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1
Valentín, L. I., W. H. Valentín, S. Mercado, and C. J. Rosado. "Venous Reflux Localization: Comparative Study of Venography and Duplex Scanning." Phlebology: The Journal of Venous Disease 8, no. 3 (September 1993): 124–27. http://dx.doi.org/10.1177/026835559300800309.
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Objective: To compare the results obtained by duplex ultrasound imaging and ascending and descending phlebography in patients with chronic venous insufficiency. Design: Prospective comparison between venography and duplex ultrasound imaging in a single patient group with chronic venous insufficiency. Setting: Private vascular clinic in Puerto Rico. Patients: Twenty-one patients presenting with clinical evidence of venous disease of the lower limb. Main outcome measures: Presence of valvular incompetence in deep and superficial veins as indicated by duplex ultrasound imaging and ascending and descending phlebography. Results: Duplex ultrasound imaging showed twice as many patients with popliteal vein incompetence (eight veins compared with four veins) and twice as many incompetent long saphenous veins (14 detected by duplex, eight detected by venography). In the proximal venous system, 13 common femoral veins were thought incompetent on venography, but only seven on duplex scanning; in the superficial femoral vein, 11 were incompetent on venography and three on duplex scanning. Conclusion: Duplex ultrasound scanning provides greater sensitivity for detection of valvular incompetence in distal veins compared with venography. Descending phlebography is poor in demonstrating distal venous valvular incompetence.
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Belcaro, G., and B. M. Errichi. "Selective Saphenous Vein Repair: A 5-Year Follow-up Study." Phlebology: The Journal of Venous Disease 7, no. 3 (September 1992): 121–24. http://dx.doi.org/10.1177/026835559200700310.
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objective: To evaluate the effect of selective saphenous vein repair (SSVR) in a 5-year follow-up study. Design: Prospective, randomized study of 44 subjects randomized to an SSVR group and a control group. Setting: University Clinic, Chieti, and Angiology and vascular Surgery Clinic, Pescara, Italy. Patients: Twenty-two patients in the SSVR group and 22 in the control group. Inclusion criteria were incompetence of the saphenofemoral junction (SFJ) with presence of valve cusps and two to five venous sites in the long saphenous vein. interventions: SFJ plication and selective interruption of the incompetent sites under general anaesthetic. Main outcome measures: Ambulatory venous pressure measurements (refilling time) and colour duplex scanning to detect the number of incompetent sites. Result: After 5 years, 18 patients in the SSVR group and 19 in the control group completed the study. SSVR increased refilling time ( p<0.02) and the number of incompetent sites was decreased ( p<0.02); in the control group, refilling time remained short and the number of incompetent sites increased ( p<0.05). Conclusion: SSVR is an effective treatment with good 5-year results on incompetence and the development of new incompetent venous sites.
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Nusrat Mahjabeen and Shaikh Zinnat Ara Nasreen. "McDonald’s suture: A successful case." Z H Sikder Women’s Medical College Journal 3, Number 1 (January 1, 2021): 38–40. http://dx.doi.org/10.47648/zhswmcj.2021.v0301.09.
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Cervical incompetence is characterized by painless dilatation of the incompetent cervix and results in miscarriages and preterm delivery during second trimester. Cervical cerclage (CC) has been utilized for the cure of loss in second trimester pregnancy. The detection of cervical incompetency is difficult. Usually patients have history of repeated second trimester demise or early preterm delivery after cervical dilatation without pain having no bleeding, contractions, or other reasons. We report a 28years old patient, 3rd gravida, para 0+2, at 11 weeks’ gestation with the diagnosis of cervical incompetence, in whom cervical cerclage (McDonald’s suture) was performed successfully. There were no operative or immediate postoperative complications. A healthy infant was delivered at 37 weeks by caesarean section. After delivery the suture was removed. Cervical cerclage during pregnancy can be safe and effective treatment for well-selected patients with cervical incompetence.
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Al Jubair, Khalid A., Abdullah Jaralla, Mohsen Fadala, Emad Bukhari, Yahya Al Faraidi, Huwaida Al Qethami, and Mohamed R. Al Fagih. "Repair of the mitral valve because of pure rheumatic mitral valvar incompetence in the young." Cardiology in the Young 8, no. 1 (January 1998): 90–93. http://dx.doi.org/10.1017/s1047951100004698.
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AbstractBetween January 1985 and April 1994, 42 children aged between 7 and 14 years (mean 11.3 years) underwent repair of severely incompetent rheumatic mitral valves with no accompanying mitral stenosis. In 19 patients the tricuspid valve was severely incompetent, while 8 patients had severe aortic incompetence. Overall, the repair incorporated shortening of elongated tendinous cords and insertion of a Duran or Carpentier prosthetic ring. The repair was the sole procedure in 15 patients, whilst 19 patients also had a De Vega tricuspid valvar annuloplasty and 8 had repair or replacement of the aortic valve. There were no hospital deaths. Postoperative transthoracic echocardiographic studies revealed trivial residual mitral valvar regurgitation in 6 patients, mild regurgitation in 18, moderate in 15, and regurgitation severe enough to warrant replacement of the mitral valve in 3 patients. The mean follow-up period was 37 months (maximum 120 months, minimum 1 month). 0139 patients followed-up, 28 attended for more than 5 years. Of these, 7 underwent replacement of the mitral valve for severe regurgitation within 4 years of the repair. Severe mitral regurgitation in 3 patients was controlled by medical therapy. One was eventu ally lost to follow-up, and one patient died of causes unrelated to surgery. The remaining 16 patients had absent to moderate mitral valvar regurgitation. These results contrast with 10 repairs of congenital mitral incompetence, where no patients required re-operation in the immediate 5 years period of follow-up. Every effort should be made in children with rheumatic mitral incompetence to preserve the natural valve by con servative repair, despite the fact that repair of the incompetent rheumatic mitral valve is not so durable as repair of congenitally incompetent valves.
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Zaniewski, M., T. Urbanek, A. Dorobisz, E. Majewski, U. Skotnicka-Graca, and J. Kostecki. "Haemodynamic changes of the deep vein system of the leg after surgery of the incompetent great saphenous vein." Phlebologie 39, no. 01 (2010): 18–23. http://dx.doi.org/10.1055/s-0037-1622288.
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SummarySurgical treatment of chronic venous disease primarily aims to restore the normal haemodynamic conditions in the venous system. The objective of the study was an assessment of the influence of incompetent saphenous vein removal on the haemodynamical changes within the venous and arterial system of the operated extremity. Patients, materials, methods: The study utilised a group of 50 patients presenting with varicose veins (C2 according to CEAP classification) and great saphenous vein incompetence selected for saphenous vein stripping. In all patients, duplex Doppler examination of femoral and popliteal veins as well as femoral and popliteal arteries was performed before surgery, on the first postoperative day and 30 days after surgery. Results: After the removal of an incompetent great saphenous vein, a statistically significant increase in the minute volume flow in the femoral (p = 0.0004) and popliteal veins (p = 0.0011) was observed. Following saphenous vein stripping, a statistically significant reduction of the venous reflux time in the deep vein system was also observed in the common femoral, femoral and popliteal veins, as compared to a pre-operative examination. Postoperatively, normalisation of the venous reflux time was achieved in 36–40% of patients from the group with concomitant deep vein system incompetence. As far as the arterial system is concerned, an increase in the volume flow in the femoral (p = 0.0463) and popliteal arteries was observed, but statistical significance was not achieved in the latter (p = 0.2912). Conclusion: The flow in the deep vein system increases after the removal of the incompetent great saphenous vein. In some patients with an incompetent deep vein system, venous reflux time returns to normal after the incompetent saphenous vein has been removed.
