Triage of patients with venous and lymphatic diseases during the COVID-19 pandemic - The Venous and Lymphatic Triage and Acuity Scale (VELTAS) : A consensus document of the International Union of Phlebology (UIP), Australasian College of Phlebology (ACP), American Vein and Lymphatic Society (AVLS), American Venous Forum (AVF), European College of Phlebology (ECoP), European Venous Forum (EVF), Interventional Radiology Society of Australasia (IRSA), Latin American Venous Forum, Pan-American Society of Phlebology and Lymphology and the Venous Association of India (VAI) This consensus document has been co-published in Phlebology [DOI: 10.1177/0268355520930884] and Journal of Vascular Surgery: Venous and Lymphatic Disorders [DOI: 10.1016/j.jvsv.2020.05.002]. The publications are identical except for minor stylistic and spelling differences in keeping with each journal's style. The contribution has been published under a Attribution-Non Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0), (https://creativecommons.org/licenses/by-nc-nd/4.0/).

The coronavirus disease 2019 (COVID-19) global pandemic has resulted in diversion of healthcare resources to the management of patients infected with SARS-CoV-2 virus. Elective interventions and surgical procedures in most countries have been postponed and operating room resources have been diverted to manage the pandemic. The Venous and Lymphatic Triage and Acuity Scale was developed to provide an international standard to rationalise and harmonise the management of patients with venous and lymphatic disorders or vascular anomalies. Triage urgency was determined based on clinical assessment of urgency with which a patient would require medical treatment or surgical intervention. Clinical conditions were classified into six categories of: (1) venous thromboembolism (VTE), (2) chronic venous disease, (3) vascular anomalies, (4) venous trauma, (5) venous compression and (6) lymphatic disease. Triage urgency was categorised into four groups and individual conditions were allocated to each class of triage. These included (1) medical emergencies (requiring immediate attendance), example massive pulmonary embolism; (2) urgent (to be seen as soon as possible), example deep vein thrombosis; (3) semi-urgent (to be attended to within 30-90 days), example highly symptomatic chronic venous disease, and (4) discretionary/non-urgent- (to be seen within 6-12 months), example chronic lymphoedema. Venous and Lymphatic Triage and Acuity Scale aims to standardise the triage of patients with venous and lymphatic disease or vascular anomalies by providing an international consensus-based classification of clinical categories and triage urgency. The scale may be used during pandemics such as the current COVID-19 crisis but may also be used as a general framework to classify urgency of the listed conditions.

Axillary web syndrome: Incidence, pathogenesis, and management.

Axillary web syndrome (AWS) refers to the development of fibrotic bands or "cords" in the axilla of patients who have undergone axillary lymph node dissection for breast cancer. We review the incidence, pathogenesis, risk factors, and management of AWS. AWS is a common complication in patients who undergo axillary lymph node dissection. Even though AWS is self-limited in most cases, it causes significant morbidity. The optimal management of AWS is unclear but physiotherapy appears to be beneficial. The widespread use of less invasive procedures to evaluate the presence of metastasis in the axillary lymph nodes (ie, sentinel lymph node biopsy) is expected to reduce the incidence of AWS. The close collaboration of surgeons, oncologists, and physiotherapists is necessary for the prevention and management of this frequent condition.

In-patient outcomes of Hematopoietic Stem Cell Transplantation in Patients with Immune Mediated Inflammatory Diseases: A Nationwide Study.

The impact of underlying immune-mediated inflammatory diseases (IMID) in patients undergoing hematopoietic stem cell transplant (HSCT) is unclear. Hematopoietic cell transplantation co-morbidity index (HCT-CI) is gaining acceptance as a reliable clinical method to score pre-transplant co-morbidities. Higher HCT-CI from a co-morbid IMID implies higher NRM. However, HCT-CI integrates many IMIDs with different pathogenesis and treatment together which may lead to spurious results. We performed a cross-sectional study using Nationwide Inpatient Sample dataset from 1998 to 2011 to compare the outcomes of HSCT in patients with different co-morbid IMIDs with patients without any co-morbid IMIDs. In both our multivariate and stringent matched-pair analysis, ulcerative colitis (UC) was associated with increased mortality while rheumatoid arthritis and psoriasis were associated with lower mortality as compared to no IMID group. Furthermore, in allogeneic HSCT subgroup, UC was associated with higher mortality and psoriasis was associated with lower mortality. In conclusion, we found that depending on the type of HSCT, each IMID has a different impact on outcomes of HSCT. Furthermore, UC patients had increased mortality if they had primary sclerosing cholangitis and had a higher risk of opportunistic infections like tuberculosis and cytomegalovirus suggesting the need for increased vigilance in this cohort.

Chylous fistula after axillary lymph node dissection: incidence, management, and possible cause.

