European guidelines for sclerotherapy in chronic venous disorders.

AIM: Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy. METHODS: This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7-10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guideline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines. RESULTS: This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidocanol and sodium tetradecyl sulphate. Other sclerosants are not discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.

Foam sclerotherapy techniques: different gases and methods of preparation, catheter versus direct injection.

INTRODUCTION: Foam sclerotherapy has gained a great popularity among phlebologists worldwide, although a major lack of homogeneity in the material used to produce sclerosant foam (SF) and to inject SF has been reported. AIMS: To highlight the literature data and a few personal clinical and experimental outcomes concerning the main variables in SF production and injection. METHODS: A review of the published literature and of our own 12 year clinical and experimental experience has been undertaken in order to focus on a few variables of the material and methods used to produce SF with Tessari method and to inject SF. RESULTS: In SF production, differences in gas components, liquid to gas ratio, as well in disposable material can variably influence the resulting SF. Similarly SF injection through ultrasound guidance, with needle, or with short/long catheter may exhibit different foam behaviours according to the variable material and techniques which are employed. More recently the introduction of long catheters, possibly together with hook phlebectomy, seems to potentiate the short-mid term outcomes of foam sclerotherapy. CONCLUSION: SF formation is greatly influenced by the choice of the gas component, the liquid-to-gas ratio, the type of syringes; also larger needles are to be preferred for injection of SF, while long catheters seem to represent a valid alternative especially when combined with tumescence to minimise saphenous diameter.

Escleroterapia de las várices de los MI mediante espuma esclerosante fribro-vein con el método Tessari / Sclerotherapy of varices in lower limbs with fibro-vein sclerosing foam according to Tessari's method

Escleroterapia de las venas varicosas en miembros inferiores mediante espuma esclerosante de acuerdo a Tessari. Experiencia preliminar. El objetivo de este trabajo es evaluar la eficacia a corto plazo y la seguridad de la espuma esclerosante obtyenida del sulfato tetradecil-sódico (Fibro-Vein) con el método de Tessari en el tratamiento de telangiectasias y venas varicosas de miembros inferiores...Se obtuvo un alto porcentaje de éxito inmediato en el grupo tratado, con la rápida aparición del espasmo masivo en la mayoría de los casos y la obliteración de todos los 61 tramos venosos medianos y grandes observada 1 es después...La espuma esclerosante según Tessari basada en Fibro-Vein ha demostrado, en esta experiencia piloto, ser un trratamiento efectivo y seguro para venas varicosas de mediano y gran tamaño. Su papel en telangiectasias queda por definirse

Escleroterapia de las várices de los MI mediante espuma esclerosante fribro-vein con el método Tessari / Sclerotherapy of varices in lower limbs with fibro-vein sclerosing foam according to Tessaris method

Escleroterapia de las venas varicosas en miembros inferiores mediante espuma esclerosante de acuerdo a Tessari. Experiencia preliminar. El objetivo de este trabajo es evaluar la eficacia a corto plazo y la seguridad de la espuma esclerosante obtyenida del sulfato tetradecil-sódico (Fibro-Vein) con el método de Tessari en el tratamiento de telangiectasias y venas varicosas de miembros inferiores...Se obtuvo un alto porcentaje de éxito inmediato en el grupo tratado, con la rápida aparición del espasmo masivo en la mayoría de los casos y la obliteración de todos los 61 tramos venosos medianos y grandes observada 1 es después...La espuma esclerosante según Tessari basada en Fibro-Vein ha demostrado, en esta experiencia piloto, ser un trratamiento efectivo y seguro para venas varicosas de mediano y gran tamaño. Su papel en telangiectasias queda por definirse

Preliminary experience with a new sclerosing foam in the treatment of varicose veins.