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Kerridge, Ian. "Competent Patients, Incompetent Decisions." Annals of Internal Medicine 123, no. 11 (December 1, 1995): 878. http://dx.doi.org/10.7326/0003-4819-123-11-199512010-00011.
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Francis, R. "Treating temporarily incompetent patients." BMJ 311, no. 7009 (September 30, 1995): 876–77. http://dx.doi.org/10.1136/bmj.311.7009.876b.
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Chaudhri, K. "Treating temporarily incompetent patients." BMJ 311, no. 7010 (October 7, 1995): 948–49. http://dx.doi.org/10.1136/bmj.311.7010.948c.
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van Gent, WB, and CHA Wittens. "Influence of perforating vein surgery in patients with venous ulceration." Phlebology: The Journal of Venous Disease 30, no. 2 (December 19, 2013): 127–32. http://dx.doi.org/10.1177/0268355513517685.
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Objectives The exact role of perforating vein surgery is still unclear. The aim of this study is to analyze the influence of perforating vein surgery in patients with venous ulceration. Methods This study was part of a randomized controlled trial in which conservative and surgical treatment of venous ulceration was compared. It is a secondary analysis of prospectively gathered data. Ninety-seven active leg ulcers were surgically treated with a subfascial endoscopic perforating vein surgery (SEPS) procedure. Concomitant superficial venous incompetence was treated with flush saphenopopliteal ligation and/or saphenofemoral ligation and limited stripping of the great saphenous vein. All patients were also treated with ambulatory compression therapy. Ulcer healing and recurrences are described in detail. To measure the completeness of the SEPS procedure duplex ultrasonography was performed on each patient before and 6 weeks and 12 months after surgery. Also newly formed perforators after surgery were scored and their influence was analyzed. Results Analyses were performed on 94 ulcerated legs with a mean follow-up of 29 months. In all treated legs, only 45% all perforators were treated. In 55% one (29%) or more (26%) perforators were missed. Healing was not significantly influenced by the number of remaining incompetent perforating veins, but recurrence was significantly higher in patients who had incomplete SEPS procedure ( p = 0.007 log-rank). New incompetent perforating veins did not affect ulcer healing or recurrence. The plotted location of new perforators did not show a pattern. Deep vein incompetence and treatment of superficial venous incompetence had no significant influence on healing or recurrence rates in a complete or incomplete SEPS procedure. Conclusion In this series a well-performed SEPS procedure lowers the venous ulcer recurrence rate significantly, indicating the clinical importance of incompetent perforating veins in patients with an active venous ulcer.
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Conrad, P. "Endoscopic Exploration of the Subfascial Space of the Lower Leg with Perforator Vein Interruption Using Laparoscopic Equipment: A Preliminary Report." Phlebology: The Journal of Venous Disease 9, no. 4 (December 1994): 154–57. http://dx.doi.org/10.1177/026835559400900405.
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Objective: To describe a method of endoscopic exploration of the medial subfascial space of the lower leg using laparoscopic equipment and dividing incompetent perforating veins crossing this space with diathermy. Design: Prospective study in seven patients with significant perforating vein incompetence in the medial lower leg. Setting: Department of Surgery, Nepean Hospital, New South Wales, Australia. Intervention: Laparoscopic equipment is used to explore endoscopically the medial subfascial space of the lower leg. Incompetent perforating veins preoperatively marked by duplex examination are identified and divided by endoscopic diathermy. Main outcome measures: The endoscopic division close to their source from the deep veins of incompetent perforating veins of the medial compartment of the lower leg. Results: Endoscopic interruption of incompetent perforators in the medial compartments of seven legs achieved with minimal morbidity. Conclusions: Endoscopic diathermy interruption of incompetent perforators in the medial compartment of the lower leg using laparoscopic equipment is a rapid and accurate procedure with minimal morbidity, as shown in a small series of seven legs.
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Ummer, Sameer Babu, and B. Kanchana. "A study to compare the usefulness of a careful clinical examination with venous Doppler studies in patients with varicose veins." International Surgery Journal 5, no. 6 (May 24, 2018): 2107. http://dx.doi.org/10.18203/2349-2902.isj20181841.
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Background: The significance of recognizing and locating incompetent perforating veins for treating the patients with varicose vein and venous ulcers is well established. Several methods of diagnosing incompetent perforating veins have been evaluated in the past, however, none show satisfactory accuracy in predicting incompetent perforating veins. Clinical examination with digital palpation of fascial defects is the most widely used method. These fascial clefts are generally thought to keep up a correspondence to incompetent perforating veins. Further evidence is obtained when digital pressure relief on the defect leads to filling of superficial varicose veins or if a tourniquet applied beneath the defect prevents it. The purpose of the present study was to compare clinical examination with that of Doppler venous study in the diagnosis of incompetent perforating veins of lower limbs.Methods: T This is a Cross-sectional comparative study which was carried out in 34 (13 women, 21 men) patients with lower limb varicose veins admitted to the department of general surgery in Aarupadai Veedu medical college and hospital. 38 limbs were studied in 34 patients. They were evaluated by clinical tests and Doppler ultrasound. Results: Saphenofemoral incompetence was correctly diagnosed in all the 38 limbs both by clinical test and Doppler ultrasound. In the evaluation of perforator competency, the sensitivity was 88.14% by clinical tests and 98.31% by Doppler ultrasound.Conclusions: From this study and results, it shows that doppler ultrasound evaluation of the varicose veins should be done for accurate diagnosis in all patients before planning surgery.
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Gianesini, Sergio, Savino Occhionorelli, Erica Menegatti, Anna Maria Malagoni, Mirko Tessari, and Paolo Zamboni. "Femoral vein valve incompetence as a risk factor for junctional recurrence." Phlebology: The Journal of Venous Disease 33, no. 3 (January 29, 2017): 206–12. http://dx.doi.org/10.1177/0268355517690056.
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Background Recurrent varicose veins occur up to 80% of procedures. The sapheno-femoral junction can be involved in more than 50% of cases. A detailed pathophysiological explanation of the phenomenon is still missing. The aim of the present work is to evaluate the role of femoral vein incompetence as risk factor for sapheno-femoral junction recurrence. Methods Three-hundred-eighty-one patients presenting an incompetent great saphenous vein system and eventually also an incompetent femoral tract (C2-6EpAsdPr) underwent a great saphenous vein high ligation with flush ligation also of the incompetent tributaries along the leg, sparing the saphenous trunk. Pre-operatively, all patients underwent a sonographic evaluation assessing the superficial and deep venous systems, including a detailed analysis of the iliac-femoral vein tract above the sapheno-femoral junction. A retrospective statistical analysis assessed the recurrence risk associated with iliac-femoral vein tract incompetence. Results In a 5.5 ± 1.9 years follow-up, great saphenous vein trunk reflux recurrence was detected in 45/381 (11.8%) cases. The reflux source was found in a reconnected sapheno-femoral stump in 11/45 cases (24.5%), in the pelvic network in 8/45 cases (17.8%), in a neovascularization process in 7/45 (15.5%) and in a newly incompetent great saphenous vein tributary in 19/45 (42.2%). At the pre-operative assessment, iliac-femoral vein tract reflux was present in 7 (26.9%) of the 26 cases who developed a sapheno-femoral junction recurrence and in 25 (7%) of the 355 patients who did not demonstrate sapheno-femoral junction recurrence (odds ratio: 4.8; confidence interval 95%: 1.8–12.6; p < .003). Discussion Despite many technical diagnostic and therapeutic refinements, varicose veins recurrence remains a frequent event. The present investigation points out the association among iliac-femoral vein tract incompetence and sapheno-femoral junction recurrences after high ligation.
