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Vascular calcifications are associated with increased cardiovascular morbidity and mortality. Their prevalence is higher in patients with chronic kidney disease than in the general population and they are linked not only to classical risk... more
Vascular calcifications are associated with increased cardiovascular morbidity and mortality. Their prevalence is higher in patients with chronic kidney disease than in the general population and they are linked not only to classical risk factors such as hypertension, diabetes, dyslipidemia and smoking but also to derangements in mineral metabolism and to chronic inflammation. The development of vascular calcifications is an active phenomenon that is linked to an imbalance between promoting and inhibitory factors. They affect also young patients on dialysis and it is therefore necessary to recognize them at an early stage. The distinction between intima and media calcification can be important for a different therapeutic approach. There are a number of devices for the identification of vascular calcifications, including x-ray imaging, ultrasonography and computerized technologies. The purpose of this paper is to show the advantages and disadvantages of ultrasonography in comparison to other tools for the diagnosis of vascular calcifications.
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The correct management of patients with kidney stones is a crucial issue for nephrologists. In recent years, the incidence and prevalence rates of nephrolithiasis have maintained a growing trend worldwide, showing a strong correlation... more
The correct management of patients with kidney stones is a crucial issue for nephrologists. In recent years, the incidence and prevalence rates of nephrolithiasis have maintained a growing trend worldwide, showing a strong correlation with other systemic disease such as diabetes mellitus, hypertension, obesity, metabolic syndrome and chronic kidney disease. International guidelines indicate computed tomography as the first choice for all adult patients with suspected acute symptoms for obstructive nephrolithiasis. Intravenous pyelogram is more useful in the follow-up of patients with relapsing nephrolithiasis and known stone composition, while the high costs and the long image acquisition times limit the routine use of magnetic resonance. Recent innovative tools have improved the accuracy of kidney stone localization and measuring with B-Mode and color Doppler imaging, thereby reducing the gap between ultrasonography and computer tomography. The aim of this review is to report the latest evidence on risk factors and on the pathophysiology of nephrolithiasis, and to compare the utility of the available imaging techniques in the management of patients with kidney stones, focusing on the role of ultrasonography and the present and future strategies to improve its accuracy.
Research Interests: Radiology, Neuroimaging, Magnetic Resonance Imaging, Medicine, Humans, and 14 moreUltrasonography, Clinical Sciences, Kidney Stones, Carotid Endarterectomy, Kidney Disease, Sensitivity and Specificity, Asymptomatic, Blood Flow Velocity, Neurosciences, Carotid Stenosis, Carotid Arteries, stenosis, Patient selection, and Myositis ossificans
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Cardiovascular disease is the main cause of mordibity and mortality in patients with chronic kidney disease (CKD) affected by a series of risk factors (hypertension, anemia, left ventricular hypertrophy, cardiac failure and dyslipidemia).... more
Cardiovascular disease is the main cause of mordibity and mortality in patients with chronic kidney disease (CKD) affected by a series of risk factors (hypertension, anemia, left ventricular hypertrophy, cardiac failure and dyslipidemia). The combined presence of these factors raises the cardiovascular risk in CKD patients considerably compared with that of the general population. Nephrologists can play a role in preventing and treating these risk factors and thereby delaying the development of CKD. In preventing CKD, nephrologists who practice ultrasound techniques should have basic know how of echocardiography so that they can screen CKD patients for early referral to a cardiologist. Echocardiography is a noninvasive ultrasound technique that requires adequately trained doctors to perform it. Nephrologists who practice it need to obtain good training and postgraduate certification of competence in echocardiography. These nephrologists should team up with cardiologists rather than replace them, and at the same time be aware that they possess the basic knowledge to manage cardiovascular disease in CKD patients.
