Comparing Ultrasonography and Surface Landmark-Guided Lumbar Puncture in Patients with Obesity and Difficult Anatomy; a Randomized Controlled Trial.

Introduction: Previous studies have shown higher lumbar puncture (LP) success rates when using ultrasound guidance. This study aimed to compare the first-attempt success rate of ultrasound-guided LP with blind technique of needle insertion using the palpable spinal surface landmark in patients with obesity or a difficult anatomy. Methods: This prospective randomized controlled study was performed at the emergency department of Ramathibodi Hospital, an academic tertiary university hospital, from August 2015 to July 2016. Results: 40 patients were enrolled (20 surface landmark-guided and 20 ultrasound-guided LPs). 52.5% of the patients were male with the mean age of 60.33 ± 4.24 years. The first-attempt success rate in the ultrasound-guided LP group was significantly higher than the landmark-guided LP group (80% vs. 35%, respectively), with risk difference (RD) of 45.00% (95% confidence interval (CI): 17.72%, 72.28%). This indicated absolute risk reduction and number needed to treat of 45.00% and 2.22, respectively. The median procedural duration required to achieve successful LP in the ultrasound-guided LP group was significantly shorter than the surface landmark-guided LP group (5 [IQR: 3-18] minutes vs. 13.5 [IQR: 5-30] minutes, respectively). Traumatic puncture as a complication occurred less frequently in the ultrasound-guided LP group than the surface landmark-guided LP group with risk ratio (RR) = 0.33 (95% CI: 0.08, 1.46) and RD = -20.00% (95% CI: -44.00%, 4.00%). This indicated absolute risk reduction and number needed to harm of 20.00% and 5.00, respectively. However, the difference was not significant. Conclusion: Using ultrasound to help localize the insertion point before LP increased the first-attempt success rate and improved other LP outcomes in Thai patients with obesity or a difficult anatomy. It also shortened the procedural duration and reduced the incidence of traumatic tap.

Early postoperative duplex ultrasound findings of the hepatic artery in postoperative vascular complications from paediatric liver transplantation.

PURPOSE: To evaluate duplex US findings of the HA in all three postoperative vascular (HA, PV, HV and IVC) complications of paediatric LT for early detection and some helpful secondary signs to determine these vascular complications. MATERIALS AND METHODS: We collected data from 44 post-LT paediatric patients who underwent daily duplex US for seven consecutive days and three months after LT during January 2017-June 2020. Four duplex US parameters of the HA (extrahepatic PSV, intrahepatic PSV, RI and AT) were compared in patients with and without complications. RESULTS: The PSV of the extrahepatic HA in patients with HA complications was higher than that in patients without complications (P value = 0.019). The PSV at 107.7 cm/s is the optimal cut-off parameter associated with HA complications [a sensitivity of 88.9% and a specificity of 80.0% (ROC area is 0.84)]. The intrahepatic RI was higher on the first day than on the last day and gradually decreased in patients without vascular complications (P value = 0.000). The intrahepatic PSV significantly decreased with time when comparing the first and last days in patients without PV and HV-IVC complications (P value = 0.014 and 0.038). In contrast, patients with vascular complications showed no significant decrease. CONCLUSION: The extrahepatic PSV relates to HA complications after paediatric LT but not PV and HV-IVC complications. Non-significantly decreased intrahepatic RI and PSV from the first day to the day of complication diagnosis may correlate with the occurrence of vascular complications.

Diameter-reflux relationship of the saphenous vein in the C0-C3 patients of chronic venous disease.

OBJECTIVE: To evaluate the relationship between the saphenous vein's diameter and reflux and determine the cut point of the saphenous vein's diameter that indicates lack of reflux. MATERIAL AND METHODS: A retrospective cohort study conducted in 807 limbs underwent the venous ultrasound for 36 months. The saphenous vein's diameter in the reflux and non-reflux groups was evaluated. The receiver operating characteristics (ROC) curve was constructed to determine the saphenous vein's diameter that maximizes the summation of sensitivity and specificity for saphenous vein reflux in C0-C3 patients. RESULTS: The reflux group had a significantly greater diameter than a non-reflux group at four great saphenous vein (GSV) levels and two small saphenous vein (SSV) levels (p-value < 0.001). The venous reflux correlated significantly with GSV diameter at all four GSV levels and two SSV levels (p-value <0.001). The ROC area of the diameter at four GSV levels ranges from 0.59 to 0.69. The optimal cut-off diameter for GSV reflux is 3.8 mm at the proximal thigh, 2.8 mm at the distal thigh, 3.2 mm at the proximal calf, and 2.5 mm at the distal calf. The ROC area of the diameter at two SSV levels ranges from 0.66 to 0.67. The optimal cut-off diameter for SSV reflux is 2.5 mm at the proximal calf and 2.3 mm at the distal calf. CONCLUSION: The saphenous vein's diameter has been proved to be significantly correlated with the presence of reflux in duplex ultrasound in all lower limbs' levels. Unfortunately, the study's cut point diameter is considered poor accuracy and is not an accurate measurement to use as the screening test for the presence of reflux.

