Nutcracker syndrome is a rare entity in which compression of the left renal vein (LRV), usually by the overlying superior mesenteric artery (SMA), results in renal venous congestion and reflux in the left ovarian vein (LOV). Patients may present with hematuria, left flank pain, dyspareunia, and vaginal or abdominal wall varicose veins. We report a patient with nutcracker syndrome who presented atypically with left flank pain that was exacerbated in the postprandial state. We hypothesize that the physiologic dilation of the SMA after oral intake caused increased LRV compression at that site and augmented lateral LRV distention. The patient had no evidence of SMA syndrome or chronic mesenteric insufficiency. Her symptoms resolved after we performed an LOV to inferior vena cava transposition.

Background: Meconium stained liquor is a commonly observed phenomenon in the day-to-day obstetric practice, the incidence being 12-22%. Meconium stained liquor can be considered as a normal physiological event in a term fetus in the absence of fetal heart rate abnormalities. It has greater significance as one of the parameters of fetal distress, when associated with abnormal fetal heart rate pattern. The aim of the present study was to study the association of, fetal heart rate abnormalities, mode of delivery and neonatal outcome with different grades of meconium stained liquor.Methods: A prospective study was conducted in one hundred and fifty cases of meconium stained liquor beyond 37 weeks gestation admitted to the labor room in a tertiary care Centre. Depending on the consistency of meconium, the patients were divided into two groups namely, Thick meconium stained liquor (group K) and Thin meconium stained liquor (group N). Maternal conditions, Intrapartum fetal heart rate pattern, Apgar scores and neonatal morbidities were studied in relation to the grade of meconium. The proportions between the two groups were compared using chi-square test and Fisher’s exact t-test.Results: The incidence of post term pregnancy (p=0.004), unbooked (p=0.007) status and oligohydramnios (p=0.01) were significantly higher among group K when compared to group N. Non-reassuring fetal heart rate pattern (p=0.002) and Apgar score ≤7 (p=0.02) were significantly higher in group K. In group K, non-reassuring fetal heart rate pattern and reduced beat to beat variability were significantly associated with low Apgar score (p=0.01).Conclusions: Neonatal outcomes like low Apgar score, meconium aspiration syndrome are strongly associated with thick meconium stained liquor. Visual grading of liquor into thick and thin meconium stained may help in timely obstetric intervention leading to a better neonatal outcome.

Introduction: We conducted a survey of vascular surgery (VS) trainees and program directors (PDs) to examine differing attitudes regarding pregnancy, starting a family, and work-life balance. Methods: A 20 question survey was e-mailed to VS residents (0+5), fellows (5+2) and PDs using Survey Monkey Inc. (San Mateo, California). Results: The survey was sent to 781 participants (608 VS trainees, 173 PDs) with a similar response rate among residents [39% (133/343)), fellows [37% (98/265)], and PDs [38% (65/173)]. Of the 296 total respondents, most were male [61% (181)] and ≤40 years old [81% (240)]. VS trainees and PDs believed their work load or scheduling-coverage issues significantly increased when a trainee or peer was pregnant [PDs = 73% (38/52); fellows = 66% (59/89); residents = 54% (38/71), 13 PDs, 7 fellows and 59 residents had never worked with a pregnant peer or trainee]. Male respondents overall were significantly more likely than females to opine that a pregnant vascular trainee or attending was less capable of performing her job while pregnant [28% (50/179) vs.16% (18/110); P = .024). Women overall reported each of the following factors more commonly than men as reasons for delaying childbearing: impairing professional advancement [42% (42/99) vs 14% (23/165); P < .001], limited time to devote to children [60% (59/99) vs 39% (64/165); P = .001], not wanting to burden peers or associates [36% (36/99) vs 13% (22/165); P < .001), extra stress [67% (66/99) vs 30% (50/165); P < .001], perceived negative view of peers and program directors towards pregnancy [29% (29/99) vs 1% (2/165); P < .001], and encouragement not to have children from peers or attending [15% (15/99) vs 2% (3/165); P < .001). More females than males overall regret their career choice in VS as it relates to starting a family [22% (24/107) vs. 12%; 21/170); P = .028]. When asked about the major barriers for female vascular surgeons who wanted to become pregnant, PDs cited an unsupportive home environment more than trainees [37% (24/65) vs 22% (51/231); P = .015], whereas trainees cited safety concerns affecting the pregnancy, such as radiation, more than PDs [71% (164/231) vs 43% (28/65); P < .001] Conclusions: There are significant differences in views toward pregnancy among males and females and among trainees and PDs overall. Contrasting gender-based perceptions of the impact of pregnancy on vascular training need to be addressed before adequate solutions to the challenge of work-life balance can be achieved. Significant opportunities exist for trainees and PDs to address these knowledge gaps.