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The Doctor-Patient relationship is of fundamental importance in the field of care and continues to undergo profound transformations. In ancient times the doctor was "authoritarian": the patient was considered a passive element, incapable... more
The Doctor-Patient relationship is of fundamental importance in the field of care and continues to undergo profound transformations. In ancient times the doctor was "authoritarian": the patient was considered a passive element, incapable of understanding, knowing and acting for his own health. The doctor then became a "paternalistic" figure and it is only recently that the patient has become a responsible subject who interacts with the doctor in the definition and evaluation of every health intervention. The patient needs to be actively involved and informed, participating in the therapeutic process and in monitoring the positive and negative effects of the treatment. The doctor needs to communicate in a way that is simple and appropriate in order to avoid misunderstandings, which are very common as patients and doctors can often attribute different meanings to certain words. Doctors need to be aware that such a possibility exists and verify that the patient has understood the real meaning of his words. As good communication between doctors and patients is a strategic factor in care, communication courses should be included in any Medical Degree course.
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The term "obstructive uropathy" refers to the complex structural and functional changes following the interruption of normal urinary runoff, which can occur at every level of the urinary tract. Depending on its origin, duration... more
The term "obstructive uropathy" refers to the complex structural and functional changes following the interruption of normal urinary runoff, which can occur at every level of the urinary tract. Depending on its origin, duration and severity, urinary tract obstructions can be acute or chronic, mono or bilateral, partial or complete. The obstruction can be localized or extended to the entire pielo-caliceal system and/or homolateral urethra. The term "hydronephrosis" indicates the dilation of the pelvis detected through imaging techniques. Among these, ultrasound is considered the gold standard in the diagnosis of obstructive uropathy: it allows to distinguish three degrees of urinary tract dilation, depending on the extent of the dilation itself and the thickness of the parenchyma. Nephrologists are confronted daily with patients who experience kidney failure and must be able to quickly distinguish between chronic and acute and, in the latter case, to discern betwe...
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The lack of backfiltration reduces plasma levels of C-reactive protein and interleukin-6. Paired filtration dialysis is the hemodialfitration technique that abolishes backfiltration. By physically separating convection from diffusion, it... more
The lack of backfiltration reduces plasma levels of C-reactive protein and interleukin-6. Paired filtration dialysis is the hemodialfitration technique that abolishes backfiltration. By physically separating convection from diffusion, it allows pure ultrafiltrate to be available during the entire session, so the ultrafiltrate can be regenerated and used as infusion fluid. On these premises, we have developed a European, open, randomised, multicentre study aimed at evaluating the effect of hemodiafiltration with on-line endogenous reinfusion (on-line HFR) on anemia. At least 130 chronically uremic hemodialysed (bicarbonate hemodialysis) stable patients with mild anemia (Hb between 9 and 11 g/dL) will be enrolled and normalized for iron stores by concomitantly repleting iron deposits (if ferritin <300 microg/L) and reducing the dose of erythropoietin to maintain Hb values within the range at enrollment (9-11 g/dL). Patients will be included in the study, randomized to the two treat...
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Central venous catheters (CVC) are widely used in clinical practice for the administration of chemotherapy, parental nutrition, hemodynamic monitoring, and hemodialysis. International guidelines have defined the right internal jugular... more
Central venous catheters (CVC) are widely used in clinical practice for the administration of chemotherapy, parental nutrition, hemodynamic monitoring, and hemodialysis. International guidelines have defined the right internal jugular vein as the preferred site of CVC insertion and underline that accurate positioning of the catheter tip is essential to maximize the blood flow and reduce long-term complications. Endocavitary electrocardiography (EC-ECG) improves the accuracy of catheter tip positioning without increasing the placement time by the recognition of typical P wave patterns during catheter insertion:the normally shaped P wave identifies the mid to upper superior vena cava, the widest P wave may be used to place the CVC tip at the superior vena cava-right atrium junction, and biphasic P waves identify the location of the right atrium. Because of its simplicity and safety, EC-ECG should always be considered during CVC placement, especially if other means of verifying correct...
