumeral amputation was facilitated by transcatheter embolization in 1 (33%) and an occlusion balloon within the subclavian artery in 2 (66%) patients. The median length of stay was 6 days (IQR: 5-13). The median length of follow-up was 132 months (IQR: 68-186) from initial intervention and 12 months (IQR: 8-31) from amputation. Two patients (40%) who had undergone transhumeral amputation required revision of the amputation site for recurrent ulceration at 2 and 38 months. Of these, 1 patient underwent 3 transcatheter embolization procedures before revision and 1 underwent 1 embolization after revision. CONCLUSIONS: Although rare, successful amputation at the level of residual malformation can be performed in select patients with refractory complications of vascular malformations including intractable pain, bleeding, or nonhealing wounds. Specific preoperative and intraoperative measures may be critical to achieve satisfactory outcomes, and endovascular techniques continue to play a role after amputation.

Results of a 10-year follow-up study of botulinum toxin A therapy for primary axillary hyperhidrosis in Australia.

Primary hyperhidrosis has a prevalence of 3-5% in the United States. It is a psychosocially disabling condition leading to low self-esteem, chronic stress and depressive symptoms. Several medical and surgical treatments exist, including botulinum toxin A, which internationally, has been shown effectively and safely to treat this condition achieving high patient satisfaction. In Australia, botulinum toxin A has been available under the Medicare benefits scheme for axillary hyperhidrosis since 2013, but efficacy and treatment satisfaction had not been evaluated. We present the results of the first Australian study on efficacy and patient satisfaction with botulinum toxin A in primary axillary hyperhidrosis with evaluation of possible prognostic factors.

The Possible Role of Peripheral Refraction in Development of Myopia.

Recent longitudinal studies do not support the current theory of relative peripheral hyperopia causing myopia. The theory is based on misunderstanding of the Hoogerheide et al. article of 1971, which actually found relative peripheral hyperopia to be present after, rather than before, myopia development. The authors present two alternative theories of the role of peripheral refraction in the development and progression of myopia. The one for which most detail is given is based on cessation of ocular growth when the periphery is at an emmetropic stage as determined by equivalent blur of the two line foci caused by oblique astigmatism. This paper is based on an invited commentary on the role of lens treatments in myopia from the 15th International Myopia Conference in Wenzhou, China in September 2015.

Choice of Grating Orientation for Evaluation of Peripheral Vision.

PURPOSE: Peripheral resolution acuity depends on the orientation of the stimuli. However, it is uncertain if such a meridional effect also exists for peripheral detection tasks because they are affected by optical errors. Knowledge of the quantitative differences in acuity for different grating orientations is crucial for choosing the appropriate stimuli for evaluations of peripheral resolution and detection tasks. We assessed resolution and detection thresholds for different grating orientations in the peripheral visual field. METHODS: Resolution and detection thresholds were evaluated for gratings of four different orientations in eight different visual field meridians in the 20-deg visual field in white light. Detection measurements in monochromatic light (543 nm; bandwidth, 10 nm) were also performed to evaluate the effects of chromatic aberration on the meridional effect. A combination of trial lenses and adaptive optics system was used to correct the monochromatic lower- and higher-order aberrations. RESULTS: For both resolution and detection tasks, gratings parallel to the visual field meridian had better threshold compared with the perpendicular gratings, whereas the two oblique gratings had similar thresholds. The parallel and perpendicular grating acuity differences for resolution and detection tasks were 0.16 logMAR and 0.11 logMAD, respectively. Elimination of chromatic errors did not affect the meridional preference in detection acuity. CONCLUSIONS: Similar to peripheral resolution, detection also shows a meridional effect that appears to have a neural origin. The threshold difference seen for parallel and perpendicular gratings suggests the use of two oblique gratings as stimuli in alternative forced-choice procedures for peripheral vision evaluation to reduce measurement variation.

Effect of induced transverse chromatic aberration on peripheral vision.

Transverse chromatic aberration (TCA) is one of the largest optical errors affecting the peripheral image quality in the human eye. However, the effect of chromatic aberrations on our peripheral vision is largely unknown. This study investigates the effect of prism-induced horizontal TCA on vision, in the central as well as in the 20° nasal visual field, for four subjects. Additionally, the magnitude of induced TCA (in minutes of arc) was measured subjectively in the fovea with a Vernier alignment method. During all measurements, the monochromatic optical errors of the eye were compensated for by adaptive optics. The average reduction in foveal grating resolution was about 0.032 ± 0.005 logMAR/arcmin of TCA (mean ± std). For peripheral grating detection, the reduction was 0.057 ± 0.012 logMAR/arcmin. This means that the prismatic effect of highly dispersive spectacles may reduce the ability to detect objects in the peripheral visual field.

Objectively determined refraction improves peripheral vision.