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Brock, Dan W. "Good Decisionmaking for Incompetent Patients." Hastings Center Report 24, no. 6 (November 1994): S8. http://dx.doi.org/10.2307/3563473.
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Olins, Nancy J. "Feeding Decisions for Incompetent Patients." Journal of the American Geriatrics Society 34, no. 4 (April 1986): 313–17. http://dx.doi.org/10.1111/j.1532-5415.1986.tb04228.x.
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Gevers, Sjef, Joseph Dute, and Herman Nys. "Surrogate Decision-making for Incompetent Elderly Patients: The Role of Informal Representatives." European Journal of Health Law 19, no. 1 (2012): 61–68. http://dx.doi.org/10.1163/157180912x615194.
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Abstract Informal or unofficial representation refers to the practice (more common in some European jurisdictions than in others), that persons not designed by a court or by the patient himself, make medical decisions on the patient’s behalf in case of their incompetence. If the law provides for this, it is usually next of kin (spouse, children, brothers and sisters, etc.) who are allowed to act in such a capacity. Informal representation raises several questions. Are family members always familiar with what their relative would have wished, ready to take responsibility, and not too much reigned by their emotions? The basic legal concern is whether there are sufficient procedural and other safeguards to protect the incompetent patient from representatives who do not serve their best interests. In addressing these issues, after a brief survey of the law in the Netherlands as compared with that in Belgium, Germany and England/Wales, we will argue that informal representation as such is not at variance with international and European standards. However, an ‘informal’ approach to surrogate decision-making should always go together with sufficient protection of the incompetent patient, including procedural safeguards with regard to the decision that the patient is incompetent, limits to the decision-making power of informal representatives and effective forms of conflict resolution.
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Greiner, Milka, and Geoffrey L. Gilling-Smith. "Leg Varices Originating from the Pelvis: Diagnosis and Treatment." Vascular 15, no. 2 (April 2007): 70–78. http://dx.doi.org/10.2310/6670.2006.00030.
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This article reports the investigation and treatment of 24 women presenting with recurrent lower limb varicosities secondary to reflux within the pelvic venous circulation. Diagnosis based on selective retrograde pelvic phlebography enabled precise identification and classification of sites of incompetence. A total of 74 veins were treated by embolization with platinum coils and glue prior to repeat surgery to the lower limb veins. At 4-year follow-up, signs of stasis had disappeared in all patients. Repeat phlebography revealed no evidence of recurrent reflux at the sites of treatment. One patient developed recurrent varices due to incomplete embolization of incompetent pelvic veins. Endovascular occlusion of incompetent pelvic veins is an effective treatment for varicose veins secondary to pelvic venous incompetence.
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Emanuel, Ezekiel J. "Proxy Decision Making for Incompetent Patients." JAMA 267, no. 15 (April 15, 1992): 2067. http://dx.doi.org/10.1001/jama.1992.03480150073040.
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Grudzińska, Ewa, Sławomir Grzegorczyn, and Zenon P. Czuba. "Chemokines and Growth Factors Produced by Lymphocytes in the Incompetent Great Saphenous Vein." Mediators of Inflammation 2019 (January 10, 2019): 1–10. http://dx.doi.org/10.1155/2019/7057303.
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The role of cytokines in the pathogenesis of chronic venous disease (CVD) remains obscure. It has been postulated that oscillatory flow present in incompetent veins causes proinflammatory changes. Our earlier study confirmed this hypothesis. This study is aimed at assessing chemokines and growth factors (GFs) released by lymphocytes in patients with great saphenous vein (GSV) incompetence. In 34 patients exhibiting reflux in GSV, blood was derived from the cubital vein and from the incompetent saphenofemoral junction. In 12 healthy controls, blood was derived from the cubital vein. Lymphocyte culture with and without stimulation by phytohemagglutinin (PHA) was performed. Eotaxin, interleukin 8 (IL-8), macrophage inflammatory protein 1 A and 1B (MIP-1A and MIP-1B), interferon gamma-induced protein (IP-10), monocyte chemoattractant protein-1 (MCP-1), interleukin 5 (IL-5), fibroblast growth factor (FGF), granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), platelet-derived growth factor-BB (PDGF-BB), and vascular endothelial growth factor (VEGF) were assessed in culture supernatants by a Bio-Plex assay. Higher concentrations of eotaxin and G-CSF were revealed in the incompetent GSV, compared with the concentrations in the patients’ upper limbs. The concentrations of MIP-1A and MIP-1B were higher in the CVD group while the concentration of VEGF was lower. In the stimulated cultures, the concentration of G-CSF proved higher in the incompetent GSV, as compared with the patients’ upper limbs. Between the groups, the concentration of eotaxin was higher in the CVD group, while the IL-5 and MCP-1 concentrations were lower. IL-8, IP-10, FGF, GM-CSF, and PDGF-BB did not reveal any significant differences in concentrations between the samples. These observations suggest that the concentrations of chemokines and GFs are different in the blood of CVD patients. The oscillatory flow present in incompetent veins may play a role in these changes. However, the role of cytokines in CVD requires further study.
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Seren, Mustafa, Mert Dumantepe, Osman Fazliogullari, and Suha Kucukaksu. "Combined treatment with endovenous laser ablation and compression therapy of incompetent perforating veins for treatment of recalcitrant venous ulcers." Phlebology: The Journal of Venous Disease 32, no. 5 (June 30, 2015): 307–15. http://dx.doi.org/10.1177/0268355515594075.
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Objective Patients with healed venous ulcers often experience recurrence of ulceration, despite the use of long-term compression therapy. This study examines the effect of closing incompetent perforating veins (IPVs) on ulcer recurrence rates in patients with progressive lipodermatosclerosis and impending ulceration. Methods Patients with nonhealing venous ulcers of >2 months’ duration underwent duplex ultrasound to assess their lower extremity venous system for incompetence of superficial, perforating, and deep veins. Endovenous laser ablation (EVLA) of perforating veins was performed on patients with CEAP 6 disease with increasing hyperpigmentation, lipodermatosclerosis, and/or progressive malleolar pain. A minimum of 2 months of compressive therapy was attempted before endovenous ablation of IPVs. Demographic data, risk factors, CEAP classification, procedural details, and postoperative status were all recorded. Results Forty ulcers with 46 associated IPVs were treated with EVLA in 36 patients with CEAP 6 recalcitrant venous ulcers. Treated incompetent perforator veins were located in the medial ankle (85.7%), calf (10.7%), and lateral ankle (3.5%). Endovenous laser ablation was successful in 76% (35/46) with the first laser treatment of incompetent perforator veins and 15.2% (7/46) additional ablation procedures were performed. Of the 46 treated IPVs, 42 (91.3%) were occluded on the duplex examination at 12 months. The average energy administrated per perforating vein treated was 162 joule. Two patients reported localized paresthesia, which subsided spontaneously, but no deep venous thrombosis or skin burn was observed. Conclusion Especially in the case of liposclerotic or ulcerated skin in the affected region, PAP of IPVs is highly effective, safe, and appears to be feasible. Patients with active venous ulcers appear to benefit from EVLA of incompetent perforators in order to reduce the risk of ulcer recurrence.
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Sonnenberg, S., M. Bitsiadou, A. Gidman, and N. Gowland Hopkins. "Results of subfascial endoscopic perforator vein surgery without perioperative marking of perforator veins." Phlebology: The Journal of Venous Disease 21, no. 1 (March 1, 2006): 50–52. http://dx.doi.org/10.1258/026835506775971180.
