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Whether patients with renal artery stenosis should undergo therapeutic revascularization is controversial. In this retrospective study, we evaluated prognostic intrarenal Doppler ultrasound parameters that might have a predictive value for a beneficial response after renal revascularization. From January 2003 until December 2012, all renovascular interventions for renal artery stenosis were analyzed. The resistive index and the maximal systolic acceleration were determined by Doppler ultrasonography prior to intervention. Thirty-two patients who underwent a renal revascularization procedure were included: 13 combined positive responders and 19 combined non-responders. The combined positive responders had a significant lower resistive index than the combined non-responders (0.5 vs. 0.6, P = 0.001) and a significant lower maximal systolic acceleration (1.0 vs. 3.8, P = 0.001) before revascularization. A prediction model (RI ≤ 0.5 and ACCmax ≤ 1.3 m/s2) was formulated to identify a subgroup that benefits from renal revascularization. This model has an expected sensitivity of 69% and specificity of 89% for improvement in renal function and/or blood pressure after revascularization. The non-invasive intrarenal Doppler ultrasound parameters resistive index and maximal systolic acceleration can be used as tools to predict improvement in renal function and/or blood pressure after revascularization of renal artery stenosis. The clinical value of this prediction model should be evaluated in a prospective trial. [ABSTRACT FROM AUTHOR]

Objectives: The accurate prediction of foot ulcer healing remains a major challenge in clinical practice. To date, no reliable bedside tests are available. The primary aim of this study was to determine the prognostic performance of the maximal systolic acceleration (ACC max ) to predict ulcer healing. Secondary objectives comprised the investigation of the prognostic accuracy in patients prone to medial arterial calcification, and to assess the potential risk of amputation., Methods: A single-centre retrospective cohort study was conducted. Patients ≥ 18 years-old who presented with a new-onset ulcer (i.e. Fontaine IV and neuropathic ulcers) on the foot and underwent an ACC max measurement at the hallux were included. Ulcer healing was defined as an intact skin with epithelialization after three or 12 months of follow-up. Prognostic performance was calculated by using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR) and negative likelihood ratio (NLR)., Results: In total, 136 patients with 143 wounds were included. Almost half of the patients were diagnosed with diabetes mellitus (47%) and wound infection was present in 42% of cases. After three months of follow-up, a NPV of 97.9%, PLR of 3.25 and NLR of 0.19 was found when applying an ACC max threshold of 0.5 m/s 2 . When looking at 12 months, these numbers were 85.6%, 2.72 and 0.50, respectively. Subgroup analysis for patients with diabetes mellitus and chronic kidney disease showed comparable results. The risk of amputation increased significantly when a measurement below 1.0 m/s 2 was present (odd ratio 5.3, p = 0.010)., Conclusions: ACC max measurements at the hallux can have additional prognostic value in patients with foot ulcers. An ACC max below 1.0 m/s 2 is associated with non-healing of an ulcer and a higher risk of amputation, while higher ACC max values are associated with limb salvage. Therefore, ACC max could be used for grading ischemia in a wound classification system., Competing Interests: Authors' Disclosure of Conflicts of Interests None., (Copyright © 2024. Published by Elsevier Inc.)