PURPOSE: The purpose of this study was twofold: to verify a fast, clinically applicable method for determining off-axis refraction and to assess the impact of objectively obtained off-axis refractive correction on peripheral low-contrast visual acuity. METHODS: We measured peripheral low-contrast resolution acuity with Gabor patches both with and without off-axis correction at 20 degrees in the nasal visual field of 10 emmetropic subjects; the correction was obtained using a commercial open-field Hartmann-Shack wavefront sensor, the COAS-HD VR aberrometer. Off-axis refractive errors were calculated for a 5-mm circular pupil inscribed within the elliptical wavefront by COAS using the instruments' inbuilt "Seidel sphere" method. RESULTS: Most of the subjects had simple myopic astigmatism, at 20 degrees in the nasal visual field ranging from -1.00 to -2.00 DC, with axis orientations generally near 90 degrees. The mean uncorrected and corrected low-contrast resolution acuities for all subjects were 0.92 and 0.86 logMAR, respectively (an improvement of 0.06 logMAR). For subjects with a scalar power refractive error of 1.00 diopters or more, the average improvement was 0.1 logMAR. The observed changes in low-contrast resolution acuity were strongly correlated with off-axis astigmatism (Pearson r = 0.95; p < 0.0001), the J180 cross-cylinder component (Pearson r = 0.82; p = 0.0034), and power scalar (Pearson r = -0.75; p = 0.0126). CONCLUSIONS: The results suggest that there are definite benefits in correcting even moderate amounts of off-axis refractive errors; in this study, as little as -1.50 DC of off-axis astigmatism gave improvements of up to a line in visual acuity. It may be even more pertinent for people who rely on optimal peripheral visual function, specifically those with central visual field loss; the use of open-field aberrometers could be clinically useful in rapidly determining off-axis refractive errors specifically for this patient group who are generally more challenging to refract.

Quick contrast sensitivity measurements in the periphery.

Measuring the contrast sensitivity function (CSF) in the periphery of the eye is complicated. The lengthy measurement time precludes all but the most determined subjects. The aim of this study was to implement and evaluate a faster routine based on the quick CSF method (qCSF) but adapted to work in the periphery. Additionally, normative data is presented on neurally limited peripheral CSFs. A peripheral qCSF measurement using 100 trials can be performed in 3 min. The precision and accuracy were tested for three subjects under different conditions (number of trials, peripheral angles, and optical corrections). The precision for estimates of contrast sensitivity at individual spatial frequencies was 0.07 log units when three qCSF measurements of 100 trials each were averaged. Accuracy was estimated by comparing the qCSF results with a more traditional measure of CSF. Average accuracy was 0.08 log units with no systematic error. In the second part of the study, we collected three CSFs of 100 trials for six persons in the 20° nasal, temporal, inferior, and superior visual fields. The measurements were performed in an adaptive optics system running in a continuous closed loop. The Tukey HSD test showed significant differences (p < 0.05) between all fields except between the nasal and the temporal fields. Contrast sensitivity was higher in the horizontal fields, and the inferior field was better than the superior. This modified qCSF method decreases the measurement time significantly and allows otherwise unfeasible studies of the peripheral CSF.

Direct oral anticoagulants in skin surgery: a systematic review of their complications and recommendations for perioperative management.

INTRODUCTION: Many patients undergoing cutaneous surgery are prescribed at least one anticoagulant or antiplatelet agent. With the recent emergence of direct oral anticoagulants (DOACs), there is a deficit of knowledge regarding optimal perioperative management. This review aims to evaluate the evidence and risk surrounding management of DOACs in patients undergoing skin surgeries. METHODS: Systematic review of EMBASE, Scopus, and PubMed, with inclusion of studies that detailed perioperative management of DOACs in those undergoing skin surgery. Primary outcome measures were perioperative hemorrhagic and thromboembolic complications. RESULTS: Seven thousand seven hundred and forty-one abstracts were identified, with 13 articles meeting inclusion criteria. Two studies investigated complication risk associated with DOAC continuation in skin surgery and found an average rate of hemorrhagic complications of 1.74%. Two studies evaluated complications associated with DOAC cessation prior to skin surgery, with a pooled thromboembolic complication rate of 0.15%. Articles comparing continuation and cessation discovered no decreased risk of bleeding with DOAC cessation prior to surgery (P = 0.93). Seven of the 13 articles compared complications in a control vs a DOAC group undergoing cutaneous procedures. Evidence was conflicting but may have suggested a small increase in bleeding risk in those on DOAC therapy. CONCLUSION: Optimal management of anticoagulants perioperatively is difficult because of conflicting information, complicated by advent of novel agents. Risk of hemorrhagic complications with both continuation and interruption of DOAC therapy was low. Perioperative DOAC management can be guided by procedural bleeding and patient clotting risk and can often be continued in minor dermatologic procedures.

Impact of a Bronchiolitis Clinical Pathway on Management Decisions by Preferred Language.

