bluuebunny/crossref_metadata_2025 huggingface dataset:
Preemption and the MLR Provision of the Affordable Care Act
Authors: Hoffmann Jeffrey
Published: January 2017

This Note focuses on the medical loss ratio provision (“MLR Provision”) of the Patient Protection and Affordable Care Act (ACA). The MLR Provision states that health insurance companies must spend at least a certain percentage of their premium revenue on “activities that improve healthcare quality” (in other words, meet a minimum threshold medical loss ratio) and comply with reporting requirements determined by the Secretary of the United States Department of Health and Human Services (HHS). Because states have historically had authority over the regulation of health insurance, there is an outstanding question as to whether or not the MLR Provision has legal authority to preempt conflicting state MLR regulations.

Part II of this Note outlines the major requirements in the MLR Provision and discusses the history of MLR regulation in the United States. Part III discusses the likelihood that the courts will soon resolve the question of preemption regarding the MLR Provision.
Abnormalities in Central and Peripheral Nerve Conduction in Patients with Anorectal Incontinence
Authors: Snooks S J , Swash M , Henry M M
Published: January 2017

Thirty women with idiopathic anorectal incontinence were investigated by nerve conduction studies. Twenty-two (73%) patients had abnormal nerve conduction studies. In 7 (23%) of these patients there was conduction delay in the cauda equina between L1 and L4 vertebral levels but in the remainder the distal innervation of the pelvic sphincters was abnormal.
Large Gallstones May Pass Spontaneously
Authors: Johnson C D , Celestin L R
Published: January 2017

We report two cases in which gallstones greater than 1 cm in diameter passed spontaneously from the common bile duct into the duodenum. The possibility of spontaneous passage should be borne in mind in the management of patients with common duct stones.
Quantitative Analysis of Skin Flap Blood Flow in the Rat Using Laser Doppler Velocimetry
Authors: Marks Nicholas J
Published: January 2017

Two experiments carried out on rat skin flaps are described, where microvascular flow has been measured noninvasively by a laser Doppler velocimeter. Using this technique it is possible to define the limits of an axial pattern flap in terms of microvascular flow; this was found to increase when the flap is elevated. ‘Random-pattern’ perfusion is defined by a fall in flow. This recovers sequentially along the flap, and at a constant rate at all sites. A differential in microvascular perfusion is thus maintained along a random-pattern flap for at least the first postoperative week. In a second experiment it is shown that there appears to be a linear relationship between the reduction in skin blood flow in a random-pattern flap and the distance from the base at which the measurements are made.

It is suggested that these data support the view that the blood flow in a skin flap recovers primarily from its base rather than via peripheral neovascularization, and that this is due to vascular collaterals opening within the flap rather than to a relaxation of sympathetic tone.
Episodic Postoperative Oxygen Desaturation: The Value of Added Oxygen
Authors: Jones J G , Jordan C , Scudder C , Rocke D A , Barrowcliffe M
Published: January 2017

Six patients were studied following general anaesthesia for cholecystectomy or hip replacement. Intravenous morphine was given for postoperative pain relief. Continuous measurements were made of breathing pattern and arterial oxygen saturation for a 12-hour period postoperatively. The effect of breathing either air or 28% oxygen for alternate 2-hour periods was examined. There was no significant effect of oxygen on the number of periods of central apnoea, obstructive apnoea or partial upper airways obstruction. The number of episodes of decreases in oxygen saturation to below 80%, associated with these breathing disturbances, was reduced from 59 to zero by the administration of oxygen. There was a gradual improvement in oxygenation whilst breathing air during the 12-hour postoperative period. The administration of oxygen had a beneficial effect on average arterial oxygen saturation.
Trace Metal Abnormalities in Long-Stay Hyperactive Mentally Handicapped Children and Agitated Senile Dements
Authors: Barlow P J , Francois P E , Goldberg I J L , Richardson I , Izmeth M G A , Kumpeson K , Sykes P
Published: January 2017

Gross metal poisoning as a causative factor in mental handicap is now relatively rare although historically it was important. Currently attention is being focused on the importance of chronic metal poisoning, there being much debate on, for instance, the possible effects of low levels of lead on intelligence in childhood. This paper examines the levels of a number of metals, both toxic and essential, in two groups of agitated patients in a long-stay psychiatric hospital in the UK. The two groups examined comprise ‘hyperactive’ mentally handicapped children and senile dementia patients, all of whom showed moderate to severe agitation. Blood and hair tissue were used to assess the body status of a number of metals and the results were compared with controls matched as closely as possible and from a similar hospital environment. The most significant findings are the raised levels of aluminium in the agitated senile dementia patients and the low levels of zinc and raised levels of lead in the hyperactive children.
Indications for and Results of Operation in Inflammatory Bowel Disease
Authors: Schofield P F , Manson J M
Published: January 2017

Of 363 patients with inflammatory bowel disease presenting between 1972 and 1983, 166 required definitive operation. A classification by histological type distinguishes Crohn's disease (CD) from ulcerative colitis (UC) and indeterminate inflammatory bowel disease. CD is divided into predominantly ileal disease (81), total or subtotal colonic disease (74) and distal disease (22), whilst UC is classified into colonic (95) or distal disease (63).