Objective: The Society for Vascular Surgery stated there are a lack of studies describing long-term surveillance for aortobifemoral (AoBF) bypasses. Our goal was to investigate the value of DU studies as a surveillance tool for AoBF bypasses. Methods: We retrospectively identified patients in our prospectively maintained database who underwent AoBF bypasses between 1995-2018. Surveillance was performed routinely with DU post-operatively, every 6 months for 1 year, and then annually. We considered “abnormal” DU findings to include peri-graft fluid, pseudoaneurysm or, peak systolic velocities (PSVs) > 350 cm/sec or PSV ratio > 3.5 anywhere from the proximal aortic to distal femoral anastomosis. If abnormalities were identified patients underwent intervention or shorter surveillance intervals. Results: Of 153 AoBF bypasses, 60 patients with 120 graft limbs fulfilled our post-operative surveillance protocol with a mean follow-up of 4.0 years (0.5-24 years). “Normal” DU surveillance studies were documented throughout follow-up in 112 (93%) limbs. Of these, 2 (1.7%) developed acute limb occlusion. Eight (6.7%) limbs had “abnormal” DU findings: 5 failing grafts with focal elevated PSVs, 2 with peri-graft fluid leading to a diagnosis of an infected graft, and 1 with a pseudoaneurysm (PSA). Contrast arteriography or CT-angiography confirmed > 75% diameter stenosis, fluid or PSA in all 8 limbs. Graft revision (5 endovascular, 2 surgical) was performed in 7 of the 8 limbs initially or after 2 successive “abnormal” DU studies within 6 weeks of each other; 1 patient refused intervention. Without surveillance, urgent or emergent treatment might have proved necessary in 7.5% (7 + 2 = 9/120) of cases instead of only 1.7% (2/120) of cases. Conclusion: Vascular surgeons should adopt DU as a useful surveillance tool to identify AoBF bypasses that are failing or have other problems not identified clinically. Persistence of “abnormal” DU findings should prompt operative or endovascular intervention.

Background: Abnormal vaginal bleeding may be caused by an extensive spectrum of disorders, both gynecologic and non-gynecologic. Diagnostic accuracy of abnormal uterine bleeding is important for the management.  Trans vaginal sonography (TVS) is one of the commonest investigation used for the diagnosis, but the diagnosis is not always accurate for all clinical conditions. Saline instillation sonography (SIS) has been shown to improve the diagnosis. Authors aimed to compare the TVS and SIS diagnosis with the final histopathological diagnosis.Methods: Seventy-five patients with the complained of abnormal uterine bleeding attending outpatient department of a tertiary care institute were enrolled for the study. Trans vaginal sonography (TVS) and saline instillation sonography (SIS) was done on outpatient basis. The diagnosis was compared with final histopathological diagnosis, in term of diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value.Results: Seventy-five patients who were enrolled for the study. Sixty-four patients underwent surgery and final histopathological diagnosis was established. Four patients SIS was not possible, data was analysed for sixty patients.Conclusions: In SIS abnormal uterus diagnosis confidence was significantly improved (p value 0.001) when compared to TVS. The diagnosis of submucous myoma significantly improved (p=0.015) by SIS when compared to TVS. There was no significant difference between TVS and SIS diagnosis of Myoma remote from the endometrium (p=0.522), Adenomyosis (p=1), Focal endometrial abnormality (p=0.654) and Diffuse endometrial abnormality (p=1). The SIS sensitivity, specificity, PPV and NPV were either improved or same, when compare to TVS for all the diagnosis except for the diagnosis of focal endometrial abnormality.