Background: Clinical pathways standardize healthcare utilization, but their impact on healthcare equity is poorly understood. This study aims to measure the effect of a bronchiolitis pathway on management decisions by preferred language for care. Methods: We included all emergency department encounters for patients aged 1-12 months with bronchiolitis from 1/1/2010 to 10/31/2020. The prepathway period ended 10/31/2011, and the postpathway period was 1/1/2012-10/31/2020. We performed retrospective interrupted time series analyses to assess the impact of the clinical pathway by English versus non-English preferred language on the following outcomes: chest radiography (CXR), albuterol use, 7-day return visit, 72-hour return to admission, antibiotic use, and corticosteroid use. Analyses were adjusted for presence of a complex chronic condition. Results: There were 1485 encounters in the preperiod (77% English, 14% non-English, 8% missing) and 7840 encounters in the postperiod (79% English, 15% non-English, 6% missing). CXR, antibiotic, and albuterol utilization exhibited sustained decreases over the study period. Pathway impact did not differ by preferred language for any outcome except albuterol utilization. The prepost slope effect of albuterol utilization was 10% greater in the non-English versus the English group (p for the difference by language = 0.022). Conclusions: A clinical pathway was associated with improvements in care regardless of preferred language. More extensive studies involving multiple pathways and care settings are needed to assess the impact of clinical pathways on health equity.

Transarterial treatment of congenital renal arteriovenous fistulas.

OBJECTIVE: Congenital renal arteriovenous fistulas (CRAVF) represent a distinct clinical entity with characteristic hemodynamic and angiographic features. Treatment is warranted given potential for growth with renal and hemodynamic compromise. We report our experience in a rare series of treated symptomatic CRAVFs. METHODS: Over a 10-year period, patients treated for symptomatic CRAVFs (no history of predisposing renal pathology, instrumentation, neoplasm, or trauma) were retrospectively investigated for clinical presentation, imaging features, treatment outcomes, and complications. Technical success included delivery of embolic agent with complete obliteration of fistula. Clinical success included resolution of symptoms and freedom from recurrence and/or reintervention. Renal parenchymal loss was estimated by postembolization angiography and categorized as 0%, <25%, 25%-50%, or >50%. RESULTS: Twenty-five patients were referred with a presumptive diagnosis of intraparenchymal renal artery aneurysms. Of these, 10 had true intrarenal aneurysms, three had angiomyolipomas, and 12 had CRAVFs (mean age, 54; range, 29-71 years; eight women). Presenting symptoms included hematuria (eight gross, eight microscopic), refractory hypertension (diastolic blood pressure ≥ 90 mm Hg despite three or more medications; n = 6), flank pain (n = 8), high-output state (HOS; featuring tachycardia and jugular venous distention; n = 3), and flank bruit (n = 1). Defining angiographic features included a high-flow AVF fed by a single, enlarged intrarenal branch shunting into an aneurismal draining vein, occasionally featuring a calcified rim (four patients). All patients underwent transarterial embolization with coils (n = 5), coils and n-butylcyanoacrylate (n = 3), detachable balloons (n = 2), or Amplatzer plugs (n = 2). Technical success was 100%. Hematuria, tachycardia, jugular venous distension, pain, and bruit resolved in all. Hypertension improved in four of six patients (required less than three medications postembolization). Complications included postembolization syndrome in nine patients. Parenchymal loss was limited to <25% and observed in five patients without development of acute kidney injury or worsening hypertension. There were no recurrences or reinterventions at a mean follow-up of 55 months (range, 5-96 months). There was one death at 8 years follow-up from intercurrent coronary disease in a patient without high-output state. CONCLUSIONS: With greater awareness and accurate diagnosis, effective and durable transarterial treatment of CRAVFs can be safely performed.

Staged endovascular and surgical treatment of slow-flow vulvar venous malformations.

OBJECTIVE: The objective of the study was to report our experience in a rare series of treated symptomatic slow-flow vulvar venous malformations (VVMs) using a staged, multidisciplinary approach. STUDY DESIGN: Consecutive patients with symptomatic lesions treated over a 7 year period (2005-2012) were followed up for technical success, resolution of symptoms, aesthetic outcomes, and complications. Direct endovenous sclerotherapy (DEVS) using sodium tetradecyl sulfate (STS) foam was performed in all patients under ultrasound and contrast-enhanced fluoroscopic guidance. Surgical excision and layered primary closure was performed within 24 hours after the last DEVS session. RESULTS: Eleven patients (mean age, 25 years; range, 4-43 years) were treated. Presenting symptoms included pain (n = 11), soft tissue swelling (n = 11), local heaviness (n = 11), dyspareunia (n = 2), and dysmenorrhea (n = 2). Most were isolated lesions (n = 8). There were 2 cases of Klippel-Trénaunay syndrome and 1 case of Maffucci syndrome. The latter required Nd:YAG laser photocoagulation prior to sclerotherapy. On average, approximately 3 DEVS sessions were required prior to surgical excision (range, 1-6). Mean estimated surgical blood loss was 130 mL (range, 20-400 mL). Mean follow-up was 23 months (range, 3-55 months). Elimination of pain and soft tissue redundancy was achieved in all patients with satisfactory aesthetic outcomes. All patients experienced minor pain and swelling after DEVS. Following surgical excision, there was 1 case of hematoma and wound dehiscence requiring surgical evacuation. No other reinterventions, endovascular or surgical, were required. CONCLUSION: VVMs require increased awareness and appropriate preoperative evaluation for proper identification and treatment. A multidisciplinary approach can provide improvement in clinical signs and symptoms with satisfactory cosmesis and minimal complications.