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Objectives:This study assesses the anatomical outcome of subfascial endoscopic perforator vein surgery (SEPS) in cases where no perioperative marking of incompetent perforators was used. Methods:Patients who had undergone SEPS and who had been investigated with a preoperative duplex ultrasound scan were identified from hospital records. These patients were recalled for a follow-up duplex ultrasound scan, which was compared with the preoperative investigation. Results:In total, 15 patients (17 limbs) were studied. Four legs (23.5%) had no incompetent perforators at follow-up scan. The remaining 11 limbs (76.8%) all had at least one incompetent perforator. Six limbs (35.2%) showed incompetent perforators in the same position as the incompetent perforators identified at the preoperative duplex scan. A total of 10 incompetent perforators persisted at follow-up (35.7% of preoperatively identified incompetent perforating veins). Nine legs (52.9%) had developed at least one new incompetent perforator since undergoing SEPS. Conclusion:In our study, a large proportion of incompetent perforators persisted at post-operative follow-up duplex scan. These probably represent perforators missed during surgery. Endoscopy of the subfascial space alone is not a reliable method for incompetent perforator identification. Alternative methods of localization should be employed perioperatively.
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Deng, Hong-Li, Yu-Xuan Cong, Hai Huang, Bin-Fei Zhang, Ya-Hui Fu, Jin-Lai Lei, Hu Wang, Peng-Fei Wang, Yan Zhuang, and Chao Ke. "The Effect of Integrity of Lateral Wall on the Quality of Reduction and Outcomes in Elderly Patients with Intertrochanteric Fracture: A Controlled Study." BioMed Research International 2021 (August 9, 2021): 1–8. http://dx.doi.org/10.1155/2021/6563077.
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Objective. The study is aimed at evaluating the effect of the integrity of lateral wall on the quality of reduction and outcome in intertrochanteric fracture treated with proximal femoral nail antirotation (PFNA). Methods. Medical record systems for elderly patients with intertrochanteric fracture treated with PFNA were included. The patients were divided into incompetent and intact lateral wall groups. Patients’ baseline characteristics, quality of reduction, and Harris Hip scores (HHS) were collected. Results. The study included 115 patients with intertrochanteric fractures, with 59 in the incompetent lateral wall group and 56 in the intact group. Lateral wall thickness was 16.47 ± 2.46 mm and 23.68 ± 1.59 mm in the incompetent group and intact group ( t = − 18.766 , P < 0.001 ), respectively. There was no significant difference in the quality of reduction ( P = 0.646 ) between intact and incompetent groups. Mean HHS at final follow-up were 83.02 ± 13.89 in the incompetent group and 86.04 ± 3.39 in the intact group, with no significant difference ( P = 0.123 ). In addition, there was no significant difference in weight-bearing or clinical healing between intact and incompetent groups. The partial weight-bearing with crutches was allowed at 2.71 ± 0.93 and 2.66 ± 1.01 weeks after the operation in the incompetent and intact groups. Time to clinical healing was 5.83 ± 0.99 and 6.00 ± 0.92 months in the incompetent and intact groups, respectively. However, the operative time in the incompetent group ( 58.54 ± 18.14 mins) were longer than that in the intact group ( 51.79 ± 17.77 mins). Conclusions. In conclusion, it seems that lateral wall thickness does not affect the quality of reduction and outcome in patients with intertrochanteric fracture receiving PFNA.
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Gindes, Daniel. "Judicial Postponement of Death Recognition: The Tragic Case of Mary O'Connor." American Journal of Law & Medicine 15, no. 2-3 (1989): 301–31. http://dx.doi.org/10.1017/s0098858800009850.
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A recent New York Court of Appeals decision seriously impedes the ability of incompetent patients to control their medical care. In the case of Mary O'Connor, the court virtually eliminated an incompetent's rights to bodily integrity and privacy. The court relied on formalistic evidentiary arguments to vitiate the patient's refusal of death-prolonging treatment. This Case Comment examines both the doctrine and policy underlying the O'Connor decision, suggesting that the court erred in its holding and reasoning.An alternative framework is presented, arguing that courts should honor competently expressed patient decisions concerning medical treatment. New York's highest court, instead, posited an incompetent patient who becomes competent for a moment to render a decision. This legal fiction is nothing more than a thinly masked technique for imposition of the judges’ values on the patient. This Case Comment argues that in the absence of clear direction from the patient, family and loved ones generally should make care decisions for the patient.
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Mosquera, D. A., R. A. Manns, and R. G. M. Duffield. "Phlebography in the Management of Recurrent Varicose Veins." Phlebology: The Journal of Venous Disease 10, no. 1 (March 1995): 19–22. http://dx.doi.org/10.1177/026835559501000105.
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Objectives: (1) To report the results of phlebography (varicography and venography) in the identification of important venous communications in patients with reurrent varicose veins. (2) To assess whether phlebography provides additional valuable information when compared with clinical and hand-held Doppler examination. Design: Retrospective review. Setting: Vascular unit, district general hospital. Patients: A consecutive series of 46 patients attending with recurrent varicose veins. Interventions: Clinical examination, hand-held Doppler, venography and varicography. Main outcome measures: (1) Sites of incompetent venous communications. (2) Assessment of value of preoperative phlebography when compared with clinical and hand-held Doppler examination. Results: Sixty-four venograms were performed on 46 patients of mean age 52 years, range 30–81 years. Calf perforator (88%) and mid-thigh perforator incompetence (38%) were common. Groin recurrence (33%) included examples of neovascularization, inadequate previous surgery and inadequate assessment. Popliteal recurrence (34%) secondary to incompetent gastrocnemius, popliteal fossa and short saphenous veins also present. Preoperative phlebography supplied valuable additional information in 75% of Patients. Conclusion: Phlebography of recurrent varicose veins provides useful information supplementary to that furnished from clinical examination alone.
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Belcaro, G., A. Ricci, G. Laurora, M. R. Cesarone, M. T. De Sanctis, and L. Incandela. "Superficial Femoral Vein Valve Repair with Limited Anterior Plication." Phlebology: The Journal of Venous Disease 9, no. 4 (December 1994): 146–49. http://dx.doi.org/10.1177/026835559400900403.
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Objective: To evaluate the effects after 3 years of a new surgical technique, limited anterior plication (LAP) of the superficial femoral vein. Design: Patients with venous hypertension resulting from deep and superficial venous incompetence were randomized into two treatment groups. Setting: Angiology and Vascular Surgery, Pierangeli Clinic, Pescara, and Cardiovascular Institute, Chieti University, Italy. Patients: Both groups were treated with superficial vein surgery. Group 2 was also treated with LAP. Interventions: Valvuloplasty of the superficial femoral vein was performed with plication of the anterior vein wall after limited dissection of the vein. Main outcome measures: During a 3-year follow-up results were evaluated with colour duplex and ambulatory venous pressure (AVP) measurements. Endpoints were AVP, refilling time (RT), number of incompetent venous sites, presence/absence of the reflux at the superficial femoral vein and the diameter of the vein. Results: No complications were observed. All femoral veins treated with LAP were competent at 36 months. Significantly lower AVP and longer RT were observed in the LAP group. The number of incompetent venous sites was lower in both groups. The average diameter of the vein was higher in Group 1. Conclusions: In selected subjects – moderate deep venous incompetence, functional cusps, incompetence mainly due to relative enlargement of the vein – LAP may be an alternative to external valvuloplasty.
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Robinson, Ellen M. "Caring for Incompetent Patients and Their Surrogates." American Journal of Nursing 101, no. 7 (July 2001): 75–76. http://dx.doi.org/10.1097/00000446-200107000-00030.