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Kidney transplantation is the treatment of choice for end-stage renal disease, given the better quality of life of transplanted patients when compared to patients on maintenance dialysis. In spite of surgical improvements and new... more
Kidney transplantation is the treatment of choice for end-stage renal disease, given the better quality of life of transplanted patients when compared to patients on maintenance dialysis. In spite of surgical improvements and new immunosuppressive regimens, part of the transplanted grafts still develop chronic dysfunction. Ultrasonography, both in B-mode and with Doppler ultrasound, is an important diagnostic tool in case of clinical conditions which might impair kidney function. Even though ultrasonography is considered fundamental in the diagnosis of vascular and surgical complications of the transplanted kidney, its role is not fully understood in case of parenchymal complications of the graft. The specificity of Doppler ultrasound is low both in case of acute complications such as acute tubular necrosis, drug toxicity and acute rejection, and in case of chronic conditions such as chronic allograft nephropathy. Single determinations of resistance indices present low diagnostic ac...
Research Interests: Humanities and Medicine
Hospital procedures to stock tools and equipment supplies for day-by-day clinical diagnosis and treatment place physicians to face up with their ones responsibilities. Nephrologists have to deal with dialysis machines, related technology... more
Hospital procedures to stock tools and equipment supplies for day-by-day clinical diagnosis and treatment place physicians to face up with their ones responsibilities. Nephrologists have to deal with dialysis machines, related technology updating and associated consumables. Overall they have to cope with local health service reality, which looks for progressive doctors skill improvement at lowest or no cost at all. Aim of the first part of this review is to analyze all these issues according European Union, Italian and local main lines and associated laws. Moreover, will be reviewed purchase strategies always looking at patient wellness as final aim of the entire process. They will be illustrated sequences of administrative measures, recent Central Commissioning Headquarters, and laws that since 2006 have defined the related procedures (i.e. open, limited, negotiated, and competitive).
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Native arteriovenous fistula is the preferred vascular access because of it does not usually cause infections and seems to be closely related with prolonged patient survival, compared to prosthetic grafts and central venous catheters; it... more
Native arteriovenous fistula is the preferred vascular access because of it does not usually cause infections and seems to be closely related with prolonged patient survival, compared to prosthetic grafts and central venous catheters; it also is cost effective. Venous stenosis is one of the main causes of AVF failure. It is caused by a number of upstream and downstream events. The former group comprises hemodynamic and surgical stressors, inflammatory stimuli and uraemia, while downstream events involve the proliferation of smooth muscle cells and myofibroblasts and the development of neo-intimal hyperplasia. Percutaneous transluminal angioplasty is the gold standard for arteriovenous fistula stenosis. It allows the visualization of the whole vascular circuit and the immediate use of the vascular access for the next dialysis session. Ultrasound-guided percutaneous endovascular angioplasty is a feasible and safe alternative to conventional fluoroscopic technique: it is equally effect...
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Il rene è coinvolto, in prima battuta, nel mantenimento dell'omeostasi dei fluidi e dell'equilibrio idro-elettrolitico ed acido-base, nonché nell'eliminazione delle scorie tossiche. La funzione renale sembra essere... more
Il rene è coinvolto, in prima battuta, nel mantenimento dell'omeostasi dei fluidi e dell'equilibrio idro-elettrolitico ed acido-base, nonché nell'eliminazione delle scorie tossiche. La funzione renale sembra essere strettamente collegata a quella cardiovascolare e, negli ultimi anni, il termine di ‘sindrome Cardio-Renale’ è stato utilizzato per spiegare le correlazioni cliniche tra patologia renale e cardiaca. Lo scompenso cardiaco congestizio (SCC) rappresenta la prima causa di ospedalizzazione nei Paesi occidentali e i pazienti affetti presentano spesso, in associazione, un quadro di malattia renale cronica (MRC) di grado variabile. Sono stati considerati diversi modelli fisiologici e fisiopatologici per spiegare come una condizione di malattia renale cronica possa influenzare lo stato di insufficienza cardiaca. Sicuramente la via metabolica del guanosin monofosfato ciclico (cGMP) e quello dell'ossido nitrico (NO) giocano un ruolo fondamentale di concerto con l'...