Lower-Extremity Venous Ultrasound in DVT-Unlikely Patients with Positive D-Dimer Test.

RATIONALE AND OBJECTIVES: To review the clinical data, D-dimer level and the ultrasonographic findings from complete venous ultrasound of the lower extremity in deep venous thrombosis (DVT)-unlikely patients with abnormal D-dimer test were compared to DVT-likely patients to ascertain the appropriate ultrasound examination protocol for patients in this group. MATERIAL AND METHODS: A retrospective cohort study was conducted of all patients who underwent a complete (whole leg) venous ultrasound in one 13-month period. The medical history, demographic, clinical risk factors, and ultrasonographic findings of the patients with high clinical probability for deep vein thrombosis (Wells score ≥2), along with patients with a low clinical probability of deep vein thrombosis (Wells score ≤1) but with a D-dimer level higher than the threshold (≥500 ng/ml FEU) were evaluated. RESULTS: There were 96 patients in the DVT-likely group and 86 patients in the DVT-unlikely group. The indication for ultrasound examination in the DVT-unlikely group was preoperative assessment to avoid the risk of pulmonary thromboembolism. The patients in the DVT-likely group had more positive ultrasound results for DVT (15.63% vs. 5.18%, p value = 0.03) than the patients in the DVT-unlikely group. In the DVT-unlikely group, the median D-dimer level in the patients with positive ultrasound for DVT showed statistically significantly higher levels than the patients with negative ultrasound for DVT did (2208 vs. 921 ng/ml FEU, p value = 0.02). The optimal D-dimer cut-off from the receiver operating characteristics analysis shows the maximized summation of sensitivity and specificity (80% and 66.67%) at 1251 ng/ml FEU. The prevalence of acute thrombus in a thigh vein in DVT-unlikely, preoperative patients is low (1.2%). CONCLUSION: To minimize the number of unnecessary complete venous ultrasound lower-extremity examinations, the use of a higher D-dimer cut-off level and limiting proximal or thigh vein ultrasound examinations in the preoperative patient is considered.

Morphologic change in deep venous thrombosis in the lower extremity after therapeutic anticoagulation.

BACKGROUND: To evaluate the anticoagulant treatment response in venous thrombi with different morphologies (size, shape, and echogenicity) by measuring the change in thrombus thickness. MATERIALS AND METHODS: This was a retrospective cohort study of 97 lower extremity DVT patients diagnosed by venous ultrasound between March 2014 and February 2018. The demographics, clinical risk factors, anticoagulant treatment, and ultrasound findings at the first diagnosis and 2-6 months after treatment were evaluated. RESULTS: The anticoagulant treatment with LMWH followed by VKAs showed a significant decrease in the mean maximum difference in lower extremity DVT thrombus thickness compared with VKAs alone (P-value < 0.001). After adjustment by treatment, the thrombi found in dilated veins showed a significant decrease in the thickness of such thrombi compared with those found in small veins: 4 mm vs. 0 mm (Coef. = 3, 95% CI: 1.9, 4.1 and P-value < 0.001). Anechoic and hypoechoic thrombi showed a significant decrease in the thickness compared with hyperechoic thrombi: 5 mm vs. 0 mm (Coef. = 4, 95% CI: 3.25, 4.74 and P-value < 0.001) and 3 mm vs. 0 mm (Coef. = 2, 95% CI: 1.34, 42.66 and P-value < 0.001), respectively. Concentric thrombi showed a significant decrease in thickness compared with eccentric thrombi: 4 mm vs. 0 mm (Coef. = 2, 95% CI: 1.45, 2.55 and P-value < 0.001). CONCLUSION: The anticoagulant treatment with LMWH followed by VKAs shows a significant decrease in lower extremity DVT thrombus thickness compared with VKAs alone. After adjustment by treatment, the morphologic finding of acute thrombi shows a significantly decreased thickness compared with the morphologic finding of chronic thrombi.

Duplex ultrasound findings and clinical classification of lower extremity chronic venous insufficiency in a Thai population.