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Morrison, Allan B. "Physician liability for treating mentally incompetent patients." Psychiatric Bulletin 12, no. 12 (December 1988): 520–22. http://dx.doi.org/10.1192/pb.12.12.520.
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The issue of the rights and obligations of those involved in doing research on patients who are incapable of giving their consent to treatment is a difficult one. This difficulty is reflected in the papers and discussion which form the basis of the book Consent and the Incompetent Patient: Ethics, Law and Medicine (eds. S. R. Hirsch & J. Harris) and that were the subject of the conference that led to it. Had I been in attendance, I am sure that I would have gained insights not available from the printed version on which I have had to rely. Nonetheless, I have sufficient sense of the proceedings to see where there are areas that an American view, or at least the views of one American lawyer, might be of interest.
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Wilson, Daniel R., Rodgers Wilson, and Kenneth Tepe. "Court-authorized medication for incompetent hospitalized patients." New Directions for Mental Health Services 23, no. 75 (1997): 73–80. http://dx.doi.org/10.1002/yd.2330237509.
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Madycki, G., P. Dabek, A. Gabrusiewicz, and W. Staszkiewicz. "Recurrent varicose veins assessed by colour-coded duplex scanning: own experience." Phlebologie 29, no. 03 (2000): 58–61. http://dx.doi.org/10.1055/s-0037-1617235.
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SummaryAim: Authors performed a retrospective analysis of causes of recurrent varicose veins following surgery. Methods: They evaluated 89 patients (65 women and 24 men, mean age 49.7 years). All patients previously underwent same surgical procedures (long saphenous vein stripping with/without local multiple avulsions). For the purpose of the study, colour/duplex examinations were applied (Siemens Sonoline Elegra unit). Results: Depending on the type and area of recurrent varicose veins, patients were classified into 4 groups. Group I – 22 patients (persistence of varicose tributaries of LSV in thigh or thigh perforator). Group II – 27 patients (recurrence along the LSV in the calf). Group III – 26 patients (recurrence due to left incompetent short saphenous vein). Group IV – 14 patients (isolated incompetent perforators). Authors conclude, that colour-coded duplex scanning is currently a method of choice in the diagnosis of recurrent varicose veins. High incidence of recurrence due to short saphenous vein incompetence should draw particular attention to this vein in the preoperative assessment of venous system. Recurrence of varicose veins at thigh level is not caused by deep vein insufficiency, but is related to inadequate vein surgery or might be linked to the problem of neovascularisation in this area.
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Busch, Kathryn, Judith Doyle, Martin Forbes, Geoffrey White, John Harris, and Michael Stephen. "Horseshoes Are Not Always Lucky: A Rare Cause of Varicose Veins." Journal for Vascular Ultrasound 33, no. 1 (March 2009): 36–39. http://dx.doi.org/10.1177/154431670903300108.
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Introduction Color duplex ultrasound (CDU) assessment for patients with varicose veins has increased in prevalence as new techniques for treatment continue to emerge. Occasionally, patients present with atypical varicosities that warrant the typical study to be extended to unveil the true underlying cause of the condition. Clinical Details A 41 year old man presented to our laboratory for assessment of bilateral varicose veins. He had recently developed venous eczema. Examination of the patient revealed large varicose veins associated with the long saphenous system, especially prominent on the left side. Methods Using a standard venous incompetence study protocol, CDU was performed with a Philips IU22 machine. The lower-extremity deep and superficial venous systems were assessed for patency and competency. Measurements of incompetent venous junctions and noteworthy vessel diameters were included. The examination was extended to include the pelvic and abdominal veins on the basis of unusual findings during the CDU imaging of the legs. Results Superficial venous insufficiency was detected involving the saphenofemoral junctions (SFJs), long saphenous veins (LSVs), and tributaries bilaterally. Bilateral incompetent calf perforators were identified. On the left, two large SFJs were identified and the LSV measured up to 2.1 cm in diameter. On both sides, an incompetent superficial pelvic vein arising from the SFJ was identified tracking proximally. Examination of the iliac veins revealed normal right iliac veins. On the left, the common iliac vein was extrinsically compressed as was the inferior vena cava. Further examination revealed a horseshoe kidney. The confluence of the lower poles of the kidneys were anterior to the aorta, inferior vena cava, and left common iliac vein, compressing the venous vasculature, accounting for the venous hypertension and left sided prominence. Further management included confirmatory radiological imaging and intervention. Conclusion Atypical varicose veins may be a result of a plethora of causes. It is crucial to the patient's outcome to reveal the true nature of the underlying cause. Abdominal sources of venous incompetence need appropriately tailored intervention to prevent recurrence and potential worsening of symptoms.
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Kalodiki, E., L. Calahoras, G. Geroulakos, and A. N. Nicolaides. "Liquid Crystal Thermography and Duplex in the Preoperative Marking of Varicose Veins." Phlebology: The Journal of Venous Disease 10, no. 3 (September 1995): 110–14. http://dx.doi.org/10.1177/026835559501000307.
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Objective: To determine the role of liquid crystal thermography (LCT) in preoperative marking of varicose veins and incompetent perforating veins. Design: Single patient group study comparing techniques. Setting: Teaching hospital vascular laboratory. Patients: Two hundred patients (265 legs) referred to St Mary's Hospital Vascular Laboratory for preoperative varicose vein marking. Methods: Patients were studied using LCT and duplex ultrasonography to identify calf perforating veins. Results: In part I of the study LCT identified 47 ‘areas at risk’, 42 of which were demonstrated to contain incompetent perforating veins on duplex examination (positive predictive value 89%). Thirty-eight of these 42 patients were explored at operation and 36 (95%) were confirmed as incompetent. The remaining two perforating veins could not be located. In part II of the study LCT identified 327 ‘areas at risk’, 299 of which were demonstrated to contain incompetent perforating veins on duplex examination (positive predictive value 91%). Conclusion: LCT is useful in the identification of incompetent perforating veins, it is easy to perform, less time consuming, cheaper and can replace duplex scanning.
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Holme, T. C., and D. Negus. "The Treatment of Venous Ulceration by Surgery and Elastic Compression Hosiery; A Long-Term Review." Phlebology: The Journal of Venous Disease 5, no. 2 (June 1990): 125–28. http://dx.doi.org/10.1177/026835559000500208.
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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.
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Gibson, Kathleen, Neil Khilnani, Marlin Schul, and Mark Meissner. "American College of Phlebology Guidelines – Treatment of refluxing accessory saphenous veins." Phlebology: The Journal of Venous Disease 32, no. 7 (October 13, 2016): 448–52. http://dx.doi.org/10.1177/0268355516671624.
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The American College of Phlebology Guidelines Committee performed a systematic review of the literature regarding the clinical impact and treatment of incompetent accessory saphenous veins. Using an accepted process for guideline developments, we developed a consensus opinion that patients with symptomatic incompetence of the accessory great saphenous veins (anterior and posterior accessory saphenous veins) be treated with endovenous thermal ablation (laser or radiofrequency) or ultrasound-guided foam sclerotherapy to eliminate symptomatology (Recommendation Grade 1C).
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Einarsson, E., B. Eklöf, and P. Neglén. "Sclerotherapy or Surgery as Treatment for Varicose Veins: A Prospective Randomized Study." Phlebology: The Journal of Venous Disease 8, no. 1 (March 1993): 22–26. http://dx.doi.org/10.1177/026835559300800106.