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Kidney transplant recipients (KTRs) are susceptible to low levels of vitamin D, which may be responsible for mineral and bone metabolism disorders and play some role in the occurrence of cardiovascular, metabolic, immunologic, neoplastic,... more
Kidney transplant recipients (KTRs) are susceptible to low levels of vitamin D, which may be responsible for mineral and bone metabolism disorders and play some role in the occurrence of cardiovascular, metabolic, immunologic, neoplastic, and infectious complications after kidney transplant. Kidney Disease Improving Global Outcomes (KDIGO) guidelines of the year 2017 recommended vitamin D supplementation in the first 12 months after transplant using the same treatment strategies for the general population. However, no recommendations are provided after the first 12 months due to a lack of sufficient data. This review analyses some studies that assessed the vitamin D status of KTRs and the effects of nutritional and active vitamin D supplementation on bone mineral density, cardiovascular disease, proteinuria, and graft function in KTRs.
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In recent decades, the survival of dialysis patients has gradually increased thanks to the evolution of dialysis techniques and the availability of new drug therapies. These elements have led to an increased incidence of a series of... more
In recent decades, the survival of dialysis patients has gradually increased thanks to the evolution of dialysis techniques and the availability of new drug therapies. These elements have led to an increased incidence of a series of dialysis-related diseases that might compromise the role of dialysis rehabilitation: vascular disease, skeletal muscle disease, infectious disease, cystic kidney disease and cancer. The nephrologist is therefore in charge of a patient group with complex characteristics including the presence of indwelling vascular and/or peritoneal catheters, conditions secondary to chronic renal failure (hyperparathyroidism, anemia, amyloid disease, etc.) and superimposed disorders due to old age (cardiac and respiratory failure, cancer, type 2 diabetes mellitus, etc.). Early clinical and organizational management of such patients is essential in a modern and ''economic'' vision of nephrology. The direct provision of ultrasound services by the nephrologi...
Research Interests: Nephrology, Dialysis, Medicine, Comorbidity, Catheterization, and 15 moreItaly, Humans, Internal Medicine, Disease, Incidence, Peritoneal Dialysis, Age Factors, Cardiovascular Diseases, Intensive Care Medicine, Disease Progression, Bacterial infections, Chronic Kidney Failure, Early Diagnosis, Predictive value of tests, and Renal Dialysis
The aim of our study was to assess the role of Doppler ultrasonography (DU) by resistive index (RI) and the difference of the RI (DeltaRI) in patients with acute unilateral renal obstruction. We studied 36 consecutive patients (12 female,... more
The aim of our study was to assess the role of Doppler ultrasonography (DU) by resistive index (RI) and the difference of the RI (DeltaRI) in patients with acute unilateral renal obstruction. We studied 36 consecutive patients (12 female, 24 male; mean age 45.6 +/- 8.4 years) with suspected renal colic by intravenous pyelography (IVP) and DU with determination of the RI and the Delta RI. A RI of &gt;= 0.70 and a DeltaRI of &gt;= 0.06 were considered suggestive of obstruction. IVP was considered as the &quot;gold standard&quot;. In the studied population, RI was 0.664 +/- 0.060 in the affected kidney site of symptoms and 0.614 +/- 0.025 in the contralateral one, with an overall Delta RI of 0.049 +/- 0.062. At IVP, 14 patients resulted within normal range (Group A; 39%), 6 patients showed lithiasis without obstruction (Group B; 17%), 8 patients showed delayed excretion of the contrast medium (Group C; 22%), and 8 patients showed a functional exclusion of the kidney (Group D; 22%). One-way analysis of variance showed the IVP group significantly related to Delta RI with the highest values in Groups C (DeltaRI of 0.093 +/- 0.051; p&lt;0.001) and D (DeltaRI of 0.116 +/-0.030; p&lt;0.001) in comparison with Group A (DeltaRI of 0.001 +/-0.038) and Group B (DeltaRI of 0.015 +/-0.024). No differences were detected between Groups C and D (p=0.223) and between Groups A and B (p-0.472). DeltaRI measurement with DU permitted to predict the renal obstruction with a sensitivity of 93.8%, a specificity of 95.0% and an accuracy of 94.4%. Intrarenal Doppler ultrasonography represents a sensitive and highly specific test that can significantly contribute to the diagnosis of obstruction in patients with acute renal colic. It should be used as the first line imaging method in suspected acute renal colic, as well as for patients with renal insufficiency, pregnant women or for patients with adverse reactions to contrast media