Most patients with ileal disease required operation for chronic persistent symptoms. In patients with total colonic involvement a greater proportion of patients with CD than those with UC came to surgery. Very few patients with distal disease required surgery. After resection for ileal disease there was a low incidence of anastomotic leakage (3%) and no operative mortality. There was an overall operative mortality of 8% after colonic resection. This was much lower in the non-urgent cases but rose to 12% in urgent cases.
Sri Lankan Cleft Lip and Palate Project: A Preliminary Report
Authors: Lambadusuriya S P , Mars M , Ward C M
Published: January 2017

By means of a surgical expedition involving an independently financed team of surgeons, anaesthetists, nurses, orthodontists and speech therapists, 195 patients in Sri Lanka with cleft lip and palate were treated over a period of 4 weeks while over 300 patients were examined in detail to assess faciomaxillary growth, components of speech and the psychosocial impact of the untreated deformity in childhood and adult life. Lip surgery proved to be simple and safe but in certain older patients palatal closure was complicated by wide palatal shelf displacement, mucosal fibrosis and heavy bleeding. This is a preliminary report and much data has yet to be analysed but there is little doubt that impaired facial growth following palatal repair is predominantly an iatrogenic deformity.
The Irritable Bowel: A Pathological or a Psychological Syndrome?
Authors: Waxman D
Published: January 2017

The irritable bowel syndrome is discussed together with some of its theories, methods of investigation and various treatment regimens. Eight case histories are reported. In each patient, symptoms appeared to be precipitated by situations interpreted by that patient as stressful. A programme of prospective desensitization using hypnosis is described. Where symptoms of depression were additionally present, antidepressant medication was prescribed. This was subsequently phased out as and when indicated. Where patients had been taking antidiarrhoeal or antispasmodic drugs, various stool bulking agents or benzodiazepines, these were also slowly discontinued as treatment progressed. Cases were followed up from 3 months to 12 years. In 2 cases recurrence of symptoms was again successfully treated. There was no recurrence of any of the bowel symptoms in any other patient. The results support the view that the irritable bowel syndrome is psychogenic in origin.
Responses of School Psychologists* in Two Contrasting Socio-Cultural Contexts (France and Great Britain) to Integration of Handicapped Pupils in the Ordinary School Setting
Authors: Aubrey Carol
Published: January 2017

The aim of the study was to examine published professional communications by psychologists in France and Great Britain on a topical issue — integration — during the year of 1983, as a reflection and comparison of present status, practice and current ideologies. British psychologists, secure in their central legal involvement in the assessment procedures of the new 1981 Education Act, did not raise integration of handicapped children in the ordinary school as an issue. A theme running through their literature was the issue of integrating assessment/intervention-type procedures of applied behavioural models with the legal requirements of assessment/classification of children with special needs. Much concern was expressed by French psychologists, in relation to the two integration Circulars of January 1982 and January 1983. They saw the Circulars affecting directly the conceptual framework within which they worked, the development of individual skills and their more precarious career prospects. Criticism was made of the lack of definition of handicap, reducing the child to a single scholastic dimension, and thus confusing psychology with pedagogy.
Fetal Alcohol Syndrome
Authors: Ugent Warren D. , Graf Mercedes Herrera , Ugent Anita S.
Published: January 2017

Fetal alcohol syndrome (FAS), a recently discovered pattern of physical, cognitive, developmental and behavioural abnormalities, occurs in some offspring of women who consume alcohol heavily during pregnancy. This paper explores the implications of FAS and lesser fetal alcohol effects. Issues of international incidence, characteristics, identification and treatment, along with their relevance for the school psychologist, are discussed.
Use of Classroom Environment Assessments in School Psychology
Authors: Fraser Barry J.
Published: January 2017

It is desirable today that school psychologists, in addition to being concerned with student achievement, give consideration to important psychosocial aspects of classroom environments. This paper makes several economical hand-scorable classroom environment instruments readily accessible to school psychologists and provides an overview of numerous past uses of these instruments including studies of the effects of classroom environment on student outcomes, use of environment variables as process criteria in evaluating educational innovations and teachers' practical attempts to use learning environment assessments to guide improvements in classrooms. Some applications of classroom environment assessments in school psychology are considered.
Children's Planning in Writing: Development and Instruction
Authors: Dudink Ad , Hoeks Jan , Wouters Luuk
Published: January 2017

This study was designed to assess a model of the development of planning in writing skills. We also attempted to teach children (nine and twelve years old) how to plan before writing a composition. The model proved to be replicable, but the effects of training on planning could not be attained. We concluded that planning, so fundamental for adequate school behaviour, develops only through many years of practice. Short-term training can hardly elicit the reflective behaviour necessary for planning activities. Further we discuss the pitfalls of the training and suggest possible improvements.
Effects of Interleukin-1α and Cyclosporin A in vivo and in vitro on Bone and Lymphoid Tissues in Mice
Authors: Mccauley Laurie K. , Rosol Thomas J. , Stromberg Paul C. , Capen Charles C.
Published: January 2017