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Objective: To compare the long-term results following radical surgery or compression sclerotherapy (CST) of primary varicose veins. Design: Prospective, randomized study of 164 patients. The patients were assessed with clinical tests and foot volumetry, before the 6 months, 1, 3 and 5 years after treatment. Setting: Department of Surgery, University of Lund, Sweden. Patients: 164 patients referred to the clinic for treatment of symptomatic primary varicose veins. Eighty patients were randomized to surgery and 84 to CST. Interventions: Sclerotherapy was applied using the ‘empty vein’ technique followed by compression bandage for 6 weeks. The extent of surgery was determined by each patient's disease and included flush ligation of the long or short saphenous veins and subsequent stripping, ligation of incompetent perforating veins and resection of local varicosities. Main outcome measures: The recurrence rate of varicose veins and incompetence of perforators and saphenous veins. Results: Good results were achieved in both treatment groups immediately after the procedure, but the failures appeared earlier in the CST group and the number was higher compared with the surgery group. After 5 years only 10% of the operated patients were considered as treatment failures compared with 74% of the patients treated with CST. The clinical results were supported by the foot volumetry measurements. Conclusions: This study clearly indicates that patients with primary varicose veins and incompetent saphenous veins should be treated with surgery, and CST should be confined to local varicosities, isolated insufficient perforators or recurrences after adequate surgery.
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Zolotukhin, Igor A., Evgeny I. Seliverstov, Elena A. Zakharova, and Alexander I. Kirienko. "Short-term results of isolated phlebectomy with preservation of incompetent great saphenous vein (ASVAL procedure) in primary varicose veins disease." Phlebology: The Journal of Venous Disease 32, no. 9 (October 19, 2016): 601–7. http://dx.doi.org/10.1177/0268355516674415.
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Objective To establish an effect of isolated phlebectomy in patients with incompetent great saphenous vein (Ambulatory Selective Varices Ablation under Local anesthesia (ASVAL) procedure) on the reflux and diameter of the trunk and to assess recurrence rate of varicose veins at one year. Material and methods We conducted a prospective study on patients with primary varicose veins and with C2 or C2,3 or C2,3,4 or C2,4 classes of chronic venous disease and great saphenous vein incompetence. The study included 67 patients (51 women and 16 men; 75 limbs in total). Age varied from 17 to 71 years; mean age was 46.8 years (SD 13.9). We recorded the presence or absence of reflux in the great saphenous vein with duplex ultrasound before and after surgery. The recurrence of varicose veins was evaluated at 12 months. All the patients underwent isolated phlebectomy with preservation of incompetent great saphenous vein (ASVAL procedure) under local anesthesia. Results At one year after removing of tributaries of the incompetent trunk, 66% of them were competent. Reflux persisted in 17% of great saphenous veins with reflux above mid-thigh and in 61% of trunks with reflux extended below the mid-thigh (p = 0.0004). The diameter of all the veins decreased significantly no matter reflux disappeared or not. Varicose veins reoccurred in 13.5% cases. In 6.5% of limbs with a reflux above the mid-thigh, the recurrence was registered at one year, while in the limbs with the reflux below the mid-thigh at a baseline, the recurrence rate was 25% (p = 0.036). Conclusion Isolated phlebectomy with a preservation of incompetent great saphenous vein leads to disappearance of reflux in a majority of cases and to significant decrease of vein diameter in all the cases. ASVAL procedure could be considered as a less aggressive and less expensive approach in selected cases. Clear indications for isolated phlebectomy need to be established.
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Bean, Graham, Shizuhiko Nishisato, Neil A. Rector, and Graham Glancy. "The Assessment of Competence to Make a Treatment Decision: An Empirical Approach." Canadian Journal of Psychiatry 41, no. 2 (March 1996): 85–92. http://dx.doi.org/10.1177/070674379604100205.
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Objective: To compare physicians' judgements of competency in routine clinical practice with the findings obtained from a structured clinical interview. Methods: Ninety-six patients referred for electroconvulsive therapy were administered the Competency Interview Schedule (CIS) prior to their first treatment. Cluster analysis was employed to categorize patients to 1 of 5 cluster centres represented by case studies previously judged competent or incompetent by lawyers and health professionals. Results: A match-mismatch table revealed 88% (N = 66) of the 75 patients found competent by the attending physician and 90.5% (N = 19) of the 21 patients found incompetent by the attending physician were classified in agreement with the CIS. The 9 misclassified patients found competent by the attending physician but classified incompetent by the CIS had consented to treatment. The 2 misclassified patients found incompetent by the attending physician but classified competent by the CIS had refused treatment. Examination of individual item scores from the CIS indicated that, in some cases, a different standard of competency was applied in routine clinical practice depending upon the patient's treatment decision. Conclusions: The CIS is presented as a useful guide for clinicians with an interest in competency evaluations but caution is advised in using the instrument to make formal evaluations of competency owing to the imprecise definition of competency in various jurisdictions.
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Nelzén, P. Oskar E., Johan Skoog, Malin Öster, and Helene Zachrisson. "Impact on venous haemodynamics after treatment of great saphenous vein incompetence using plethysmography and duplex ultrasound." Phlebology: The Journal of Venous Disease 35, no. 7 (January 20, 2020): 495–504. http://dx.doi.org/10.1177/0268355519898952.
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Objectives To evaluate postoperative venous haemodynamics and quality of life after treatment of great saphenous vein (GSV) incompetence. Methods Radiofrequency ablation and high ligation and stripping were performed in 62 patients (65 limbs) and 58 (65 limbs), respectively. Phlebectomies were performed in both modalities. Strain-gauge plethysmography on the foot combined with superficial venous occlusion was used to measure refilling time after knee bends. Strain-gauge plethysmography, duplex ultrasound and quality of life were assessed before and one month after treatment. Results Duplex ultrasound displayed successful intervention in all but two limbs. Refilling time increased similar in radiofrequency ablation and high ligation and stripping after treatment ( p < 0.001). Postoperatively, strain-gauge plethysmography detected remaining reflux in 71% of the patients. Multivariate analysis showed that two or more incompetent calf branches were associated with remaining reflux (OR 4.82 (95% CI: 1.33–17.5), p = 0.02). No difference in quality of life was seen in patients with remaining reflux. Conclusions Despite successful treatment, a majority of the limbs showed remaining reflux, in which incompetent calf branches appear to play an important role. Clinicaltials.gov: Lower Limb Venous Insufficiency and the Effect of Radiofrequency Treatment Versus Open Surgery. Nr: NCT02397226
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Gloviczki, P. "Surgical Treatment of the Superficial and Perforating Veins." Phlebology: The Journal of Venous Disease 15, no. 3-4 (December 2000): 131–36. http://dx.doi.org/10.1177/026835550001500309.
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Objective: To review the techniques and results of surgical treatment of the superficial and perforating veins in patients with chronic venous insufficiency. Methods: The current techniques used at the Mayo Clinic for treatment of simple varicose veins and venous ulcers are presented. Results of subfascial endoscopic perforator vein surgery (SEPS) are discussed and data from large centres are tabulated. Results are compared with those reported following non-operative management. Synthesis: High ligation and invagination stripping of the incompetent segment of the saphenous vein, with stab avulsion of branch varicosities, is the optimal surgical technique to ablate superficial venous incompetence. SEPS is safer than open perforator vein ligation and is the technique of choice to interrupt incompetent perforating veins. A review of 12 series on SEPS, that included 361 limbs, found an ulcer recurrence rate of 10% in those 211 patients who underwent ablation of superficial reflux together with SEPS. One hundred and fifty limbs had SEPS alone, without saphenous stripping: ulcer recurrence in this group at a mean of 23 months was 12%. Results in primary valvular incompetence were significantly better than in post-thrombotic syndrome. Conclusions: Ablation of superficial reflux remains the main surgical treatment of all forms of chronic venous insufficiency. SEPS is safe and effective to interrupt medial calf perforators and results in rapid ulcer healing and low recurrence in patients with primary valvular incompetence. The treatment of post-thrombotic syndrome remains a challenge. Results of the North American Venous Ulcer Surgery (NAVUS) trial, a prospective, randomised, multicentre study, will be required to provide level 1 evidence of the effectiveness of surgical treatment over medical therapy in the treatment of venous ulcers.
