Clinical Efficacy of Conservative Treatment with Micronized Purified Flavonoid Fraction in Female Patients with Pelvic Congestion Syndrome

Deep learning and radiomics-driven algorithm for automated identification of May-Thurner syndrome in Iliac CTV imaging

Objective

This research aimed to create a dataset of Iliac CTV scans for automated May-Thurner syndrome (MTS) detection using deep learning and radiomics. In addition, it sought to establish an automated segmentation model for Iliac Vein CTV scans and construct a radiomic signature for MTS diagnosis.

Methods

We collected a dataset of 490 cases meeting specific inclusion and exclusion criteria, anonymized to comply with HIPAA regulations. Iliac Vein CTV scans were prepared with contrast agent administration, followed by image acquisition and evaluation. A deep learning-based segmentation model, UPerNet, was employed using 10-fold cross-validation. Radiomic features were extracted from the scans and used to construct a diagnostic radiomic signature. Statistical analysis, including Dice values and ROC analysis, was conducted to evaluate segmentation and diagnostic performance.

Results

The dataset consisted of 201 positive cases of MTS and 289 negative cases. The UPerNet segmentation model exhibited remarkable accuracy in identifying MTS regions. A Dice coefficient of 0.925 (95% confidence interval: 0.875-0.961) was observed, indicating the precision and reliability of our segmentation model. Radiomic analysis produced a diagnostic radiomic signature with significant clinical potential. ROC analysis demonstrated promising results, underscoring the efficacy of the developed model in distinguishing MTS cases. The radiomic signature demonstrated strong diagnostic capabilities for MTS. Within the training dataset, it attained a notable area under the curve (AUC) of 0.891, with a 95% confidence interval ranging from 0.825 to 0.956, showcasing its effectiveness. This diagnostic capability extended to the validation dataset, where the AUC remained strong at 0.892 (95% confidence interval: 0.793-0.991). These results highlight the accuracy of our segmentation model and the diagnostic value of our radiomic signature in identifying MTS cases.

Conclusion

This study presents a comprehensive approach to automate MTS detection from Iliac CTV scans, combining deep learning and radiomics. The results suggest the potential clinical utility of the developed model in diagnosing MTS, offering a non-invasive and efficient alternative to traditional methods.

Pelvic Varicose Veins in Women. Russian Experts Consensus

Pelvic Varicose Veins in Women. Russian Experts Consensus.

Medical treatment for pelvic congestion syndrome with flavonoid: A pilot study

OBJECTIVE

To investigate the efficacy of medical management by flavonoid in women with pelvic congestion syndrome (PCS) by comparison of the changes in venous size and quality of life (QoL) before and after treatment.

MATERIALS AND METHODS

Eleven women who met the diagnostic criteria of PCS were enrolled in the study. Flavonoid 500 mg twice or 1000 mg once daily was prescribed. Objective outcome was evaluated by measurement of ovarian vein diameter via transvaginal ultrasound in each case before and after 3-6 months of the treatment. PCS related symptoms were evaluated by Pelvic Varicose Vein Questionnaire (PVVQ), and Visual Analog Scale (VAS) as subjective outcomes. Wilcoxon signed rank test was used to compare the differences pre- and post-treatment. Data analysis was performed using SPSS 22.0. Statistical significance was defined as P value < 0.05.

RESULTS

From January 2022 to September 2023, 11 women met the criteria and were diagnosed with pelvic congestion syndrome. The age ranged from 40 to 72 years old with mean of 57 y/o. 90.9 % of the subjects (10/11) reported significant decreases in VAS (mean = 5.9 pre-vs. 2.5 post-treatment, p = 0.005) and PVVQ (mean = 51.6 pre-vs. 30.5 post-treatment, p = 0.005). Transvaginal ultrasound also showed significant decreases in ovarian vein diameter, from 8.1 mm to 6.2 mm (p = 0.016).

CONCLUSION

Our study demonstrated that medical treatment with flavonoids significantly reduced of ovarian venous diameter in patients with pelvic congestion syndrome. Additionally, the impaired quality of life was markedly improved proven by the significant decreases of PVVQ and VAS scores following treatment. Based on these findings, we suggest that flavonoids may be considered as first-line treatment for patients with pelvic congestion syndrome in routine clinical practice.

Diagnosis and Management of Pelvic Venous Disorders in Women

Pelvic venous reflux and obstruction can lead to chronic pelvic pain and extra-pelvic varicosities. This paper will discuss the contemporary understanding of this pathophysiology and its clinical manifestations. It will review evidence-based clinical and imaging criteria of pelvic venous disorders, data supporting benefit from venous interventions, criticisms of the available data and highlight evidence research gaps that exist. Finally, it will argue that comparative outcomes research utilizing standardized patient selection for embolization and stenting, embolization treatment strategies that eliminate the pelvic varices (at least to start), and clinically relevant outcome measures are necessary to establish the benefit of vascular treatments.