BACKGROUND: Recently a new method of using a foam sclerosing agent for the treatment of leg veins has been described. We present a pilot study of a new technique for producing the sclerosing foam (Tessari's method) (SFT) and its use in sclerotherapy of major and minor varicosities. OBJECTIVE: A preliminary multicenter experience of sclerotherapy performed by means of this new kind of sclerosing foam made of purified sodium tetradecylsulfate is described. The authors evaluated the safety and efficacy of different doses and concentrations of the drug as well as different methods of preparing the foam in addition, the results of this technique were evaluated. METHODS: Over a 6-week period the three authors performed sclerotherapy or duplex-guided sclerotherapy using SFT, treating 77 patients. The SFT was formed using a three-way stopcock and two syringes, mixing air with liquid sodium tetradecylsulfate to create a foam. Each author used different concentrations (0.1-3%) and doses (2-8 ml) of SFT according to the size and number of the veins. Alternate methods of preparing the foam were examined as well. Seventy percent of the sclerotherapy sessions were performed on either the long or short saphenous veins, recurrent varices, or collaterals. Thirty percent of the treatments were for reticular varices and telangiectases. RESULTS: At 1-month follow-up, the vast majority of treated larger veins were either obliterated or showed a normal state of cephalad blood flow. Results for minor varicosities were good, but with related complications of hyperpigmentation and small areas of cutaneous necrosis. Two patients experienced transient scotomas and one patient developed segmental phlebitis of a collateral vein. The best foam was obtained by mixing one part liquid sodium tetradecylsulfate and four to five parts air, but the duration of the foam product was also related to several other factors. CONCLUSION: This preliminary pilot study demonstrates that the technique of producing sclerosing foam according to Tessari's method (three-way stopcock device) is very promising, especially for larger veins. No serious complications were reported, and further standardization of the method may improve the results and feasibility of this technique. Further studies are needed to validate this new technique.

Surgical treatment of far lateral lumbar disc herniation. Identification of compressed root and discectomy by lateral approach.

STUDY DESIGN: A new method is described of compressed root identification and discectomy for extraforaminal disc herniation, by a lateral intertransversalis approach. OBJECTIVES: To describe a safe surgical approach that does not require resection of adjacent bone structures during extraforaminal discectomy. SUMMARY OF BACKGROUND DATA: Most earlier series have reported approaches that damaged bordering bone structures with wide laminoarthrectomy. This is an attempt at a safer, simpler surgical approach. METHODS: Thirteen patients with lateral hernia have undergone this surgical procedure since 1995. Herniectomy was performed after identification of the compressed root within the iliopsoas muscle. RESULTS: All the patients resumed the upright position with the aid of semirigid brace 24 hours after surgery. Upon awakening from the anesthesia, no patient reported peripheral pain. Motor deficits resolved after physical rehabilitation in all but one patient. At a mean follow-up of 14 months, there was no report of back pain. CONCLUSION: The procedure described in this article offers a simple alternative to the valid procedures presently at hand. It offers the advantage of no bone resection and of minimizing nerve structures manipulation.

Early ultrasound diagnosis of developmental dysplasia of the hip.

The results of ultrasound diagnosis of developmental dysplasia of the hip (DDH) in several studies of 1,000 and 1,332 consecutive patients, performed according to Graf's method from 1984 to the present, are presented. Prior to 1984 the authors used radiography exclusively in suspected cases of DDH, however, the change from radiography to ultrasonography resulted in significant improvement in the ability to diagnose and treat DDH. Different standard methods of treatment have been developed for the management of each morphological type of the newborn's and infant's hip. Ultrasound is more sensitive than clinical assessment for diagnosing DDH since it detects the dysplastic morphology of the hip when Ortolani's test is negative. Instability can be demonstrated directly. The success of treatment of DDH depends on the time of diagnosis the early diagnosis obtained by ultrasound screening can significantly improve the results of treatment.

Diagnostic value of compression ultrasonography and fibrinogen-related parameters for the detection of postoperative deep vein thrombosis following elective hip replacement: a pilot study.

