OBJECTIVE: This study aims to evaluate the application value of contrast-enhanced transthoracic echocardiography (cTEE) in the diagnosis of patent foramen ovale (PFO) under different states of stimulation, with the goal of enhancing the accuracy and efficiency of PFO diagnosis.
METHODS: This research consecutively enrolled patients suspected of having PFO from October 2022 to February 2024, presenting primary clinical symptoms such as unexplained syncope, headache, dizziness, and stroke. Patients underwent standard transthoracic echocardiography (TTE) and cTEE under three different states of stimulation (resting state, coughing, and Valsalva maneuver). Based on the presence of microbubbles in the left heart and their initial appearance time, patients were classified into PFO and control groups, with further diagnostic confirmation via transesophageal echocardiography (TEE) or foramen ovale closure procedures.
RESULTS: The study results revealed significant differences between the PFO and control groups regarding age (p = 0.034) and headache symptoms (p = 0.001). In the PFO group, TTE showed a higher positivity rate both at rest and during coughing, highlighting the association between PFO and specific clinical symptoms. The number of microbubbles observed during TTE increased significantly under various stimulation states, particularly during the Valsalva maneuver (p < 0.05). This increase became more pronounced as the duration of the maneuver was extended, underscoring the differential response of PFO patients under varied physiological testing conditions, especially during prolonged Valsalva maneuvers.
CONCLUSIONS: The study confirms the significant value of cTEE in diagnosing PFO under different stimulation states, particularly emphasizing the application of the Valsalva maneuver to significantly improve the sensitivity and specificity of PFO detection. Thus, incorporating cTEE examinations under various stimulation states holds significant clinical importance for enhancing the accuracy and efficiency of PFO diagnosis.

UNASSIGNED: To use the three-dimensional (3D) ultrasound for assessment of pelvic floor muscle function in non-diabetic females with insulin resistance (IR), and to evaluate its functional relationship with insulin levels.
UNASSIGNED: From October 2022 to November 2023, 216 non-diabetic females with insulin-resistant (IR group) and 118 normal females (control group) were sequentially recruited from our hospital for our study. The 3D ultrasound was used to assess the levator hiatus in resting state for all females regarding diameter lines, perimeters and areas; as well as the Valsalva manoeuvre (VM). The t-test and linear regression model were used to analyse the collected data.
UNASSIGNED: The analysis indicates that there were significant differences in the resting state of the levator hiatus between the IR and the control groups (14.8 ± 5.8 cm2 and 11.6 ± 2.7 cm2, p < 0.05); and in the VM (18.2 ± 6.3 cm2 and 13.4 ± 3. 4 cm2, p < 0.05). In addition, the anterior-posterior (AP) diameters of the hiatus on VM were significantly increased in the IR group (40.0 ± 4.7 mm and 33.0 ± 4.4 mm, p < 0.05). With insulin levels as the dependent variable, multivariate regression analysis shows that insulin levels were significantly correlated with the levator hiatus area on VM (p < 0.05) and waist circumference (p < 0.05). The pelvic organ descent on VM in the IR group was significant (p < 0.05).
UNASSIGNED: The areas of resting state levator hiatus and on VM were significantly larger in the IR than that in the control groups. In addition, the position of the pelvic organ on VM in the IR group was significantly descended. The insulin levels were correlated with the pelvic floor muscle function.
With regard to insulin resistance and pelvic floor function, previous studies focused on the role of polycystic ovaries, metabolic syndrome, and pelvic prolapse. The use of ultrasound can improve understanding of the static, dynamic and organ prolapse conditions. This study aimed to assess pelvic floor muscle function in non-diabetic women with insulin resistance, a condition where the body uses insulin less effectively. A total of 216 women with insulin resistance and 118 without it were examined using 3D ultrasound during rest and while performing the Valsalva manoeuvre. Our results show that the pelvic floor muscles had extra space between them and moved differently in women with insulin resistance than in those without the condition. This suggests that insulin resistance may affect function of pelvic floor muscles to cause adverse consequences.