The purpose of this study was to investigate the effects of interleukin-1α (IL-1α) infusion and the ability of cyclosporin A (CYA) to alter IL-1α-induced effects on bone in vivo and in vitro and lymphoid organs in vivo. Mice were administered: IL-1α (2,4, or 6 days), CYA (6 days), or IL-1α and CYA (6 days). Hypercalcemia was induced in mice treated with IL-1α compared to controls and CYA treated mice, and decreased urinary calcium excretion was present in IL-1α and CYA groups. Osteoclastic bone resorption was increased with a resultant loss of total bone area and bone formation (as measured by mineral apposition rate) was decreased in mice infused with IL-1α. Although CYA-treatment increased bone formation as compared to IL-1α-treatment; CYA in combination with IL-1α did not alter the reduction in mineral apposition rate caused by IL-1α. IL-1α also stimulated bone resorption in vitro which was significantly inhibited by cyclosporin A. IL-1α-induced splenic granulopoiesis, peripheral blood neutrophilia, thymic atrophy, and lymphoid hyperplasia in lymph nodes. CYA-treatment resulted histologically in a severe depletion of lymphocytes in the thymus, a moderate depletion of lymphocytes in lymph nodes but no difference in the histology of the spleen compared to controls. In summary, interleukin-1α was effective in stimulating hypercalcemia and bone resorption both in vivo and in vitro but cyclosporin A was effective in inhibiting IL-1α -mediated bone resorption only in vitro. IL-1α also had marked effects on spleen, thymus, and circulating blood cells; however, most parameters were not affected by the concurrent administration of cyclosporin A.
Unauthorised migration beyond structure/agency? Acts, interventions, effects
Authors: Squire Vicki
Published: January 2017

What are the most appropriate conceptual tools by which to develop an analysis of ‘unauthorised migration’? Is ‘migrant agency’ an effective critical concept in the context of a so-called European migration ‘crisis’? This article reflects on these questions through a detailed exploration of the ‘structure/agency debate’. It suggests the need for caution in engaging such a conceptual frame in analysing the politics of unauthorised migration. Despite the sophistication of many relational accounts of structure-agency, the grounding of this framework in questions of intentionality risks reproducing assumptions about subjects whose decision to migrate is more or less free from constraint. The article argues that such assumptions are analytically problematic because they involve a simplification of processes of subjectivity formation. Moreover, it also argues that they are normatively and politically problematic in the context of debates around unauthorised migration because discussions of structure/agency can easily slip into the legitimisation of wider assumptions about the culpability and/or victimhood of people on the move. Drawing on Michel Foucault’s theorisation of subjectification, the article proposes an alternative analytics of acts, interventions, and effects by which to address the politics of unauthorised migration in the midst of a so-called ‘migration crisis’.
Treatment of Varicose Long Saphenous Veins with Sclerosant in Microfoam Form: Long-Term Outcomes
Authors: Cabrera J. , Cabrera J. , Garcí-Olmedo A.
Published: January 2017

Objective:

To determine whether the injection of sclerosant in microfoam form offers a clear alternative to surgery in large varices of the lower extremities.

Design:

Retrospective observational follow-up study (3–6 years).

Patients:

Five hundred lower limbs in which pretreatment duplex ultrasound demonstrated insufficiency of sapheno-femoral junctions (diameters 9–32 mm) and long saphenous veins.

Main outcome measure:

Obliteration and subsequent disappearance of treated veins.

Results:

After ≥ 3 years follow-up, 81% of treated varicose long saphenous veins were obliterated and 96.5% of superficial branches disappeared. The obliteration of saphenous veins required one injection in 86%, two in 10.5% and three in 3.5% of cases. There were no serious complications such as deep vein thrombosis Pulmonary embolism.

Conclusion:

The quality and stability of outcomes and ease of repeat treatments when required may make sclerotherapy with microfoam a therapeutic approach of choice for the functional and anatomical elimination of extensive pathological venous areas.
Lower Limb Deep Venous Incompetence is Rare in Patients Undergoing Obesity Surgery
Authors: Westling A. , Boström A. , Gustavsson S. , Karacagil S. , Bergqvist D.
Published: January 2017

Objective:

To investigate the incidence of lower limb venous insufficiency in morbidly obese patients.

Patients and methods:

The study group comprised 125 patients (109 women, 16 men). The median (range) age and body mass index were 35 (19–59) years and 42 (32–68) kg/m2 respectively. Eleven patients had clinical signs of varicose veins or had previously undergone varicose vein surgery. Patients were investigated with duplex ultrasound scanning on the day before surgery. Iliac, femoral, popliteal, and long and short saphenous veins in both legs were studied.

Results:

A total of 33 patients had abnormal reflux in the superficial veins (>0.5 s). In the deep veins 2 patients had valvular incompetence in the common femoral vein with reflux times of 2 and 0.7 s respectively. At reinvestigation 18 and 24 months after surgery the reflux times were normalised.

Conclusion:

In this study the incidence of deep venous incompetence in the lower limb in morbidly obese patients is low.
Lack of Tourniquet Effect of Below-Knee Stockings
Authors: Chauveau M. , Vin F. , Houot B.
Published: January 2017

Objective:

To determine whether below-knee compression stockings impede venous return by a tourniquet effect.

Design:

Randomised, cross-over clinical trial.

Patients:

Ten outpatient women suffering from mild or moderate primary varicose veins without skin trophic disorder.

Methods:

Air plethysmography with venous occlusion (50 mmHg) was used to measure arterial inflow (AI), venous volume (V50) and maximum venous outflow (MVO), without stockings and when wearing French class 1 (10-15 mmHg) and class 2 (15-20 mmHg) below-knee stockings.