To determine their ability to diagnose postoperative deep vein thrombosis (DVT) D-dimer - by three methods -, fibrinogen degradation products (FgDP) and fibrinogen levels were measured in 68 consecutive patients before elective surgery for hip replacement and on postoperative day 1, 3, 6, and 10. All patients received prophylaxis and underwent compression real-time B-mode ultrasonography (C-US) on postoperative day 5 and 9, and bilateral ascending venography on day 10. Twenty-two out of 68 patients developed asymptomatic postoperative DVT, which was limited to the calf veins in 14 and involved the proximal veins in 8 patients. C-US was negative in all patients on day 5. On day 9, C-US sensitivity and specificity for proximal DVT were 63% (95% confidence interval: 26%-90% and 98% (89%-100%) respectively. Postoperative changes in the laboratory parameters evaluated were not different in patients with or without DVT until day 10. On day 10, mean D-dimer, FgDP and fibrinogen levels were significantly higher in patients with DVT than in those without DVT (p values between 0.006 and 0.032), but only D-dimer was higher with DVT involving two or more venous segments than with thrombosis involving one venous segment only (p < 0.05). Stepwise logistic regression analysis identified D-dimer and fibrinogen on day 10 as predictors of postoperative DVT. In a receiver operator curve and after weighing for the coefficients generated by logistic regression analysis, the combination of a latex photometric immuno-assay and of PT-derived fibrinogen yielded-at a cut-off value of 7.0 a sensitivity of 100% (73%-100%) and a specificity of 58% (39%-75%) for DVT, with a negative predictive value of 100% (78%-100%), a positive predictive value of 52% (32%-71%) and an overall accuracy of 71% (55%-83%). These results suggest that two simple, fast and reproducible tests may permit the identification of patients at low risk of having postoperative DVT and that a combination of sensitive laboratory assays and of the highly specific C-US may select patients requiring anticoagulant treatment. Efficacy and cost-effectiveness of this approach should be evaluated in large clinical management studies.

Early diagnosis of congenital dysplasia of the infant hip by means of ultrasound screening.

The authors present a study carried out in 1990 analyzing the results of ultrasound screening of the infant hip in order to evaluate possible dysplasia. They stress the already unquestionable role of ultrasound screening as a valid, sensitive and useful device in the diagnosis of congenital dysplasia of the hip and emphasize that the earlier the examination is carried out, the easier it is to begin suitable treatment rapidly and with positive results. They recommend that ultrasound screening should be carried out by an orthopaedist in order to further shorten diagnosis and treatment times.

[Influence of nutrition, age and vitamin D status on fasting urinary excretion of calcium in postmenopausal women]. / Influenza della nutrizione, dell'età e dell'assetto vitaminico D sull'escrezione urinaria del calcio a digiuno nelle donne in menopausa.

The purpose of the present study was to evaluate the influence of nutrition, age, and Vitamin D status on fasting urinary calcium (Ca) as a function of creatinine excretion (Ca/Cr) and of glomerular filtration rate (Ca/GFR) in postmenopausal women. Fasting urinary calcium, urinary Cr and GFR were measured in 18 women aged 54 to 91 years before and after six days of a calcium (400 mg/die) and sodium (100 mEq/die) restricted diet with a controlled content of proteins, lipids and glucides. Aged (over 64 y.) women having an adequate vitamin D status showed fasting urinary Ca/Cr and Ca/GFR after the controlled diet significantly lower than those showed before. It is concluded that fasting Ca/Cr and Ca/GFR may be nutrition-dependent. A revision of the significance of the fasting urinary Ca excretion is consequently suggested.

[Nutrients, anthropometric characteristics and osteoporosis in women in the recent and late postmenopausal period]. / Nutrienti, caratteristiche antropometriche ed osteoporosi delle donne in età postmenopausale recente e remota.

Bone mineral content (BMC) at two different radial sites (mid-diaphysis and ultra-distal epiphysis), anthropometric measurements (Body Mass Index, Lipidic Area, and Muscular Area) and nutrients intake were measured in two populations of women selected on the basis of early (< 9 years) or remote (> 15 years) menopause. The results show the presence of positive relationships between BMC, and protein and lipid intakes in the population of women in early menopause; in the other population no relationships were found. Glucid, fibre and calcium intakes were not related to the BMC of both populations. The positive relationships between BMC, and protein and lipid intakes in the population of women in early menopause is likely mediated by anthropometric characteristics as Body Mass Index and Muscular Area.

[The blood calcium error induced by oral calcium loading: study of the homeostatic compensation mechanism]. / L'errore calcemico indotto dal carico orale di calcio: studio dei meccanismi omeostatici di correzione.