UNASSIGNED: In intracranial pathologic conditions of intracranial pressure (ICP) disturbance or hemodynamic instability, maintaining appropriate ICP may reduce the risk of ischemic brain injury. The change of ICP is often accompanied by the change of intracranial blood status. As a non-invasive functional imaging technique, the sensitivity of electrical impedance tomography (EIT) to cerebral hemodynamic changes has been preliminarily confirmed. However, no team has conducted a feasibility study on the dynamic detection of ICP by EIT technology from the perspective of non-invasive whole-brain blood perfusion monitoring. In this study, human brain EIT image sequence was obtained by in vivo measurement, from which a variety of indicators that can reflect the tidal changes of the whole brain impedance were extracted, in order to establish a new method for non-invasive monitoring of ICP changes from the level of cerebral blood perfusion monitoring.
UNASSIGNED: Valsalva maneuver (VM) was used to temporarily change the cerebral blood perfusion status of volunteers. The electrical impedance information of the brain during this process was continuously monitored by EIT device and real-time imaging was performed, and the hemodynamic indexes of bilateral middle cerebral arteries were monitored by transcranial Doppler (TCD). The changes in monitoring information obtained by the two techniques were compared and observed.
UNASSIGNED: The EIT imaging results indicated that the image sequence showed obvious tidal changes with the heart beating. Perfusion indicators of vascular pulsation obtained from EIT images decreased significantly during the stabilization phase of the intervention (PAC: 242.94 ± 100.83, p < 0.01); perfusion index which reflects vascular resistance increased significantly in the stable stage of intervention (PDT: 79.72 ± 18.23, p < 0.001). After the intervention, the parameters gradually returned to the baseline level before compression. The changes of EIT indexes in the whole process are consistent with the changes of middle cerebral artery velocity related indexes shown in TCD results.
UNASSIGNED: The EIT image combined with the blood perfusion index proposed in this paper can reflect the decrease of cerebral blood flow under the condition of increased ICP in real time and intuitively. With the advantages of high time resolution and high sensitivity, EIT provides a new idea for non-invasive bedside measurement of ICP.

OBJECTIVE: To investigate the superiority of transrectal high-frequency ultrasound (TRUS) in precise assessment of middle compartment prolapse in comparison with routine transperineal ultrasound (TPUS).
METHODS: Prospectively analyzed and compared detection rates of entire cervical length and uterine descent on TPUS and TRUS in 101 patients with pelvic organ prolapse (POP).
RESULTS: Detection rates of entire cervix on TRUS were significantly higher than those on TPUS both at rest and during Valsalva maneuver (90.10% VS 49.50%, 92.08% VS 9.90% respectively, both p < 0.05). Uterine descent was able to be evaluated in 92.08% of patients by TRUS and in 5.94% of patients by TPUS, which was statistically significant (p < 0.05). The interobserver repeatability for the measurements of anterior lip, cervical canal and posterior lip on TRUS was excellent. The mean lengths of anterior lip, cervical canal and posterior lip were significantly increased during Valsalva maneuver than those measured at rest (p < 0.05). And mean length of anterior lip was longer than posterior lip both at rest and during Valsalva (p < 0.05).
CONCLUSIONS: TRUS can significantly raise detection rates of entire cervix, and make the direct evaluation of uterine descent feasible. TRUS can be used as a complementary method to TPUS to attain more comprehensive and accurate presurgical imaging information in middle compartment prolapse patients.