Results:

No carry over due to the cross-over design was detected. There was no significant variation in MVO induced by class 1 (44 vs 45 ml/s) or class 2 (42 vs 41 ml/s) stockings. AI decreased significantly with class 2 (0.93 vs 1.22 ml/s, /? = 0.012) but not with class 1 (1.22 vs 1.20 ml/s) stockings. V50 did not change with class 1 (97 vs 95 ml) but decreased with class 2 (80 vs 98 ml, p = 0.031) stockings.

Conclusion:

No tourniquet effect of class 1 and class 2 below-knee stockings was observed. Venous capacity and arterial inflow were reduced by class 2 stockings.
A New Method for Lower Limb Volume Measurement — Laser Plethysmography: Comparison with Two Commonly Used Methods
Authors: Stephan D. , Tavera C. , Raponsky J. , Moreau S. , Weltin D. , Duver S. , Jeanne J. F. , Ziani E. , Chauveau M.
Published: January 2017

Objective:

(1) To assess agreement between laser plethysmography (LPG) and mercury strain-gauge plethysmography (MSGP) measurement of calf volume variation. (2) To assess agreement between LPG and water volumetry measurement of calf volume.

Design:

Pilot study to evaluate a method of measuring absolute lower leg volume and volume changes in volunteers; randomisation of the leg measured and of the order of measurement, evaluation of between-method correlation and limits of agreement.

Setting:

Hôpital Civil, Strasbourg.

Participants:

Seventeen healthy volunteers.

Main outcome measures:

Measurement of relative volume change by MSGP and LPG before and after venous occlusion by means of a thigh cuff inflated to 20 mmHg (zlV20) and 60 mmHg (/dV60); absolute volume of a 20 cm segment of lower limb measured by differential water plethysmography (two different volume water boots) and by LPG.

Results:

Comparison of LPG with MSGP led to fairly good correlation coefficients (r = 0.89 and r = 0.91 for δV20 and δV60, respectively) but also to an important dispersion of between-method differences (wide limits of agreement). There was a high degree of agreement between LPG and water volumetry: the correlation coefficient was 0.99 and limits of agreement were [− 6.7% 0.8%] but a significant bias was seen.

Conclusions:

Laser plethysmography is a new method for measurement of lower limb volume. When tested on inert material, very good accuracy and reproducibility were obtained. Comparison with water volumetry gave good agreement. Evaluation of reproducibility on healthy volunteers is required for complete validation of the device.
The Haemodynamic Efficacy of Six Different Compression Stockings from Compression Class 2 in Patients Suffering from Chronic Venous Insufficiency
Authors: Häfner H. M. , Jünger M.
Published: January 2017

Objective:

To describe the efficacy of six different compression stockings from compression class 2 on venous haemodynamics in patients with chronic venous insufficiency (CVI).

Design:

An open, randomised, prospective study.

Setting:

University Department of Dermatology, Tübigen, Germany.

Patients:

Twenty-two patients (11 women, 11 men; mean age 55.1 years, SD 10.3 years) suffering from chronic venous insufficiency (CVI) at clinical stages C14EpAs, A14, Ap, PR.

Interventions:

The acute effect of six different compresion stockings from compression class 2 (CEN) on venous haemodynamics were measured using dynamic mercury strain gauge plethysmography. At the same time as venous function, the pressure exerted by the compression hosiery was determined under resting conditions and during exercise.

Main outcome measures:

Resting pressure exerted in the supine position was equivalent in all compression hosiery to the data defined in textile technology for compression class 2 (25–35 mmHg at the ankle). Compression hosiery produced a statistically significant improvement in venous refilling time t 0. The differing improvement in venous function could be explained by the quotient for maximum active pressure/resting pressure on standing (r = 0.98, p <0.01).

Conclusion:

Compression stockings from the same compression class possess differing acute effects on venous haemodynamics. The efficacy of the various compression devices derives to an exceptional degree from the elasticity of the material, and can be characterised in vivo by the ratio between maximum pressure exerted during exercise and the resting pressure on standing.
What is New in Venous Surgery
Authors: Braithwaite B. D.
Published: January 2017

The aim of this article is to discuss recent developments in the management of venous disease. A literature search was done of English language journals from 1995 to 2000 to identify articles that discussed new innovations. In addition, the proceedings of specialist meetings were reviewed to include opinions of experts leading the field of venous practice. The article discusses the use of non-invasive investigations, thermal ablation of varicose veins, the economics of superficial and deep venous disease and the possible changes that might occur in the future management of patients with venous disease.
Health-Related Quality of Life in Patients with Venous Ulceration
Authors: Howard A. , Davies A. H.
Published: January 2017

Aim:

To review the role of Health Related Quality of Life (HRQL) assessments in the management of patients with venous ulceration.

Method:

A search of electronic databases and reference lists delivered numerous articles containing a variety of HRQL assessments for venous ulcer treatment.

Synthesis:

The salient points from the literature were collaborated in order to establish which outcome measures best reflect the quality of care delivered. The treatment of chronic venous leg ulceration is often prolonged and a permanent cure is frequently unattainable. An improvement in a patient's condition needs to be demonstrated in order to determine the benefit of a surgical treatment. The assessment of HRQL is increasingly recognised as a valuable surgical outcome measurement.