Background: Diagnosing peripheral arterial disease (PAD) can be challenging owing to medial arterial calcification (MAC) in patients with diabetes mellitus (DM) and chronic kidney disease (CKD). Current bedside tests, such as the ankle-brachial index and toe-brachial index, are often insufficient. The maximal systolic acceleration (ACC max ) is a velocimetric Doppler-derived parameter and could be a new promising test in the diagnostic workup of these patients. The primary aim of this study was to evaluate the diagnostic performance of the ACC max to detect PAD., Methods: A retrospective cohort study was performed in a tertiary referral hospital. Patients ≥18 years old with suspected PAD who underwent ACC max measurement(s) along with computed tomography angiography of the abdominal aorta and lower extremities (reference test) were eligible for inclusion. ACC max measurements of the posterior tibial artery, anterior tibial artery and peroneal artery were collected. Diagnostic performance was assessed by using sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and area under the curve (AUC)., Results: In total, 340 patients (618 limbs) were included. Approximately 40% suffered from DM and 30% had CKD. Diagnostic performance of the ACC max to detect PAD for the posterior tibial artery showed a sensitivity of 90%, specificity of 93%, positive likelihood ratio of 12.83, and negative likelihood ratio of 0.11 (AUC, 0.953). For the anterior tibial artery, these results were 94%, 97%, 32.06, and 0.06 (same sequence as presented before) with an AUC of 0.984. The peroneal artery had a performance of 86%, 89%, 7.51, and 0.16, respectively (AUC, 0.893). Diagnostic accuracy of the ACC max did not diminish in subgroup analysis for patients with DM or CKD., Conclusions: The ACC max showed excellent diagnostic performance to detect PAD, independent of patients prone to medial arterial calcification., Competing Interests: Disclosures None., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Medial arterial calcification (MAC), frequently associated with diabetes mellitus (DM) and chronic kidney disease (CKD), is a systemic vascular disorder leading to stiffness and incompressible arteries. These changes impede the accuracy of bedside tests to diagnose peripheral arterial disease (PAD). This review aimed to evaluate the reliability of bedside tests for the detection of PAD in patients prone to MAC., Methods: A systematic search (Pubmed, Embase, Web of Science, Cochrane, and Emcare) was performed according to the PRISMA guidelines to identify relevant studies providing data on the performance of bedside tests for the detection of PAD in patients prone to MAC. Studies were included when bedside test were compared to a reference standard. Primary endpoints were the positive and negative likelihood ratios (PLR, NLR). Methodological quality and risk of bias were evaluated using the QUADAS-2 tool., Findings: In total, 23 studies were included in this review. The most commonly evaluated test was the ankle-brachial index (ABI), followed by toe-brachial index (TBI), toe pressure (TP) measurements, and continuous wave Doppler (CWD). The majority of patients were older, male, and had DM. We found that ABI <0·9 was helpful to diagnose PAD, but failed to rule out PAD (NLR >0·2). The same applied for TP (NLR >0·3) and TBI (5 out of 6 studies revealed an NLR >0·2). CWD (loss of triphasic pattern) is reliable to exclude PAD (NLR 0-0·09), but was only validated in two studies. Overall, methodological quality was poor which led to risk of bias in 20 studies., Interpretation: The diagnosis of PAD in patients prone to MAC remains challenging. The ABI performed reasonably in the diagnosis of PAD, while the CWD (loss of triphasic signal) can be used to rule out PAD. This systematic review showed that test performances were generally poor with serious concerns in methodological quality of the included studies. We therefore counsel against the use of a single bedside test., Funding: None to declare., Competing Interests: We declare no competing interests., (© 2022 The Author(s).)