Identification of outcomes in clinical studies for pelvic venous disorders

OBJECTIVE

There is increasing recognition that health systems need to measure and improve the value of patient care by measuring outcomes. Chronic pelvic pain secondary to pelvic venous insufficiency can have a significant impact on the quality of life (QOL) of women affected. Despite growing recognition, pelvic venous disorders (PeVDs), an important cause of chronic pelvic pain, remain underdiagnosed. Developing a core outcome set (COS) for benchmarking care delivery enhances the standardization of care. However, there is no consensus regarding a standardized minimum set of outcomes for PeVD. We aimed to generate a list of outcomes reported in previous PeVD treatment studies to lay the foundation for developing a COS for PeVD.

METHODS

This scoping review was undertaken according to the PRISMA-ScR guidelines. Initially, screening, full-text review and extraction was conducted on studies published between 2018 and 2023. Subsequently, the search was expanded using 1-year intervals, until, over a 1-year interval, no new outcomes were recorded. Closely related outcomes were classified into domains, and domains into three core areas: disease-specific, treatment-related, and QOL-related outcomes.

RESULTS

Of the 1579 records identified, 51 publications were included. From these studies, 108 different outcomes were identified. The median number of outcomes per study was 8 (interquartile range, 6-13). Closely related outcomes were organized into 42 outcome domains, which were then categorized into 3 core outcome areas; 47.6% (20/42) were disease specific, 35.7% (15/42) treatment related, and 16.7% (7/42) were QOL related. Of the 51 included studies, disease-specific outcomes were identified in 96.1% of the studies (49/51), treatment-related outcomes in 94.1% (48/51), and QOL outcomes in only 13.7% (7/51).

CONCLUSIONS

There was significant heterogeneity in outcomes reported in PeVD studies. Most PeVD treatment studies evaluated disease-specific and treatment-related outcomes of PeVD, but few reported outcomes that measured the impact on QOL. These findings will inform the next steps in developing a COS for PeVD.

Effects of Venoactive Drug Therapy and Ovarian Vein Interventions on Vasoactive Neuropeptide and Cytokine Levels in Patients with Pelvic Venous Disorders

BACKGROUND

To study and compare the effects of venoactive drug (VAD) therapy and ovarian vein embolization or resection (OVE or OVR, accordingly) on the levels of vasoactive peptides and cytokines in patients with pelvic venous disorders (PeVDs).

METHODS

The study included 70 consecutive female patients with PeVD symptoms, such as chronic pelvic pain (CPP), dyspareunia, dysuria, and vulvar varicosities. Based on the results of clinical examination and duplex ultrasound of the pelvic veins, the patients were allocated to the VAD therapy (n = 38) or OVE/OVR (n = 32). Additionally, the enzyme-linked immunosorbent assay tests were performed to determine levels of calcitonin gene-related peptide (CGRP), substance P (SP), interleukins 6 and 8 (IL-6, IL-8) and monocyte chemotactic protein-1 (MCP-1) after a 2-month course of VAD therapy and at 3 months after OVE/OVR.

RESULTS

The VAD therapy was associated with a significant decrease in CPP in 84% of patients with PeVD and isolated lesions of the parametrial veins (PVs) and uterine veins (UVs). VAD had no significant effect on the pelvic venous reflux. No changes in the CGRP, SP, IL-6, IL-8, and MCP-1 levels were detected after treatment. At 3 months after OVE or OVR, all patients with PeVD and combined lesions of the ovarian veins (OVs), PVs and UVs reported almost complete relief of CPP. Along with elimination of reflux in ovarian veins, the disappearance of reflux in PVs and UVs was noted. A decrease in the CGRP and SP levels was observed (0.7 ± 0.1 ng/mL and 0.12 ± 0.02 ng/mL before treatment; 0.5 ± 0.12 ng/mL and 0.09 ± 0.06 ng/mL after treatment, respectively; all P < 0.05). No changes in cytokine levels were revealed.

CONCLUSIONS

Treatment with VAD is associated with the CPP relief, but has no significant effect on the CGRP, SP, IL-6, IL-8, and MCP-1 levels. OVE/OVR results in the CPP relief, elimination of the pelvic venous reflux and a significant decrease in the CGRP and SP levels, but does not change cytokine levels.

The Effects of Different Dosages on Micronized Purified Flavonoid Fraction's Treatment of Lower Limb Chronic Venous Disease: A Meta-Analysis

BACKGROUND

Micronized purified flavonoid fraction (MPFF) is a widely prescribed and extensively investigated venoactive drug (VAD). The standard dosage for MPFF is 500 mg administered twice daily. However, a new daily dose of 1000 mg has just been introduced.