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The marketing mix is the combination of the marketing variables that a firm employs with the purpose to achieve the expected volume of business within its market. In the sale of goods, four variables compose the marketing mix (4 Ps):... more
The marketing mix is the combination of the marketing variables that a firm employs with the purpose to achieve the expected volume of business within its market. In the sale of goods, four variables compose the marketing mix (4 Ps): Product, Price, Point of sale and Promotion. In the case of providing services, three further elements play a role: Personnel, Physical Evidence and Processes (7 Ps). The marketing mix must be addressed to the consumers as well as to the employees of the providing firm. Furthermore, it must be interpreted as employees ability to satisfy customers (interactive marketing).
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Conflicts are situations in which two or more people come into disagreement: they are an integral part of social life caused by the inability to find a solution to a dispute. Conflicts are constantly present within families and in all... more
Conflicts are situations in which two or more people come into disagreement: they are an integral part of social life caused by the inability to find a solution to a dispute. Conflicts are constantly present within families and in all social organizations; in the health sector, they are part of the daily routine. The most common causes of conflict are the lack of resources and the divergence in objectives. All conflicts can quickly escalate, so it is essential to recognize them in order to defuse them as soon as possible. Doctors, as managers, must recognize the early signs of latent conflict in order to better manage them and possibly use them in order to stimulate change in the organization.
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The communication is an action that occupies a lot of part of the life of every individual and understands a whole activity that the purpose has to reach a preset goal: the communication obligatorily foresees the presence of a... more
The communication is an action that occupies a lot of part of the life of every individual and understands a whole activity that the purpose has to reach a preset goal: the communication obligatorily foresees the presence of a recipient/receiving.During communication we used both the word, but also the gesture and the way of do/say. The oral communication represents the most complete system however, evolved, end and thin to communicate, able to also express concepts and thoughts and not only behaviors: with it he can also lie and to supply misinformation. The oral communication also possesses an important temporal value, in how much you/he/she can define him now, the before and the then, but also the ability to determine the human relationships, because it participates in to define the different roles in which broadcasting station and receiver are found at that time. The truest power of the words is that to create, to maintain, to modify other people's behaviors; a natural corre...
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The Italian State protects health because it represents one of the basic necessities of man and the essential condition for the existence and proper functioning of the social and civic life of the citizen. The health system has recently... more
The Italian State protects health because it represents one of the basic necessities of man and the essential condition for the existence and proper functioning of the social and civic life of the citizen. The health system has recently undergone a substantial spending cuts: regardless of human capital, technological and financial provision, however all hospitals must be able to meet the demands/expectations of care of the patient as a whole, made of organic needs, psychological and relational. We need to "humanize" the medical treatment. All health care workers should be prepared to "welcome/cure" the patient in the most atraumatic as possible, placing it at the center of a system that revolves around Him. Communicate effectively with a person who is going through a particular moment of his life is not so simple and immediate. In these cases, the preparation and the sensitivity of the practitioner to make a difference: it is necessary that sender and receiver ar...