BACKGROUND: The objective of this study was to evaluate the association between the clinical classification of chronic venous insufficiency and duplex ultrasound findings. METHODS: A total of 1010 limbs with clinically suspected chronic venous insufficiency were stratified according to the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification and underwent duplex ultrasound evaluation consecutively between January 2012 and June 2015. Venous thrombosis, venous reflux, and anatomic distribution of the deep and superficial venous systems were investigated across the CEAP clinical classes. RESULTS: There were 259 male limbs (25.6%) and 751 female limbs (74.4%) in clinical class C0 (24 limbs [2.4%]), C1 (130 limbs [13.1%]), C2 (452 limbs [44.8%]), C3 (183 limbs [18.1%]), C4 (163 limbs [16.1%]), C5 (31 limbs [3.1%]), and C6 (27 limbs [2.7%]). The mean age in clinical class C4-C6 (60.77 ± 14.67 years) was statistically significantly higher than in C0-C3 (55.73 ± 18.85 years; P < .001). Male limbs were shown to have a predilection for presenting with clinical class C4-C6 over female limbs (36.3% vs 16.9%; odds ratio, 2.8; 95% confidence interval, 2.0-3.8). Positive findings were predominantly displayed in clinical class C4-C6 compared with C0-C3 (deep venous thrombosis, 3.2% vs 1.3%; deep venous reflux, 30.8% vs 26.9%; superficial vein thrombosis, 2.7% vs 2.0%; superficial venous reflux, 56.6% vs 47.6%; perforator vein reflux, 12.7% vs 8.2% [P = .049]). A low prevalence of small saphenous vein and perforator vein reflux in C1 limbs (0.3% and 4.6%) and C3 limbs (3.8 and 6.6%) was discovered. CONCLUSIONS: The prevalence of CEAP class C0-C3 was found to be higher than C4-C6. However, men were shown to have a predilection for presenting in clinical class C4-C6 over women. The mean age of patients with clinical class C4-C6 limbs was statistically significantly higher than of those with clinical class C0-C3 limbs. The prevalence of deep venous reflux, superficial venous reflux, and coincident deep and superficial venous reflux in clinical class C4-C6 limbs was higher than in clinical class C0-C3 limbs. Detection of incompetent perforator veins was shown to have a statistically significant correlation with clinical class C4-C6 limbs.

Predicting Factors for Failure of Percutaneous Drainage of Postoperative Intra-Abdominal Collection.

Objective: To determine the predictive factors for failure of percutaneous drainage (PD) of postoperative intra-abdominal collection, to better select the patients who might benefit from PD. Material and Method: From September 2011 to February 2013, the authors reviewed 42 patients with symptomatic postoperative intra-abdominal collection who had received PD at Ramathibodi Hospital. The PD was considered as failure when clinical sepsis persisted or subsequent surgery was needed. Univariate analysis was used to examine the relationships between failure of PD and the collection and drainage-related variables. Results: The success rate of PD in the present study was 80%. No major complication was detected. The overall mortality was 12%. Univariate analysis showed that the presence of biliary fistula (p = 0.012), subhepatic location (p = 0.040) and the drainage catheter size of 12F (p = 0.002) were significant predictive variables for failure of PD. Conclusion: Image-guided PD of postoperative intra-abdominal collection was found to be a safe and effective procedure with few complications. Initial recognition of biliary fistula in the collection at subhepatic region or in patients underwent hepatobiliary surgery was the important prognostic factor for unsuccessful PD. These patients may be more beneficial for initial surgical drainage.

Visibility and variability of pleural fissures on normal digital chest radiographs of 1,000 healthy adults.

PURPOSE: To investigate the visibility and variability of pleural fissures on digital chest radiographs. METHODS: Posteroanterior digital chest radiographs of 566 males and 434 females were retrospectively reviewed for the frequencies and/or appearances of various pleural fissures. RESULTS: The right only, left only and bilateral minor fissures were visible in 722 (72.2 %), 1 (0.1 %) and 7 (0.7 %) subjects, respectively. The right minor fissures were visible as more than one line in 219 (30.0 %) subjects, i.e., 2, 3 and 4 lines in 214 (29.3 %), 4 (0.5 %) and 1 (0.1 %), respectively. The 955 visible right minor fissures exhibited variable length (<1/3 of right hemithorax, 17.8 %; 1/3-2/3, 60.1 %; >2/3, 22.1 %), alignment (medial higher 40.9 %; lateral higher 54.2 %; horizontal 4.8 %) and contour (convex upward 68.6 %; convex downward 2.7 %; flat 24.9 %; sigmoid 3.8 %). Superolateral major fissures were visualized in 14.8 % (right only 3.0 %; left only 9.0 %; bilateral 2.8 %), superomedial major fissures in 0.3 % (right 0.1 %; left 0.2 %), vertical fissures in 0.5 % (right 0.2 %; left 0.3 %), inferior accessory fissures in 5.4 % (right 4.8 %; left 0.6 %), right superior accessory fissures in 1.2 % and azygos fissures in 0.2 %. CONCLUSION: The right minor fissure was most frequently visible and exhibited variable appearances. Other pleural fissures were occasionally seen.