INTRODUCTION: Chylous fistula is a known complication in procedures such as neck dissection and aneurysm surgery. However chyle leak that develops after axillary dissection is a rare phenomenon. In this study we have evaluated the incidence, possible cause, and management of chylous fistula that develops after radical breast cancer surgeries. MATERIAL AND METHODS: Chylous fistula developed in 6 of 1863 patients who underwent axillary dissection. Their records were analyzed in terms of clinical profile and management. A review of the literature regarding the thoracic duct anatomy at its termination was carried out and a hypothesis about the possible cause of chylous leak was suggested. RESULTS: All 6 patients had procedures on the left side and had varied clinical stages and profiles. The chyle discharge was detected intraoperatively during the primary surgical procedure in 2 patients. The other 4 patients presented with chyle in their drains postoperatively. One patient did not respond to conservative management and underwent reexploration to seal the leak. Injury to the thoracic duct or its aberrant branches is apparently not the cause of chylous fistula in the axilla. The injury to the left subclavian duct or its tributary, which drains aberrantly into the thoracic duct through a valveless junction has been hypothesized to be the source of chyle in the axilla. CONCLUSION: Chylous fistula is very unusual after axillary dissection. Most of the chyle leaks in the axilla are manageable through conservative methods; surgical intervention is required rarely in special situations. Injury to the left subclavian duct or its tributary is the possible cause.

Cervical lymphadenopathy in childhood epidemiology and management.

Cervical lymphadenopathy (CL) is common in childhood. The aim of this study is to evaluate the etiology, follow-up, and treatment of persistent CL. The authors studied retrospectively 50 children with CL, hospitalized at the Department of Pediatrics and Pediatrics Surgery. Patients underwent ultrasonography. Thirty-six percent presented abnormal ultrasonographic image and underwent excisional biopsy. Biopsies revealed 4 thyroglossal cysts, 3 branchial cysts, 1 hemangioma, 2 sebaceous cysts, 1 dermoid cyst, 5 occurrences of tuberculosis lymphadenitis, 1 occurrence of Bartonella henselae lymphadenopathy, and 1 case of non-Hodgkin lymphoma. In conclusion, CL is usually a benign finding; bacterial and viral infections are the most common causes. Ultrasonography help in etiology and follow-up of CL.

Risk factors associated with the need for additional intravenous gamma-globulin therapy for Kawasaki disease.

AIM: To investigate the characteristics of patients with Kawasaki disease who needed intravenous gamma-globulin (IVGG) re-treatment. METHODS: Using the database of the 17th nationwide survey in Japan, a total 11,366 patients were identified and analysed (1,855 re-treatment patients and 9,511 responders). RESULTS: Multivariate logistic regression analysis showed that male sex (odds ratio (OR) 1.26; 95% CI 1.14-1.40), complete cases (OR 1.39; 95% CI 1.07-1.80), recurrence (OR 1.47; 95% CI 1.15-1.88), IVGG treatment within 4 d of illness (OR 2.05; 95% CI 1.84-2.27), daily dose of initial IVGG less than 1,000 mg/Kg (OR 0.54; 95% CI 0.48-0.61), exanthema (OR 2.03; 95% CI 1.62-2.56), lips and oral lesions (OR 1.57; 95% CI 1.24-1.98), peripheral extremities changes (OR 1.85; 95% CI 1.54-2.22), and cervical lymphadenopathy (OR 1.89; 95% CI 1.66-2.16) were independent risk factors associated with the need for IVGG re-treatment. CONCLUSION: Male sex, recurrence, and treatment with IVGG at a dose of 1,000 mg/d or less within 4 d of illness onset are independent risk factors associated with the need for IVGG re-treatment.

Assessment of clinical case-definition for HIV/AIDS in Tanzania.

OBJECTIVE: To evaluate the usefulness of World Health Organisation (WHO's) clinical case-definition (CCD) for AIDS in a private hospital. DESIGN: A prospective study. SETTING: Shree Hindu Mandal Hospital, Dar es Salaam, Tanzania. SUBJECTS: A total of 601 patients (> 14 years) were studied from January 1995 to December 1997. METHODS: Using HIV test results as a reference standard, sensitivity, specificity, positive predictive values (PPV) and negative predictive values of signs and symptoms were calculated. Multiple logistic regression was used to determine a set of predictive symptoms and signs. Stepwise logistic regression modelling was used to choose the final model. RESULTS: The frequently occurring signs and symptoms among the 473 sero-positive patients were fever (226), oral candidiasis (167), weight loss (161), chronic cough (157), diarrhoea (100) and pulmonary tuberculosis in 69 cases. The presence of anorectal lesions and the rarity of pneumocystis carinii pneumonia in this study are important findings. Seven clinical characteristics predicted HIV infection. These included pulmonary tuberculosis (p=0.009), lymphadenopathy (p=0.007), diarrhoea (p=0.000), chronic cough (p=0.001), dermatitis (p=0.003), herpes zoster (p=0.01) and oral candidiasis (p=0.000). CONCLUSIONS: A greater number of HIV positive patients presented with signs and symptoms different from those proposed by WHO's CCD were observed in this study. With environmental pathogens varying from one geographical region to another and new ones appearing, opportunistic disease cannot be constant in AIDS patients. Therefore, AIDS diagnosis based on clinical case definition alone without at least one positive HIV antibody test is inaccurate and no longer justified.