Conclusion:

The combination of ‘standard’ clinical outcome measures, the generic SF-36 and a specific ‘venous ulcer’ HRQL questionnaire can produce a more complete treatment outcome assessment in patients with venous ulceration.
Towards a Model of Care for Chronic Leg Ulcer: Lessons Learned from Studies in Scotland
Authors: Ruckley C. V.
Published: January 2017

Aim:

To highlight the need for a different model of care delivery for chronic leg ulcer.

Method:

Analysis of data from the Scottish Leg Ulcer Trial and from surveys of leg ulcer care provision among General Practitioners, community nurses and health boards.

Synthesis:

General Practitioners and community nurses report serious deficiencies in education, training, protocols, equipment and support from the Acute sector. The Scottish Leg Ulcer Trial in a population of 2.65 million showed three-month healing rates of 30% with no improvement after dissemination of National (SIGN) Guidelines even when supplemented by a nationwide nurse training programme. Individual community nurses cared for an average of 1.5 ulcer patients per year. The more chronic the ulcer the poorer the healing rates. Only 17% of Scottish Teaching hospitals or District General hospitals provide a specialist led leg ulcer service.

Conclusions:

In the population at large, healing rates for leg ulcer are unacceptably low. Individual community nurses do not see enough leg ulcer patients to acquire or sustain the necessary clinical skills. Very few acute hospitals provide leg ulcer services. A new model of leg ulcer care is urgently required centred on multi-disciplinary teams, working in the interface between primary and secondary care, whose prime objectives should be prevention and early intervention. As an
The Appearance of Cytokines and Adhesion Molecules in Saphenous Vein Valves in Chronic Venous Insufficiency
Authors: Satokawa H. , Hoshino S. , Igari T. , Iwaya F. , Midorikawa H.
Published: January 2017

Objective:

To evaluate the difference between competent valves and incompetent valves with regards to the development of expression of cytokines and adhesion molecules in primary varicose veins.

Methods:

Specimens were obtained from 13 patients with primary varicose veins during surgery. Valves were classified according to the angioscopic findings: 8 competent and 17 incompetent valves; type I (7 valves with elongated cusps) and type II (10 valves with expansion of commissures). The mRNA levels of interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8), tumour necrosis factor-α (TNF-α), transforming growth factor-β (TGF-β), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and endothelial leucocyte adhesion molecule-1 (ELAM-1) were measured by polymerase chain reaction (PCR) amplification of cDNA reverse-transcribed from RNAs.

Results:

In all cases there were few appearances of IL-6, IL-8 and TNF-α at the valve cusps. TGF-β and VCAM-1 levels were highly elevated in the cusps of incompetent valves compared with competent valves ( p<0.05). At the venous wall IL-6 and IL-8 occurred more frequently in incompetent valves than in competent valves ( p<0.05).

Conclusion:

This study suggests that inflammatory cytokines and adhesions molecules, especially TGF-β, IL-6, IL-8 and VCAM-1, may be related to the occurrence of valve insufficiency.
Echo-Anatomy of Long Saphenous Vein in the Knee Region: Proposal for a Classification in Five Anatomical Patterns
Authors: Ricci S. , Cavezzi A.
Published: January 2017

Objective:

Ultrasonography of the anatomical course of the long saphenous vein (LSV) and its tributaries to produce and verify an anatomical classification (five types).

Methods:

Four hundred and ninety-three limbs (293 healthy; 200 with varicose veins, VV) were investigated by ultrasonic duplex imaging by the two authors independently, identifying the LSV as the vessel in the (ultrasonic) saphenous fascial ‘eye’ compartment (SFEC), in the thigh, and within two fascial layers between tibia and medial gastrocnemius muscle, below the knee.

Results:

Type A: LSV runs entirely in the SFEC without relevant tributaries: overall (O) 112 (23%), limbs with vv (V) 13, normal limbs (N) 99. Type B: LSV runs in the SFEC with one or more relevant tributaries below the knee: O 133 (27%), V 70, N 63. Type C: LSV runs in the SFEC with a relevant tributary above the knee: O 89 (18%), V 28, N 61. Type D: LSV runs in the SFEC from the foot upwards, continuing at the middle third of the leg in a large side vein with the calibre and role of the LSV but in a more superficial location. LSV stem is absent (or hypoplasic) in the para-tibial position. At the thigh level the tributary re-enters the true LSV: O 72 (14.5%), V 42, N 30. type E: similar to type D but the LSV is absent only at the knee level: O 72 (14.5%), V 38, N 34. Unclassified: O 15 (3%), V 9, N 6.

Conclusions:

We found a good reproducibility and clinical utility of the suggested classification. Remarks: (a) the absence (or hypoplasia) of LSV at the knee level with prevalence of a tributary in almost 30% of the limbs is of importance for arterial bypass and saphenous sparing management; (b) there is a low rate of LSV complete incompetence (6%); (c) there is a correlation between absent LSV (or presence of a relevant tributary) and the incidence of VV.
Primary Cutaneous Granulomatous Phlebitis of the External Jugular Vein
Authors: Shetty S. , Gupta S. , Makhija P. , Hasan S.
Published: January 2017

Design:

Case report.