OBJECTIVE

This study investigated whether a daily dose of 1000 mg MPFF could be implemented and embraced by the public and still has the same therapeutic effects as conventional pharmaceuticals.

METHODS

For this meta-analysis, we searched MEDLINE, Embase, Science of Web, Cochrane, and PubMed databases and forward and backward citations for studies published between database inception and March 2023. Three randomized controlled trials (RCTs) of comparison of different dosages of MPFF to evaluate whether there is a significant difference between them were included, without language or date restrictions. Due to the small sample size of the study included, we conducted a simple sensitivity test using a one-by-one exclusion method, and the results showed that the study did not affect the final consolidation conclusion. The quality of the evidence was assessed using the Cochrane risk-of-bias tool.

RESULTS

Out of 232 studies, 99 were eligible and 39 RCTs had data, all with low to moderate bias. Overall, 1924 patients (experimental group: 967, control group: 957) in 3 RCTs met the criteria. There is no significant difference in patient compliance, efficacy, clinical adverse events, and quality of life scores between MPFF 1000 mg once daily and MPFF 500 mg twice daily (standardized mean difference [SMD]: 0.049 [0.048, 0.145], p=0.321, risk ratio [RR]: 0.981 [0.855, 1.125], p=0.904, and SMD: 0.063 [0.034, 0.160], p=0.203).

INTERPRETATION

In symptomatic chronic venous disease patients, MPFF 1000 mg once daily and MPFF 500 mg twice daily improve patient compliance, lower limb discomfort, clinical adverse events, and quality of life scores similarly. Regular medical care should recommend MPFF 1000 mg daily more often.

CLINICAL IMPACT

Micronized purified flavonoid fraction (MPFF) is a popular venoactive medication (VAD) in modern medicine.MPFF is effective in treating lower extremity venous problems.Currently, besides conventional 500 mg tablets, there exist alternative dosage forms such as solutions, chewable tablets, and other novel formulations for MPFF.The excessive frequency and amount of medication may have a negative impact on patient adherence.

Diagnosis and Management of Pelvic Congestion Syndrome: Comprehensive Review

BACKGROUND

Pelvic congestion syndrome (PCS) is a poorly understood condition that can be associated with chronic pelvic pain and could impact quality of life. The diagnosis is often made by exclusion of other causes of pelvic pain.

OBJECTIVE

The purpose of our review was to provide an update on the etiology, anatomy, physiology, identification, and the therapeutic management of PCS.

METHOD

We conducted a literature review involving publications from 2003 to 2024 in PubMed, Elsevier, MEDLINE, as well as manual searches of primary and review articles using keywords such as "pelvic veins", "embolization", "venography", "pelvic congestion syndrome", and "chronic pelvic pain".

CONCLUSION

PCS remains poorly understood. Symptoms can be non-specific and difficult to distinguish from other diseases; yet it is an important cause of chronic pelvic pain in women. To date, there have been only a small number of randomized trials and high-level evidence is still lacking.

OUTLOOK

We call for an increased awareness of PCS and additional clinical studies in a large number of patients.

Chronic Pelvic Pain in Congestion Pelvic Syndrome: Clinical Impact and Electromyography Pelvic Floor Activity Prior to and after Endovascular Treatment

BACKGROUND

This study aims to characterize the clinical impact of endovascular treatment in Chronic Pelvic Pain (CPP) patients due to Pelvic Congestion Syndrome (PCS) and to assess the diagnostic value of surface electromyography (sEMG) studies of pelvic floor musculature (PFM) in PCS patients pre- and post-endovascular treatment. Between January 2019 and July 2023, we studied consecutive patients who were referred for interventional radiology assessment and treatment to a tertiary trauma care hospital, had evidence of non-obstructive PCS from Magnetic Resonance Imaging (MRI), had sEMG of PFM and who had undergone endovascular treatment. The primary outcome was clinical, defined as a change in symptom severity after endovascular treatment. The secondary outcome was a difference in the sEMG values pre- and post-endovascular therapy.

RESULTS

We included 32 women (mean age 38 years). CPP was the leading symptom in 100% patients, followed by dysmenorrhea (75%) and post-coital pain (68.7%). Endovascular therapy included ovarian vein embolization in 28 patients (87.5%) and internal iliac vein embolization in only 2 patients (6.2%). After a median of 8 (range 6-10) months from endovascular treatment, 29 (90%) of patients reported an improvement of the main symptoms, and 15 (46%) were symptom-free. The sEMG values did not show a statistical difference pre- and post-PCS endovascular treatment.

CONCLUSIONS

Endovascular treatment appeared to be highly effective in CPP due to PCS and was associated with a low rate of complication. sEMG study could be useful in revealing alterations of PFM electrophysiology, but a difference pre- and post-embolization in PCS patients was not demonstrated.