Coronal multiplanar reconstruction view from isotropic voxel data sets obtained with multidetector-row CT: assessment of detection and size of mediastinal and hilar lymph nodes.

OBJECTIVE: To assess the detection and size of mediastinal and hilar lymph nodes by multiplanar reconstruction (MPR) view from isotropic voxel data sets obtained with multidetector-row computed tomography (MDCT). MATERIALS AND METHODS: Thin-section CT of 27 patients with mediastinal or hilar lymph node swelling was obtained with a 25.6-cm FOV, 512 x 512 matrix, and two protocols: A) 0.5-mm collimation, 0.3-mm interval, and B) 2-mm collimation, 1-mm interval. MPR views with a 0.5-mm slice thickness were obtained from these two data sets. Postcontrast axial CT used 5-mm collimation (set C). Two observers evaluated the presence and cranio-caudal length of swollen lymph nodes. Two other board-certified chest radiologists evaluated all three sets and established a gold standard by consensus. RESULTS: The accuracy of detection was 76%, 73%, and 68% for sets A, B, and C, respectively. There was a significant difference between sets A and C (McNemar's test: p<0.05) but not between sets A and B or B and C (p>0.05). The cranio-caudal length of lymph nodes was significantly correlated with the gold standard only in set A (Pearson's correlation coefficient: r=0.53, p<0.05). CONCLUSION: Non-contrast enhanced coronal MPR views constructed from isotropic voxel data sets may be substituted for axial enhanced CT for the evaluation of mediastinal and hilar lymph nodes.

The etiology of peripheral lymphadenopathy in children.

This prospective study evaluated 382 pediatric patients with peripheral lymphadenopathy (LA) presenting at the Pediatric Oncology and Hematology Departments of Social Security Children's Hospital and Gazi University Medical Faculty Hospital. The ages of the patients ranged between 2 months and 16 years (median 7 years); 72% of the patients were male. Of the 382 patients, 138 had localized LA (a single anatomic area involved), 171 had limited LA (two or three areas involved), and 73 had generalized LA (four or more anatomic areas involved). The specific etiology (either benign or malign) was defined in 79% of patients with generalized LA. However, in patients with localized LA and limited LA, specific etiology could be identified only in 43 and 53% of patients, respectively. Based on this study, BCG-LA and pyogenic infections are more frequently manifested by localized LA; LA of unknown origin, Hodgkin's disease, tuberculosis, nasopharyngeal carcinoma, and toxoplasmosis are frequently manifested by localized or limited LA; and cytomegalovirus infection (CMV), infectious mononucleous, rubella, acute leukemia, non-Hodgkin's lymphoma are frequently manifested by limited or generalized LA. Out of 382 patients, 196 patients had a maximum lymph node diameter of less than 2 cm. A benign etiology was shown in 159/196 of these patients. In 37/196 of these patients LA was due to a malignancy, and these cases almost invariably had some apparent additional diagnostic clinical and laboratory findings. Based on this observation a maximum lymph node size of 2 cm was considered an appropriate limit to distinguish malignant disease from benign causes except when there is other evidence of an underlying malignant disease. However, lymphadenopathies located at supraclavicular region (27 patients) either localized or as part of generalized LA had a specific benign or malignant disease in etiology (malignancy in 20, tuberculosis in 3, CMV in 2, sarcoidosis in 1, and lipoma in 1) even though they were less than 2 cm in diameter.

Pelvic lymphocele following radical para-aortic and pelvic lymphadenectomy for cervical carcinoma: incidence rate and percutaneous management.

Thirty-six women, treated with radical hysterectomy (Piver types III-IV) plus systematic para-aortic and pelvic lymphadenectomy for cervical carcinoma, underwent serial postoperative ultrasound examinations to determine the incidence of lymphocele and the therapeutic efficacy of percutaneous catheter drainage. Pelvic lymphoceles, ranging in volume from 46-300 mL, occurred in eight patients (22.2%) between the 12-24th postoperative day. Percutaneous catheter drainage, inserted under local anesthesia, was used for a mean time of 14.5 days (range 4-32), resulting in a mean daily drainage of 92.2 mL and a mean total volume of 1727.5 mL per patient. Catheter drainage allowed complete clinical and sonographic remission in all cases, and only one asymptomatic recurrence was observed at 3-month and 6-month follow-up. Ultrasound-guided percutaneous catheter drainage has proved to be a well-tolerated, safe, and effective technique in the management of lymphocele that obviates the need for more invasive surgical procedures.

The incidence and management of chylous fistulae.

Two hundred neck dissections performed at Toronto General Hospital over a 3 year period are reviewed. There were six intra-operative lymph leaks and five postoperative chylous fistulae. The postoperative chylous fistulae are analysed in detail and the approach to conservative management of lymph leaks is discussed. Two cases required re-exploration of the neck; difficulty in identifying the site of leakage and of sealing lymph channels is discussed. Also reported is the successful use of topical tetracycline powder in two cases and a review of the various treatment modalities advocated in the literature.