Setting:

Department of Otolaryngology and Head and Neck Surgery, St. John's Medical College Hospital, India.

Patient:

A 22-year-old man with a cord-like neck mass of 6 months' duration.

Investigations and intervention:

Investigations included Doppler ultrasound of the neck, which showed thrombosis of the right external jugular vein. Wedge biopsy revealed a granulomatous inflammation with focal necrosis completely replacing the vessel. Serological testing for vasculitides was negative. Transcervical excision of the vein was carried out after identifying normal vessel distally and proximally. Histopathological examination of the vein proved the lesion consistent with primary cutaneous granulomatous phlebitis (PCGP).

Conclusion:

Isolated venous inflammatory diseases with neither identifiable active vasculitis nor arteritis are rarely seen. PCGP is distinctly unusual. We report a case of PCGP of the external jugular vein presenting as an elongated cord-like nodular lesion in the lateral neck of insidious onset.
Neovascularization in Restoration of Continuity of the Rat Femoral Vein following Surgical Interruption
Authors: Glass G.M.
Published: January 2017

Recurrence of varicose veins after surgical treatment by ligation and transection has been usually attributed to development of varicosity in veins collateral to the transected vessels. Early studies reported regeneration of the great saphenous vein at the site of previous transection. The present study in the rat was undertaken to determine whether restoration of normal venous circulation in a limb after surgical interruption of the main vein develops through enlargement of collateral veins or by restoration of continuity of the interrupted vein as a result of neovascularization at the site of ligation. Following ligation in continuity or ligation and surgical transection of the rat common iliac or femoral vein, phlebographic, surgical exploratory and histological studies showed restoration of its continuity through newly formed vessels. These findings suggest that in recurrence of varicose veins the roles of neovascularization and of collateral veins deserve further investigation.
Optimum Methods of Limb Compression following Varicose Vein Surgery
Authors: Smith P.D. Coleridge , Scurr J.H. , Robinson K.P.
Published: January 2017

It has been shown that bandages rapidly lose their ability to compress the leg in ambulant patients. However, they are still widely used following varicose vein surgery. We have measured the compression produced by crepe bandages, elastocrepe bandages or graduated high compression stockings following varicose vein surgery. Pressures exerted by the bandages and stockings were measured during the first 24 h following operation. Initially the bandages exerted greater pressures than the stockings. However, the bandaging techniques lost 13-38% of their compression in the first hour and 29–48% in 24 h compared with 3-5% for the compression stocking. Further testing of the bandages on a standard wooden leg and a commercial fabric testing machine confirmed that the loss of compression in the bandaged groups was due to the poor elastic qualities of crepe and elastocrepe bandages. The stockings provided a more constant compression with maintained graduation compared with the bandages.
Varicose Veins and Arteriovenous Shunts: A Review
Authors: Scott H. J.
Published: January 2017

The pathogenesis of the development of varicose veins remains obscure, and there have been many theories suggesting the primary cause. Recognized predisposing factors include age, sex, race, weight, height, pregnancy, diet, erect stance, clothes, alcohol, heredity, bowel habit and occupation. However the primary causative factors have centred around vein wall weaknesses, valvular deficiencies, and haemodynamic effects. This review looks at the evidence for and against arteriovenous anastomoses being the initiating factor in the development of varicose veins.
Evaluation of Psathakis' Silastic Sling Procedure for Deep Vein Reflux: A Preliminary Report
Authors: McMullin G. M. , Smith P. D. Coleridge , Scurr J. H.
Published: January 2017

The ‘silastic sling’ procedure described by Psathakis for the treatment of deep vein reflux was performed on 12 patients. All had severe symptoms of chronic venous insufficiency which had not been controlled by compression therapy or previous superficial vein surgery. Duplex scanning, photoplethysmography and ambulatory venous pressure measurements were performed preoperatively and at 3-monthly intervals postoperatively. There was one death from massive pulmonary embolism. No other complication was recorded. Follow-up ranged from 6 to 18 months. There has been clinical improvement in eight cases with complete healing of ulcers in six. Two cases have shown an improvement in ambulatory venous pressure measurements, but the refilling times, measured by photoplethysmography, are unchanged in all cases. Duplex scanning postoperatively has shown that the popliteal vein remains patent.
Ultrasonic Diagnosis of Iliofemoral Venous Thrombosis: Merits and Disadvantages
Authors: Leven Hans O. , Al-Hassan Haitham
Published: January 2017

Twenty-nine patients with clinical suspicion of iliofemoral venous thrombosis were investigated by duplex-Doppler ultrasound and phlebography. Twenty-two of the patients were proven to have thrombosis in one of the lower limbs by both duplex-Doppler ultrasound and phlebology. Of these, 19 patients had iliofemoral thrombosis. The upper end of the thrombus could be demonstrated with ultrasound in only two patients. It is concluded that duplex-Doppler ultrasound is very reliable for the diagnosis of the thrombotic condition but that for proper determination of the upper end of an iliofemoral thrombosis phlebography is still needed, especially if operative treatment is contemplated.
The Treatment of Venous Ulceration by Surgery and Elastic Compression Hosiery; A Long-Term Review
Authors: Holme T. C. , Negus D.
Published: January 2017

Seventy-six patients with venous ulceration of 108 legs were treated by the ligation of incompetent calf perforating veins, with saphenous ligation and stripping where necessary and with the addition of knee length elastic compression stockings for those with deep venous reflux. Review at a mean 6 years after treatment has shown that 74% remain healed and there is no significant difference between those with and without deep vein incompetence. Where patients with rheumatoid arthritis and/or arterial insufficiency were excluded, 84% remain healed.
Surgical Enhancement of Skin Oxygenation in Patients with Venous Lipodermatosclerosis
Authors: Travers James P. , Berridge David C. , Makin Geoffrey S.
Published: January 2017

Lipodermatosclerosis and venous ulceration may result from ***long-standing venous hypertension. Furthermore, venous ulceration is associated with reduced transcutaneous oxygen tension, (Tc Po2).