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Emanuel, Ezekiel J. "A Communal Vision of Care for Incompetent Patients." Hastings Center Report 17, no. 5 (October 1987): 15. http://dx.doi.org/10.2307/3562665.
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Dobb, G. J. "Research without Informed Patient Consent in Incompetent Patients." Anaesthesia and Intensive Care 43, no. 3 (May 2015): 313–16. http://dx.doi.org/10.1177/0310057x1504300305.
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Hayden, J. "Summative assessment will protect patients from incompetent GPs." BMJ 311, no. 7015 (November 11, 1995): 1300. http://dx.doi.org/10.1136/bmj.311.7015.1300.
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Helmchen, Hanfried. "Research with patients incompetent to give informed consent." Current Opinion in Psychiatry 11, no. 3 (May 1998): 295–97. http://dx.doi.org/10.1097/00001504-199805000-00010.
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Swartz, Martha. "The Patient Who Refuses Medical Treatment: A Dilemma for Hospitals and Physicians." American Journal of Law & Medicine 11, no. 2 (1985): 147–94. http://dx.doi.org/10.1017/s0098858800008674.
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AbstractThis Article reviews recent case and statutory law concerning patients who refuse medical treatment. Among the special cases considered are: 1) the competent adult patient who refuses treatment on religious or privacy grounds; 2) the incompetent patient whose own wishes were never expressed, but whose family refuses treatment; 3) the incompetent patient who expressed the wish not to be treated before becoming incompetent; and 4) parents who refuse treatment on behalf of their child.It is pointed out that recent court decisions have blurred the distinctions between “extradordinary” care and “ordinary” care and between withholding and withdrawing life-sustaining treatment. Reference is made to the recent trend toward allowing the family of an incompetent patient to assert the patient’s rights without court intervention either in the form of direct court order or through guardianship proceedings.Finally, the implications of these legal developments for health care institutions are discussed. A protocol pertaining to incompetent patients is proposed. Health care institutions are encouraged to develop formal policies for dealing with patients who refuse treatment, and to work with their professional associations in lobbying for legislation which will clarify the law in this area.
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Vassilouthis, John, Angelos Kalovithouris, Athinodoros Papandreou, and Stergios Tegos. "The Symptomatic Incompetent Cervical Intervertebral Disc." Neurosurgery 25, no. 2 (August 1, 1989): 232–39. http://dx.doi.org/10.1227/00006123-198908000-00013.
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Abstract A series of 16 patients with symptoms such as pain in the neck, occiput, shoulder and arm; numbness in the hands: and/or difficulty in walking, is described. Neurological examination of the upper extremities disclosed signs of nerve roots dysfunction in 5 patients and long tract signs in 12, whereas examination of the lower extremities disclosed long tract signs in every patient. Positive contrast cervical myelograms suggested mild posterior bulging of one or two intervertebral discs in every patient, but computed tomographic myelograms invariably demonstrated a coincident narrow cervical spinal canal, thus revealing the true compressive potential of the aforementioned mild disc protrusion on the spinal cord. All patients underwent anterior cervical microdiscectomy of the offending disc or discs, which were found to be degenerated. No case of frank rupture of the anulus was identified. Response to treatment was graded as excellent in 12 patients, who had complete relief of symptoms, and good in 4 patients, who had mild residual complaints. This study suggests that incompetence (bulging) of a cervical intervertebral disc may acquire important clinical significance in the presence of a narrow spinal canal by compressing the spinal cord and the corresponding nerve roots. Surgical removal of the diseased disc may result in restoration of neurological function.
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Chastanet, S., and P. Pittaluga. "Influence of the competence of the sapheno-femoral junction on the mode of treatment of varicose veins by surgery." Phlebology: The Journal of Venous Disease 29, no. 1_suppl (May 2014): 61–65. http://dx.doi.org/10.1177/0268355514529207.
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Background It is usually agreed that incompetence of the sapheno-femoral junction (SFJ) is the main indication for stripping or ablation of the great saphenous vein (GSV) in the treatment of varicose veins (VVs). We wanted to test this assumption in our surgical treatment of varicose veins. Methods Study design: retrospective study of the surgical procedures for VVs in our centre between January and October 2012 in patients with reflux in the GSV. The SFJ was considered to be incompetent when both terminal and pre-terminal valves were assessed as incompetent by duplex ultrasound duplex imaging. We compared the preoperative clinical and haemodynamic data according to the surgical procedure performed. Results We reviewed a total of 389 LLs operated on for VVs in which reflux was present in the GSV. The SFJ was incompetent preoperatively in 189 LLs (48.6%). The GSV was treated in 78 cases (20.1%) stripping in 24 cases and radiofrequency ablation (RFA) in 54 cases, while phlebectomy with preservation of the GSV (ASVAL = Ambulatory Selective Varices Ablation under Local Anaesthesia) was done in the 311 remaining cases (79.9%). Incompetence of the SFJ led to stripping or RFA of the GSV in 38.1% of the cases only. Treatment by stripping or RFA was associated with male gender (50% vs 18.9% P < 0.01 χ2), an older age (62.5 vs 53.1 yrs P < 0.01 t-test), a greater body mass index (BMI) (26.1 vs 23.8 P < 0.01 t-test), a higher frequency of CEAP Class C4 to C6 (33.3% vs 4.8% P < 0.01 χ2), a higher frequency of symptoms (94.4% vs 73.6% P < 0.01 χ2) and a greater diameter of the GSV at the thigh (8.1 vs 5.2 mm P < 0.01 t-test). At last the presence of a focal dilatation of the GSV and an extension of the reflux below the lower half of the calf were also more frequent in case of stripping or RFA (respectively 55.6% vs 10.3% and 84.6% vs 18.3% P < 0.01 χ2). Conclusion An incompetent SFJ was not the only clinical feature which determined the choice for preservation or ablation of the GSV in patients with varicose veins. In our experience a greater age, a higher BMI, the presence of trophic skin changes, extension of the reflux below the knee and a more damaged GSV trunk were also taken into account in order to decide whether to ablate or to preserve the GSV.
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Alpers, Ann, and Bernard Lo. "Avoiding Family Feuds: Responding to Surrogate Demands for Life-Sustaining Interventions." Journal of Law, Medicine & Ethics 27, no. 1 (1999): 74–80. http://dx.doi.org/10.1111/j.1748-720x.1999.tb01438.x.
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The laws and ethical guidelines governing decision making for incompetent patients evolved from controversies in which family members refused life-sustaining interventions. These cases led to a consensus that advance directives to limit interventions should be respected and that a surrogate designated by the patient or specified by statute could refuse interventions, even when other relatives disagreed. Surrogate decision-making statutes and ethical principles about respect for delegated autonomy promote an active role for family members or other surrogates in medical decisions for incompetent patients. Inviting surrogates to participate actively in medical decisions recognizes the importance of the patient's personal community and assures that decisions will reflect the patient's own preferences and values.The standard approach to decisions for incompetent adults gives advance directives priority over a surrogate's substituted judgment, which in turn has priority over assessments of the patient's best interest. A patient may express advance directives by appointing a proxy, stating specific preferences, or articulating general values. We use case examples to illustrate the limitations of all three types of advance directives.