A review of the pathophysiology and evidence-based management of varicoceles and pelvic congestion syndrome

Pelvic congestion syndrome (PCS) in females and varicoceles in males may be regarded as closely related conditions since the main pathophysiological cause for both processes is pelvic venous insufficiency. Varicoceles are more prevalent amongst sub-fertile males, with an approximate incidence of 15% in the general male population. PCS is commonly diagnosed amongst premenopausal multiparous women, representing one of the leading causes of chronic pelvic pain. Both conditions appear to be predominantly left-sided and are associated with oxidative stress and pro-inflammatory cascades with subsequent effects on fertility. Clinical examination and pelvic ultrasonography play an essential role in the assessment of varicoceles, PCS and chronic pelvic pain. Venography is generally considered as a gold-standard procedure for both conditions. There is still much debate on how these conditions should be managed. This review article provides a comparative analysis of the underlying pathophysiological mechanisms of both PCS and varicoceles, their impact on fertility, as well as their clinical management.

Painful Ejaculation In A Patient With Pelvic Venous Insufficiency

Pelvic venous insufficiency (PVI) is common in women but has been rarely diagnosed in men. The clinical manifestations include varicocele and pelvic disturbances; however, we were unable to find a previous description of painful ejaculation as a symptom of PVI. We present the case of a 36-year-old man with a 7-year history of severe sharp ejaculatory pain. PVI was suspected after previous treatment attempts. The diagnosis was confirmed by descending phlebography, and he underwent coil embolization of the pelvic vessels and phlebotonic therapy. At 6 months after treatment, he reported a 75% improvement in his condition. Therefore, painful ejaculation should be considered an uncommon manifestation of PVI.

Strategies and challenges in treatment of varicose veins and venous insufficiency

Patients with varicose veins can be treated with conservative or surgical approaches based on the clinical conditions and patient preferences. In the recent decade, the recommendations for managing symptomatic varicose veins have changed dramatically due to the rise of minimally invasive endovascular techniques. The literature was systematically searched on Medline without language restrictions. All papers on the treatment of varicose veins and venous insufficiency with different procedures were included and reviewed. Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) both are same safe and effective in terms of occlusion rate, and time to return to normal activity. In comparison with RFA or EVLT, Cure conservatrice et Hemodynamique de l'Insufficience Veineuse en Ambulatoire (CHIVA) may cause more bruising and make little or no difference to rates of limb infection, superficial vein thrombosis, nerve injury, or hematoma. In terms of recurrence of varicose veins, there is little or no difference between CHIVA and stripping, RFA, or EVLT. Great saphenous vein recanalization is highest in the ultrasound-guided foam sclerotherapy (FS) group (51%) during 1 year of follow-up. The 2013 National Institute for Health and Care Excellence clinical guidelines recommend surgery as a third-line therapeutic option after EVLA or RFA and sclerotherapy. Although the mechanochemical endovenous ablation (MOCA) is a non-thermal, non-tumescent option and appears to be of similar efficacy to stab avulsion with no potential risk of nerve damage, the overall success rate of MOCA is lower than those of other procedures such as EVLA, RFA, or high ligation and stripping. EVLA is the most cost-effective therapeutic option, with RFA being a close second for the treatment of patients with varicose veins. Endovenous thermal ablation (EVLA or RFA) is recommended as a first-line treatment for varicose veins and has substituted the high ligation of saphenofemoral junctional reflux and stripping of varicose veins. Ultrasound-guided FS is associated with a high recurrence rate and can be used in conjunction with other procedures. MOCA and cyanoacrylate embolization appear promising, but evidence of their effectiveness is required.

Micronized Curcumin Causes Hyperlocomotion in Zebrafish Larvae

Zebrafish larvae have been widely used in neuroscience and drug research and development. In the larval stage, zebrafish present a broad behavioral repertoire and physiological responses similar to adults. Curcumin (CUR), a major component of Curcuma longa L. (Zingiberaceae), has demonstrated the ability to modulate several neurobiological processes relevant to mental disorders in animal models. However, the low bioavailability of this compound can compromise its in vivo biological potential. Interestingly, it has been shown that micronization can increase the biological effects of several compounds. Thus, in this study, we compared the effects of acute exposure for 30 min to the following solutions: water (control), 0.1% DMSO (vehicle), 1 μM CUR, or 1 μM micronized curcumin (MC) in zebrafish larvae 7 days post-fertilization (dpf). We analyzed locomotor activity (open tank test), anxiety (light/dark test), and avoidance behavior (aversive stimulus test). Moreover, we evaluated parameters of oxidative status (thiobarbituric acid reactive substances and non-protein thiols levels). MC increased the total distance traveled and absolute turn angle in the open tank test. There were no significant differences in the other behavioral or neurochemical outcomes. The increase in locomotion induced by MC may be associated with a stimulant effect on the central nervous system, which was evidenced by the micronization process.