The oral calcium load test, originally proposed for evaluating the intestinal calcium absorption and the renal calcium leak triggers some endocrine and metabolic responses addressed to correct the "calcemic error" induced by the load. Besides the increased plasma calcium there are: plasma PTH drop, increment in the urinary calcium excretion and in the threshold of tubular phosphate reabsorption. These responses have been measured and reciprocally correlated in 9 young adults at different times after the oral calcium load. The responses can be assessed with high precision in clinical practice and are in agreement with the known physiological models. The oral calcium load test is proposed as a tool for studying in the osteopenic population in the individual's capacity of correcting the calcemic error induced by the load.

[Reduction in parathormone secretion after oral calcium loading in osteoporotic adults]. / La riduzione della secrezione di paratormone dopo carico orale di calcio negli adulti osteoporotici.

The purpose of this study was to verify if a decreased inhibition of PTH secretion (abnormal suppressibility) in response to physiological increment of plasma calcium is present in patients with osteoporosis. The plasma concentration curve of intact PTH 1-84 following an oral calcium load (Pak) has been calculated in a selected population of 38 osteopenic patients (16 males and 22 females) and in a control group of 9 young healthy adults. All the patients included in this study a) had no past or present diseases and medications of potential influence on calcium homeostasis, b) showed a maximal calcemic response to the oral calcium load equal to that of the control group. PTH suppressibility was significantly smaller in the osteoporotic patients (-42% in males and -32% in females) than in the control group (-76%). This abnormal suppressibility of PTH is independent on sex and, in the females, also on postmenopausal estrogen deficiency. These results support the hypothesis that osteoporosis is associated to an altered secretory response of parathyroid glands maybe due to reduced sensitivity of the parathyroid cells to extracellular calcium.

[A case of cutaneous disorders of the lower limbs due to lymphostasis in a patient with multiple sclerosis. Use of a dynamic phlebologic footboard]. / Un cas de troubles cutanés aux membres inférieurs, conséquence d'une grave hémolymphostase chez un patient avec une sclérose à plaques multiples. Utilisation d'un marchepied hémo-phlébo-dynamique.

Tessari hemo-phlebo-dynamic steps are a passive physiotherapy device which cause the "ankle pump" to work, thereby contributing to venous return in the lower limbs. These steps can be used in phlebology in disorders due to stasis affecting the lower limbs, in orthopedics in functional rehabilitation as preventive treatment in the case of sedentary activities.

[A method for the in vivo measurement of the mineral content in an experimental animal]. / Un metodo per la mineralometria in vivo nell'animale da esperimento.

Bone mineral content measurement is not as widely used in experimental conditions as in clinical practice because of the lack of adequate experimental methods. An in vivo measurement method of bone mineral content in the rat is here presented. Measurements were made at the proximal tibio-peroneal segment, which has a mainly trabecular structure, by means of single photon absorptiometry. The presence of the fibula, having cortical structure, has been shown not to affect the read values, which can be therefore attributed to the tibial metaphysis, having a mainly trabecular structure. Expressing mineral content values as a function of the measured bone diameter has proven useless. Limb repositioning on the instrument holding device is critical for the reproducibility of the measurement, but the latter is not affected by the repositioning method. Method reproducibility (depending on either the intrinsic instrumental error or the repositioning error) is 5-6%. This relatively low reproducibility of the suggested method does not prevent its use in the study of physiological and pathological variations of bone mineral content in rats, and of the means to influence it.

Morphological or functional criteria in evaluation of the newborn hip?

Classifying the infant hip as normal or dysplastic before the stage of radiological significance, in other words during the first three months of life, has always been trusted to functional maneuvers causing clinical signs. From the results it is possible to deduce if the hip morphology is normal or somehow altered. In other words, because insufficient radiographic significance makes it impossible to directly assess the "morphological" criterion, diagnosis of the state of the hip is carried out using an indirect "functional" criterion. In contrast to radiographic imaging, ultrasound screening is already significant in the first weeks of life; it is therefore now possible to obtain real images of the infant hip earlier than it was possible using radiography. This eliminates the need for symptomatic evidence of dislocation. As a result, the "functional" indirect criterion used up till now for early diagnosis of infant hip can today be replaced by a direct "morphological" criterion. This innovation is not without epidemiological consequences, and this must be taken into account in order to rationalise between the opposing risks of over or under estimating the incidence of congenital hip dysplasia.