Objective: Brucellosis is the most common zoonosis worldwide. Although cardiovascular complications in human brucellosis comprise only 3% of morbidity, they are the principal cause of death. Endocarditis covers the majority of these cases. Infected aneurysms and ulcerative processes of the aorta are rare but can be life threatening as well. Currently, limited information is available about aortic and iliac involvement in brucellosis., Methods: A PubMed, Web of Science, and AccessMedicine search (without restriction on language or year of publication) was performed to identify relevant articles on aortic and iliac involvement in brucellosis. Case reports were eligible for inclusion if they reported on thoracic, abdominal, or iliac aortic pathology caused by Brucella., Results: Seventy-one cases were identified over the last 70 years, with an overall mortality rate of 22%. Most of the patients were male (86%) and had a history of Brucella exposure (66%). Approximately one quarter (23%) contracted Brucella while travelling in a (hyper)endemic region. Almost half of the infections were located in the abdominal aorta (49%), followed by the ascending (37%) and descending (13%) thoracic aorta. Infected aneurysms (61%) and ulcerative processes (16%) were seen most frequently. Aortic rupture was present in 31% of cases and occurred mainly in the abdominal (49%) and descending thoracic aorta (44%). The majority of all patients (59%) underwent open surgery combined with long term antibiotics. Over the past 15 years, a trend towards endovascular treatment was observed., Conclusion: Although aortic and iliac involvement in brucellosis is rare, it can be a life threatening manifestation. Due to low awareness, this infection may represent an under reported disease. The therapeutic cornerstone in these cases remains open surgery combined with antibiotics. The role of endovascular treatment is yet to be decided, in which the condition of the patient and the risks of long term complications need to be considered., (Copyright © 2022 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: Doppler ultrasonography (DUS) is used as initial measurement to diagnose and classify carotid artery stenosis. Local distorting factors such as vascular calcification can influence the ability to obtain DUS measurements. The DUS derived maximal systolic acceleration (ACCmax) provides a different way to determine the degree of stenosis. While conventional DUS parameters are measured at the stenosis itself, ACCmax is measured distal to the internal carotid artery (ICA) stenosis. The value of ACCmax in ICA stenosis was investigated in this study., Material and Methods: All carotid artery DUS studies of a tertiary academic center were reviewed from October 2007 until December 2017. Every ICA was included once. The ACCmax was compared to conventional DUS parameters: ICA peak systolic velocity (PSV), and PSV ratio (ICA PSV/ CCA PSV). ROC-curve analysis was used to evaluate accuracy of ACCmax, ICA PSV and PSV ratio as compared to CT-angiography (CTA) derived stenosis measurement as reference test., Results: The study population consisted of 947 carotid arteries and was divided into 3 groups: <50% (710/947), 50-69% (109/947), and ≥70% (128/947). Between these groups ACCmax was significantly different. Strong correlations between ACCmax and ICA PSV (R 2 0.88) and PSV ratio (R 2 0.87) were found. In ROC subanalysis, the ACCmax had a sensitivity of 90% and a specificity of 89% to diagnose a ≥70% ICA stenosis, and a sensitivity of 82% and a specificity of 88% to diagnose a ≥50% ICA stenosis. For diagnosing a ≥50% ICA stenosis the area under the curve (AUC) of ACCmax (0.88) was significantly lower than the AUC of PSV ratio (0.94) and ICA PSV (0.94). To diagnose a ≥70% ICA stenosis there were no significant differences in AUC between ACCmax (0.89), PSV ratio (0.93) and ICA PSV (0.94)., Conclusions: ACCmax is an interesting additional DUS measurement in determining the degree of ICA stenosis. ACCmax is measured distal to the stenosis and is not hampered by local distorting factors at the site of the stenosis. ACCmax can accurately diagnose an ICA stenosis, but was somewhat inferior compared to ICA PSV and PSV ratio to diagnose a ≥50% ICA stenosis., (Copyright © 2021. Published by Elsevier Inc.)

We report a case of 62-year-old woman with difficult urinating due to a fusion of the labia minora. The labia were cleaved in the operating rooms. Pathological examination showed that the cause of the fusion may have been lichen sclerosus.

A 54-year-old man, with a history of laparoscopic cholecystectomy, presented with a slowly progressing mass in the subcostal region on the right side. On MRI and peri-operatively, infiltration and abscess formation was seen, caused by a dropped gallstone three years after initial cholecystectomy.

Background: Because of the presence of medial calcific sclerosis, both ankle-branchial index and toe pressure measures can yield misleading results when attempting to diagnose peripheral artery disease (PAD). A new ultrasound parameter, maximal systolic acceleration (ACC max ), can be an accurate tool for diagnosing PAD, including in diabetic patients. However, it has not been evaluated thoroughly. The aim of this study was to assess the feasibility of using ACC max to diagnose and assess the severity of PAD., Methods: The human circulatory system was simulated using an in vitro circulatory system driven by a pulsatile pneumatic pump. Arterial stenosis of various degrees (50%, 70%, 80%, and 90%) was simulated in order to investigate the change in several ultrasound parameters (including ACC max ), as well as the intraluminal mean arterial pressure gradient. In a separate set of measurements, interobserver variability was measured using two investigators who were unaware of the degree of stenosis., Results: ACC max significantly decreased (P < .001), and the pressure gradient increased (P < .001) as the degree of stenosis increased. Moreover, we found a strong correlation between ACC max and the pressure gradient (R 2  = 0.937). Finally, interobserver variability with respect to ACC max was extremely low, with an intraclass correlation coefficient of 0.99., Conclusions: The results of this flow model study suggest that ACC max can be a valid, noninvasive tool for diagnosing PAD. Moreover, our finding that ACC max decreases as the severity of stenosis increases, together with the strong correlation between ACC max and the pressure gradient, suggests that ACC max may be useful as an alternative diagnostic tool for assessing the severity of PAD. These promising in vitro data warrant further study in a clinical setting., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)