This study investigates the effect of surgical removal of varicose veins upon skin oxygenation postoperatively, thereby influencing any subsequent venous ulceration.

Patients with unilateral long saphenous vein incompetence, were studied consisting of 10 males and nine females, (mean overall age = 50 ± 3 years). Tc Po2 measurements at rest and using 100% oxygen stress testing were performed 24 h preoperatively under standard test conditions, with the contralateral limb serving as control.

Patients with lipodermatosclerosis were confirmed to have an oxygen diffusion block preoperatively in the affected limb, ( P = 0.02). Surgical correction of venous hypertension produced significant improvement in oxygen diffusion after stress testing ( P = 0.003) compared to control limbs or patients with uncomplicated varicose veins.

Surgical correction of incompetent varicose veins in patients with lipodermatosclerosis resulted in the improvement of Tc Po2 which may delay or prevent subsequent venous ulceration.
The Treatment of Long-Standing Venous Ulcers with an Extract of Early Placenta – a Pilot Study
Authors: Beaconsfield Tina , Genbačev Olga , Taylor R.S.
Published: January 2017

The human placenta and its membranes have been used intermittently as wound dressings for more than 70 years. Term placenta is known to contain a number of growth factors essential to the healing process. The intense physiological activity of early placenta suggested that it should have similar attributes and we tested this hypothesis on one of the most refractory of all wounds – ulcers caused by chronic venous insufficiency.

The cytosol fraction of 6–8 week placenta was incorporated under sterile conditions into an inactive cream vehicle and applied daily to the ulcer. The preparation and quality control of this extract are described.

Eighteen patients were treated in this pilot study. The chronicity of the ulcers varied from 12 weeks to 30 years, and all had previously received conventional therapy. Ten patients with bilateral ulcers had treatment with the test preparation on one side only thereby serving as their own controls. Granulation tissue appeared between the 7th and 17th day after starting treatment, and epithelialization began within 2 weeks thereafter. The preparation produced complete healing in all cases and took 12 to 24 weeks, depending on ulcer size. None of the untreated ulcers were closed at the end of the trial. No breakdown has been seen so far on follow-up.

The healing effect suggests that trophoblast might supply the missing factor(s) normally operative in surgical wounds and uninfected traumatic wounds.
Venous Valves and Tributary Veins
Authors: Van Cleef J. F. , Griton Ph. , Cloarec M. , Ribreau C. , Lemaire R.
Published: January 2017

Our work on the four-stroke dynamic model of the muscular pump of the calf and our video films on venous ambulatory endoscopy allow us to set forth the following concept: there are always one or more openings of tributary veins close to a venous valve.

A vein has a preferential axis of flattening, and its cross-sectional configuration can be defined as: an internal wall, an external wall, two borders and two extremities. The bicuspid valves' cornua are situated on the borders of the vein. Close to the valves we distinguish the commissural tributaries on the vein's borders from the sinusal tributaries on the internal or external walls of the vein.

This configuration has consequences on the local dynamics of the blood; the valve by its protusion into the vein lumen alters the blood flow.
Surgical Treatment of Iliofemoral Vein Thrombosis in Pregnancy
Authors: Rabl H. , Fruhwirth H. , Gutschi S. , Pascher O. , Koch G.
Published: January 2017

The incidence of deep leg vein thrombosis in pregnancy is estimated at 0.13 per 1000 to 1.4 per 100.1−3 One-third occur as isolated, descending iliofemoral vein thromboses, predominantly left-sided. We report our surgical experiences in venous thrombectomy with arteriovenous fistula (AV-fistula) in the groin between the superficial femoral artery and femoral vein in 29 gravidae with a mean age of 27.5 years (range 19–41 years). Thrombosis occurred between the 20th and 36th week of pregnancy. 25 were antepartum two postpartum and two postsectionem. An iliac spur was seen once, as was an AT III deficiency. At the beginning of our series AV-fistula was not performed in three patients who all suffered from re-thrombosis after 24 h. Re-thrombectomy with an AV-fistula was performed successfully. Three of the 26 gravidae with AV-fistula also developed re-thrombosis. In two patients re-thrombectomy was successful, in the third patient the common iliac vein could not be re-opened by thrombectomy and the functioning AF-fistula had been ligated because extensive vulval oedema had developed. Asymptomatic, late re-thrombosis occurred in two patients who were seen at outpatient follow-up. We have seen one mild, non-life-threatening pulmonary embolism on the first postoperative day. No further intraoperative nor postoperative or postpartum complications developed. The re-occlusion rate is 10.3% (3/29), the complication rate is 6.9% (2/29).
Leiomyosarcomata of the Inferior Vena Cava and Large Veins
Authors: Reyes R. J. , Fletcher C. D. M. , Burnand K. G. , Browse N. L.
Published: January 2017