BACKGROUND: Contrast-enhanced transcranial Doppler (cTCD) study has been established as one of the most common investigations for detecting right-to-left shunt (RLS). Although the conventional Valsalva maneuver (c-VM) has been used to increase the sensitivity of cTCD for RLS, efforts are still needed to improve the detection rate further. We proposed a new provocation method with a syringe-modified Valsalva maneuver (sm-VM) during cTCD and compared the efficacy of this strategy with cTCD measured at resting and with the provocation of c-VM.
METHODS: Consecutive patients with suspicion of RLS who underwent cTCD in our institution between September 27, 2021, and April 1, 2022, were included in this study. Examination of cTCD was performed separately at the resting state and provoked with c-VM and sm-VM. The overall proportion of patients with RLS and their distribution with different RLS grades were compared.
RESULTS: A total of 389 patients (mean age: 49.37 years, male: 52.2%) were included in this study. The positive rate for RLS was significantly higher for cTCD detected with sm-VM than those detected at resting state and with c-VM (46.8% vs. 21.6% and 34.2%, all p < .05). Besides, cTCD detected with sm-VM was also associated with a higher proportion of patients with grade III RLS than those detected at resting state and with c-VM (11.3% vs. 1.8% and 0%, all p < .05).
CONCLUSIONS: Compared to cTCD detected at resting state and with c-VM, cTCD with sm-VM could further increase the positive detection rate of RLS.

Venipuncture is a common invasive clinical procedure, and pain management during puncture has been of interest to healthcare professionals. The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of the Valsalva maneuver (VM) for the relief of venipuncture pain in children and adults. PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, VIP database, and CBM were searched from inception to December 2023 for all available randomized controlled trials (RCTs) that evaluated the impact of VM on venipuncture. Two reviewers independently performed study selection, data extraction, and risk of bias assessment. Continuous variables were analyzed by mean differences (MD) or standardized mean differences (SMD), whereas dichotomous variables were analyzed by risk ratios (RR). A total of 22 studies involving 1740 participants were included. The pooled results showed that VM relieved pain intensity during venipuncture in children (SMD = -0.89, 95% CI = -1.47 to -0.30, p = 0.003) and adults (SMD = -1.11, 95% CI = -1.46 to -0.77, p < 0.00001), reduced anxiety intensity (SMD = -1.07, 95% CI = -1.68 to -0.47, p = 0.0005), and shortened puncture time (MD = -13.52, 95% CI = -21.14 to -5.90, p = 0.0005). There was no significant difference in the success rate of venous cannulation, MAP, HR, or incidence of adverse events in subjects who performed VM compared to controls. VM was an effective and safe method of pain management that reduced pain intensity during venipuncture in children and adults without significant adverse effects. The results of this meta-analysis need to be further validated by more rigorous and larger RCTs.

Paroxysmal supraventricular tachycardia (PSVT) is an arrhythmia commonly seen in the emergency department. Both modified Valsalva maneuver (MVM) and intravenous adenosine are the first line treatment, of which the former has e lower success rate while the latter has a higher success rate but some risks and adverse effects. Given both of these reverse rhythms quickly, combining them may achieve a better effect.
The objective of this study is to evaluate the success rate and potential risk of combining the use of intravenous adenosine while patients were doing MVM as a treatment for paroxysmal supraventricular tachycardia(pSVT).
We recruited patients with pSVT from 2017 to 2022, and randomly assigned them into 3 groups, MVM group, intravenous adenosine group, and combination therapy group, in which MVM was allowed to be performed twice, while intravenous adenosine was given in a titration manner to repeat three times, recorded the success rate and side effects in each group.
The success rate of the MVM group, adenosine group, and combination group are 42.11%, 75.00 and 86.11%, respectively. The success rate of the adenosine group and combination group is significantly higher than the n MVSM group (p < 0.01, p < 0.001), while the success rate of the combination group is higher than the adenosine group, it has no significant difference (p = 0.340). In terms of safety, the longest RR durations (asystole period) are 1.61 s, 1.60s, and 2.27 s, there is a statistical difference among the three groups (p < 0.01) and between the adenosine and combination group (0.018).
Therefore, we can conclude that combination therapy has a relatively high success rate and good safety profile, but the current study failed to show its superiority to adenosine.