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In recent years imaging techniques that use radionuclides have become more and more clinically relevant as they can provide functional information for specific anatomical districts. This has also involved nephrology, where radionuclides... more
In recent years imaging techniques that use radionuclides have become more and more clinically relevant as they can provide functional information for specific anatomical districts. This has also involved nephrology, where radionuclides are used to study patients with different degrees of renal function failure up to terminal uremia. Although chronic kidney disease, and dialysis in particular, may affect the distribution and the elimination of radiopharmaceuticals, to date there are no consistent data on the risks associated with their use in this clinical context. In addition to the lack of data on the safety of radio-exposure in dialysis patients, there is also a shortage of information concerning the risk for healthcare staff involved in conducting the dialysis sessions performed after a nuclear test. This study, performed on 29 uremic patients who underwent hemodialysis immediately after a scintigraphic examination, assessed the extent of radio-contamination of the staff and of ...
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Arteriovenous fistula (AVF) created with native vessels is the vascular access of choice for hemodialysis: the AVF is associated with a lower incidence of complications and longer survival than prosthetic grafts or central venous... more
Arteriovenous fistula (AVF) created with native vessels is the vascular access of choice for hemodialysis: the AVF is associated with a lower incidence of complications and longer survival than prosthetic grafts or central venous catheters [1, 2]. Nephrologists and vascular surgeons find it increasingly difficult to locate native vessels suitable for creation of a well-functioning, persistently patent AVF because of increasing prevalence among requiring dialysis patients of advanced age and comorbidities, such as diabetes mellitus and vascular disease [3].
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The tumors of the kidney are around the 3% of the neoplasia in adult patients and, at the postmortem examination, the renal neoplasias has a frequency of 1/300 for tumors diameter of 1 to 2 cms. In the treatment of the small neoplasias,... more
The tumors of the kidney are around the 3% of the neoplasia in adult patients and, at the postmortem examination, the renal neoplasias has a frequency of 1/300 for tumors diameter of 1 to 2 cms. In the treatment of the small neoplasias, techniques of nephron sparing and enucleation are used. These techniques have shown the same therapeutic effectiveness of the radical nephrectomy in patients with tumors smaller than 4 centimeters, with reduction of morbidity. However, there are few clinical situation in which the surgery has a high risk: patients with solitary kidney, chronic renal failure, multiple localizations involving also contralateral kidney, in patients with other malignancies and in von Hippel-Lindau Syndrome. Recently, percutaneous mininvasive techniques have been applied (ex. thermoablation): these techniques allow to reduce the duration of general anesthesia, they offer the possibility to use spinal anaesthesia (besides deep sedation and general anaesthesia) with reducti...
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The verbal communication represents the first human communication, that even more used and one most immediate. History and the development of communication is divided into historical periods, is complex and is bound to the period... more
The verbal communication represents the first human communication, that even more used and one most immediate. History and the development of communication is divided into historical periods, is complex and is bound to the period contingencies and to the social reference community. The oral communication is never isolated but is always taken by the not verbal one, including the silences, the position and the spaces (c.d. proxemics). The good communicator stimulates the cooperation through the conversation rule respect (qualities, amounts, way and relation) and reduces the possible asymmetry between broadcaster and receiver fitting its code to that of the interlocutor.
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Although atherosclerotic renal artery stenosis (ARAS) is strictly associated with high cardiovascular risk and mortality, it often may remain unrecognized being clinically silent and frequently masked by co-morbidities especially in... more
Although atherosclerotic renal artery stenosis (ARAS) is strictly associated with high cardiovascular risk and mortality, it often may remain unrecognized being clinically silent and frequently masked by co-morbidities especially in elderly patients with coexisting chronic kidney disease (CKD). The present observational study was conducted in elderly CKD-patients with atherosclerosis on other arterial beds. The aims were assessment of (1) ARAS prevalence; (2) best predictor(s) of ARAS, using duplex ultrasound; and (3) cardiovascular and renal outcomes at one-year follow-up. The cohort was represented by 607 consecutive in-patients. Inclusion criteria were age ≥65 years; CKD stages 2–5 not on dialysis; single or multiple atherosclerotic plaque on epiaortic vessels, abdominal aorta, aortic arch, coronary arteries, peripheral arteries that had been previously ascertained by one or more procedures. Duplex ultrasound was used to detect ARAS. Multiple regression analysis and ROS curve wer...