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Prabhu, M. Ajoo Anto, and Alok Mohanty. "Accuracy of clinical methods and doppler ultrasound in detection of incompetency of sapheno-femoral junction and perforators compared with operative results." International Surgery Journal 4, no. 10 (September 27, 2017): 3300. http://dx.doi.org/10.18203/2349-2902.isj20174165.
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Background: Varicose veins, though a common condition, many time remains asymptomatic. The accurate diagnosis of varicose veins is of great importance in planning effective treatment. It is essential to bring out the accuracy of various diagnostic methods of varicose veins, so that early intervention can be achieved and recurrence can be prevented. The objective of this study was to our study was done with the intention of assessing the accuracy of Clinical evaluation of incompetence of Sapheno-Femoral Junction (SFJ) and perforators over doppler ultrasound evaluation and its Intra-operative confirmation, and also to assess the sensitivity, specificity, positive and negative predictive values and significance of both clinical as well as doppler ultrasound evaluation of varicose veins.Methods: The study was conducted in the in-patients of General Surgery Department from September 2011 to August 2013. Patients presented with dilated tortuous veins in lower limb(s) and operated were included in the study. Patients who had recurrent varicose veins and who were unfit for surgery were excluded from the study. The patients were first evaluated clinically using Brodie - Trendelenburg Test I and II, Tourniquet Test, Schwartz Test, Pratt’s Test, Morrissey’s Cough Impulse Test and Fegan’s Method. Following this, patients were evaluated by Ultrasound Doppler study of Venous system of the Lower limb(s) and sites of perforator incompetence were marked. Intra-operative confirmation of incompetence was done by Turner Warwick’s Bleed back sign. The accuracy of clinical methods and doppler ultrasound evaluation compared with operative findings were assessed.Results: Accuracy of clinical methods in detecting SFJ incompetence was checked with intra-operative findings. The sensitivity was 100%, specificity 100%, PPV 100% and NPV 100%. Similar results were obtained when checking the accuracy of doppler with intra-operative findings. Accuracy of clinical methods in detecting perforator incompetence was checked with intra-operative findings. The sensitivity was 82.93%, specificity 22.22%, PPV 90.67% and NPV 12.5%. Accuracy of doppler evaluation in detecting perforator incompetence was checked with Intra-operative findings. The sensitivity was 97.56%, specificity 12.5%, PPV 91.95% and NPV 33.33%.Conclusions: Diagnosis of varicose veins is essential for planning of treatment if needed. Clinical methods predict the diagnosis of incompetent SFJ and perforators for which patient need not spend money, and are easy to perform. But doppler ultrasound evaluation has been proved to be more reliable, non-invasive and compatible in detecting venous incompetence. Hence, we conclude that doppler ultrasound evaluation is more accurate than clinical methods in detecting incompetent veins.
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Santiago, Fabricio R., Mario Piscoya, and Yung-Wei Chi. "A sonographic study of thigh telangiectasias." Phlebology: The Journal of Venous Disease 33, no. 7 (July 6, 2017): 500–501. http://dx.doi.org/10.1177/0268355517717404.
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Introduction To date, there are limited descriptive data on the ultrasonographic characteristics of reticular and perforator veins associated with telangiectasias of the thigh. Objectives Evaluate the prevalence, anatomic correlations of reticular and perforator veins associated with lateral thigh telangiectasias. Methods This was a cohort study performed between June and December of 2014. Twenty-four female patients (43 limbs) with telangiectasias of the lateral thigh were evaluated by duplex ultrasound. Reticular and perforator veins were characterized according to valvular competency, vein diameter and connection with perforator veins at the thigh. Body mass index, current use of oral contraceptive, and history of pregnancy correlation data were also collected. A non-parametric Kruskal-Wallis test and a Student's t-test test were used for analysis. Results All 43 limbs had incompetent reticular veins underlying telangiectasias sites. A total of 20 incompetent perforator veins were found to be connected to the reticular veins. Obese and overweight patients had a higher prevalence of incompetent perforator veins and larger reticular veins when compared to those with normal weight (P < 0.05). Lower extremities with telangiectasias had a higher frequency of total perforator veins (n = 33) and incompetent perforator veins (n = 16) than extremities without telangiectasias (p = 0.001). Conclusion Lateral thigh telangiectasias were associated with both incompetent reticular and perforator veins. Obese and overweight patients were especially affected.
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Berridge, D. C., K. G. Mercer, C. Thornton, M. J. Weston, and D. J. A. Scott. "A Pilot Study Comparing the Use of Below-Knee and Above-Knee Graduated Stockings in Patients with Superficial Venous Incompetence." Phlebology: The Journal of Venous Disease 14, no. 1 (March 1999): 12–16. http://dx.doi.org/10.1177/026835559901400104.
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Objective: Investigation of the effects of high- and low-ankle-pressure, above- and below-knee compression stockings on the haemodynamics of normal and superficially incompetent venous systems. Design: Prospective duplex study of a normal group and a venous incompetence group randomised to high- or low-pressure stockings. Setting: Vascular services of a University Hospital. Subjects: Six subjects with normal venous haemodynamics (12 limbs) and 12 patients with superficial venous incompetence (20 limbs). Methods: Subjects wore below-knee and then above-knee stockings for 1 week each. Duplex scans were performed at the outset and end of the study and on fitting and after wearing each stocking type. Main outcome measures: Duplex-derived femoral and popliteal venous velocities were measured and indexed against the initial velocity. Results: Below-knee stockings produced only minor changes. Above-knee stockings produced increased velocities in normal subjects. Similar changes were only seen with higher-pressure stockings in patients with incompetence. Conclusion: Above-knee, high-ankle-pressure stockings produce increased deep venous flow velocities.
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Schanzer, H., M. Skladany, and E. C. Peirce. "The Role of External Banding Valvuloplasty in the Surgical Management of Chronic Deep Venous Disease." Phlebology: The Journal of Venous Disease 9, no. 1 (March 1994): 8–12. http://dx.doi.org/10.1177/026835559400900103.
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Objective: Correction of venous reflux by perivalvular banding in patients suffering from chronic venous stasis secondary to primary valvular incompetence. Design: Prospective study in a group of patients with severe venous insufficiency. One patient (one extremity) was lost to follow-up. Setting: Tertiary care teaching hospital. Patients: Twelve patients (13 extremities) with severe or moderate venous insufficiency. Interventions: Correction of valvular incompetence by narrowing a valvular ring with an external band. Twenty-seven bands were fitted to incompetent valves of 13 extremities. Main outcome measures: Abolition of reflux and improvement of muscle pump measured by clinical, plethysmographic and venographic criteria. Results: Symptomatic improvement was found in 10 extremities (77%) and complete correction of reflux on venography in eight extremities (67%). Plethysmographically measured reflux improved in 6 extremities (50%) and muscle pump function improved in 7 extremities (58%). No correlation was found between plethysmographic and clinical or venographic outcome. Conclusion: Perivalvular banding can correct reflux and alleviate clinical symptoms of chronic venous stasis in patients with primary valvular incompetence. Selection of patients, valves to be corrected, necessary degree of valvular ring narrowing and need for additional interventions should be further investigated.
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Sundram, Clarence J., and Paul F. Stavis. "Obtaining Informed Consent for Treatment of Mentally Incompetent Patients." International Journal of Law and Psychiatry 22, no. 2 (April 1999): 107–23. http://dx.doi.org/10.1016/s0160-2527(98)00033-8.
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