OBJECTIVE: To compare the efficacy and safety of the modified versus standard Valsalva maneuver in the treatment of paroxysmal supraventricular tachycardia (PSVT).
METHODS: The PubMed, Embase, Web of Science, CNKI, WanFang Data, and VIP electronic databases were searched to identify studies comparing the modified and standard Valsalva maneuvers in the treatment of PSVT from database inception to 1 May 2023. Two reviewers independently screened the literature, extracted the data, and assessed the risk of bias of all included studies.
RESULTS: Nineteen randomized controlled trials involving 2527 patients with PSVT were included. The overall rate of cardioversion was higher in the modified than standard Valsalva group (risk ratio [RR] = 1.80, 95% confidence interval [CI] = 1.61-2.01), as was the success rate of cardioversion after a single Valsalva maneuver (RR = 2.05, 95% CI = 1.74-2.41). There was no statistically significant difference in adverse reactions between the two groups (RR = 1.07, 95% CI = 0.82-1.38).
CONCLUSIONS: Current evidence suggests that the modified Valsalva maneuver can significantly improve the success rate of cardioversion in patients with PSVT without increasing adverse reactions. The modified Valsalva maneuver is therefore worth promoting and should be considered as a routine first treatment.INPLASY registration number: 2023100092.

To evaluate the concordance between an automatic software program and manual evaluation in reconstructing, delineating, and measuring the levator hiatus (LH) on maximal Valsalva maneuver.
This was a retrospective study analyzing archived raw ultrasound imaging data of 100 patients underwent transperineal ultrasound (TPUS) examination. Each data were assessed by the automatic Smart Pelvic System software program and manual evaluation. The Dice similarity index (DSI), mean absolute distance (MAD), and Hausdorff distance (HDD) were calculated to quantify delineation accuracy of LH. Agreement between automatic and manual measurement of levator hiatus area was assessed by intraclass correlation coefficient (ICC) and Bland-Altman method.
The satisfaction rate of automatic reconstruction was 94%. Six images were recognized as unsatisfactory reconstructed images for some gas in the rectum and anal canal. Compared with satisfactory reconstructed images, DSI of unsatisfactory reconstructed images was lower, MAD and HDD were larger (p = 0.001, p = 0.001, p = 0.006, respectively). The ICC was up to 0.987 in 94 satisfactory reconstructed images.
The Smart Pelvic System software program had good performance in reconstruction, delineation, and measurement of LH on maximal Valsalva maneuver in clinical practice, despite misidentification of the border of posterior aspect of LH due to the influence of gas in the rectum.

UNASSIGNED: Totally implantable access port (TIAP) is a subcutaneously implanted, long-term infusion device that is widely used in oncology patients. However, multiple needle insertions into TIAP may lead to pain, anxiety, and dread in patients. This study aimed to compare the effectiveness of Valsalva maneuver, eutectic mixture of local anesthetics (EMLA) cream, and the combination of both in relieving pain of cannulations on TIAP.
UNASSIGNED: This was a prospective randomized controlled study. We included 223 patients treated with antineoplastic drugs and randomized them into four groups: EMLA Group (Group E), control Group (Group C), Valsalva maneuver Group (Group V), and EMLA cream combing with Valsalva maneuver Group (Group EV). Each group was given the corresponding intervention before non-coring needle insertion. The data on pain scores and overall comfort were collected by numerical pain rating scale (NPRS) and visual analog scale (VAS).
UNASSIGNED: Group E and Group EV experienced the least amount of pain scores in needle insertion, which was significantly lower than Group V and Group C (p < 0.05). Meanwhile, Group E and Group EV obtained the highest comfort level, which was significantly higher than group C (p < 0.05). Fifteen patients developed localized skin erythema after the application of medical Vaseline or EMLA cream and subsided within half an hour after rubbing.
UNASSIGNED: EMLA cream is a safe and effective way to alleviate pain during non-coring needle insertion in TIAP and enhance the overall comfort of patients. We recommend applying EMLA cream 1 h before needle insertion of TIAP, especially in patients having needle phobia or high pain scores from previous non-coring needle insertion.