Leiomyosarcomata arising in large veins are rare tumours. The preoperative diagnosis is often difficult and, if they are only discovered at an advanced stage, the prognosis is poor. We describe four patients with these tumours. Two have died of their disease and two remain free of disease 2 and 5 years after radical surgical excision.
Lothian and Forth Valley Leg Ulcer Healing Trial, Part 2: Knitted Viscose Dressing versus a Hydrocellular Dressing in the Treatment of Chronic Leg Ulceration
Authors: Callam M. J. , Harper D. R. , Dale J. J. , Brown D. , Gibson B. , Prescott R. J. , Ruckley C. V.
Published: January 2017

Objective:

To compare a new ‘advanced’ hydrocellular Polyurethane dressing (HPD) (Allevyn) with a traditional simple non-adherent knitted viscose dressing (KDV) (Tricotex) in the treatment of chronic venous leg ulcers.

Design:

A randomized trial of factorial design, with interaction testing, to allow the evaluation of two different therapeutic components (dressing and bandages) within a single trial. The treatment period was 12 weeks or until healing, whichever occurred sooner.

Setting:

The Leg Ulcer Clinics of Edinburgh and Falkirk and District Royal Infirmaries, Scotland.

Patients:

132 patients with chronic venous leg ulcers were randomized, 66 to HPD and 66 to KVD. Principal exclusions were patients with diabetes, rheumatoid disease or Doppler ankle/brachial pressure indices of less than 0.8. There were 28 withdrawals (15 KVD, 13 HPD). These were considered as treatment failures.

Interventions:

Dressings and bandaging were applied by specialist leg ulcer nurses using standard techniques throughout, the bandaging being randomized to either elastic or non-elastic multilayer systems.

Main outcome measure:

The principal end-point was ulcer healing. Also monitored were healing rates, pain and the frequency of dressing changes.

Results:

Pain relief was significantly better in the HPD group ( p=0.01). Thirty-one (47%) of the HPD patients healed within 12 weeks compared with only 23 (35%) of the those treated with KVD (95% confidence limits for difference, −5% to +29%). The higest healing rates (61% for all ulcers and 74% for those less than 10 cm2) were observed in the subgroup in which HPD was used in combination with an elastic bandaging system.

Conclusion:

Patients treated with HPD did significantly better in terms of pain relief, although the higher healing rates observed in this group failed to reach significance at the 5% level.
Hydrotherapy for Varicose Veins: A Randomized, Controlled Trial
Authors: Ernst E. , Saradeth T. , Resch K. L.
Published: January 2017

Objective:

To assess the effectiveness of regular hydrotherapy in primary varicose veins.

Design:

Randomized, single blind, prospective, controlled trial.

Setting:

Social security system related rehabilitation center for employees (nationwide assignment of inpatients).

Patients:

122 patients with primary varicose veins.

Interventions:

Group A (n=60) received daily treatments during 24 days that consisted of external application of alternating cold and warm water to both lower extremities. Group B (n=62) served as controls and was not treated with hydrotherapy. Both groups were comparable in terms of concomitant diseases and treatments.

Main outcome measures:

Foot volume, ankle circumference and venous re-fill time, using light reflex rheo-graphy, served as objective variables, while a number of typical symptoms were recorded as subjective parameters.

Results:

A more pronounced improvement in all objective signs in group A compared to B was observed. Four out of seven subjective symptoms improved more frequently in group A than in B.

Conclusions:

Hydrotherapy is effective in treating primary varicose veins. It can be considered as an adjunct measure to compression therapy and other conservative treatments.
Popliteal Valvular Construction Using a Silastic Sling (Technique II) for Deep Venous Insufficiency of the Lower Limb
Authors: Psathakis D. , Psathakis N.
Published: January 2017

Objective:

To establish the safety and efficacy of a silastic sling procedure for reconstructing popliteal vein.

Design:

Prospective survey of patients undergoing surgical treatment for popliteal vein reflux.

Setting:

Department of Surgery, County Hospital, Bad Karlshafen, Germany.

Patients:

209 patients undergoing surgery for popliteal vein incompetence.

Interventions:

Silastic sling procedure (Technique II) for correction of popliteal vein incompetence.

Main outcome measures:

Continuous wave Doppler ultrasound examination of popliteal vein, ambulatory foot vein pressure measurements, lower limb venography.

Results:

One week following surgery 202 patients (of 209) reported relief of pain and reduction of limb oedema. 77 patients with ulcers (of 85) healed following the surgical procedure. Ambulatory venous pressure improved from 71 SD 11 mmHg to 36 SD 17 mmHg. There was prolongation of the venous refilling time from 9 SD 5 seconds to 27 SD 17 seconds. Postoperative phlebography in 92 patients was performed on the tenth post-operative day and in no patient was deep vein thrombosis observed. In 82 of these patients phlebography demonstrated that the constructed popliteal valve was patent.

Conclusions:

Construction of a popliteal valve using the author's silastic sling technique is a satisfactory method for managing patients with otherwise uncontrolled popliteal vein reflux due to either primary valvular failure or previous deep vein thrombosis.