The pressure distribution under tourniquets

We measured the detailed pressure distribution under pneumatic tourniquets and Esmarch bandages in canine limbs. The results showed that pressure concentration can occur in the tissue under the tourniquet. The Esmarch-bandage tourniquet was shown to be capable of producing pressures in excess of 1000 millimeters of mercury immediately beneath the tourniquet. There is a wide variation between cuff pressure and the pressures in the underlying tissues.     

Digital tourniquets: a comparative analysis of pressures and pain perception

Digital tourniquets have been condemned because of the reported occurrence of neurovascular complications. This study compares the pressures and pain perception between three different tourniquets, namely the rubber glove finger stall, Foley's urinary catheter and the commercial band tourniquet. The subjects involved were 20 volunteers with 80 fingers studied in total. A direct pressure measuring technique was used. The pressures recorded were highest and most variable with the catheter tourniquet, whereas the rubber glove tourniquet recorded the lowest pressures. Correspondingly, visual analogue scale in relation to patient discomfort showed high scores with the catheter tourniquet and low scores with the rubber glove tourniquet. We conclude that catheter tourniquet use should be avoided as it generates extreme and variable pressures, whereas rubber glove finger stall tourniquets appear as a better alternative.     

Compartmental pressure monitoring after arterial reconstruction lacks clinical relevance

Anterior compartmental intramuscular pressure was studied by the continuous-infusion technique during and after arterial reconstruction of the abdominal or lower extremity vessels in 23 patients. Although there were significant differences between the mean pressures in those patients who had proximal or distal arterial reconstruction, the mean pressure did not increase in the sequential preocclusion, occlusion, and postoperative periods during a mean follow-up of 26 hours in proximal reconstructions and 19 hours in distal reconstructions. One patient had pressures consistent with a borderline compartmental syndrome but died of a ruptured left ventricle before complete correlation of the clinical course and pressures could be made. We conclude from this study that although routine measurement of compartmental pressures during arterial reconstruction of the lower extremities yields interesting findings, it makes no important contribution to the clinical management of the patient.     

巨趾畸形12例临床分析

目的 总结巨趾畸形的临床特点和手术疗效.方法 回顾性分析12例巨趾畸形患者的临床资料.共12例(13足)患者,其中男性8例,女性4例,平均年龄4.6岁.均在出生时被发现畸形.多趾巨大畸形患者多于单趾畸形的患者,胫侧足趾好发.对应的前足均粗大.巨趾的趾骨均粗长,部分对应的跖骨粗长.术中见所有患者均有皮下脂肪过度增生,侵犯骨间肌和关节囊.足部神经和分支无明显增粗,无脂肪浸润.手术包括软组织缩容、骺阻滞、截趾、神经切断再吻合等.结果 7例患者获得随访,随访时间平均25.6个月.根据自行制订的分级标准进行功能评定:优2例,良2例,中3例.结论 手术治疗巨趾畸形有效,应重视手术适应证、手术时机和术式的选择.     

The quadriga phenomenon: a review and clinical relevance

The flexor digitorum profundus tendons are markedly interconnected, making them less able to move independently than the tendons of the flexor digitorum superficialis. This difference is often attributed to the common muscle belly of the profundus, but also, more importantly, to cross-connections between the tendons of the profundus. The effect of this quadriga phenomenon is important in several clinical situations, including testing for strength, assessing movement of the tendons, and when deciding which exercises to teach the patient after a tendon injury. The anatomy and biomechanics of this phenomenon are reviewed in this article to help explain why certain conditions occur, and to improve the diagnosis and treatment of some conditions in rehabilitation medicine.     

The clinical relevance of systolic pressure variations in anesthetized nonhypotensive patients

OBJECTIVE: To assess the accuracy of respiratory-induced systolic pressure variation and its components to detect low left ventricular preload. DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: Sixty-seven patients undergoing major surgery under general anesthesia. INTERVENTIONS: Transesophageal echocardiographic measurements during apnea and mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: Respiratory-induced systolic pressure variation and its components and left ventricular end-diastolic area obtained by transesophageal echocardiography were noted simultaneously. Arterial pressure indices did not allow a reliable diagnosis of a low left ventricular end-diastolic area using a cut-off value of 7.9 cm(2)/m(2) (inferior boundary of the interquartile range of the areas measured in the authors' group). CONCLUSIONS: These results suggest that systolic pressure variations noticed after induction of general anesthesia do not reflect low left ventricular preload in nonhypotensive patients.     

Digital image analysis versus clinical assessment of wound epithelialization: a validation study

To evaluate the progress in wound healing, wound assessment is mandatory. Epithelialization is traditionally assessed subjectively by the clinician. In a previous study, subjective assessment of epithelialization was shown to be reliable. In this study, reliability of epithelialization measured by digital image analysis was investigated and then, we validated the subjective evaluation by comparing this assessment to measurements with digital image analysis. Clinicians assessed epithelialization in 50 burn wounds that were treated with a split skin graft. Epithelialization of these wounds was also measured by three observers using digital image analysis. Reliability of digital image analysis was tested using the intraclass correlation (IC). To test validity, subjective clinical assessment was correlated with digital image analysis (IC). The results showed that interobserver reliability of epithelialization measured by digital image analysis was good (IC coefficient 0.74). Subjective clinical assessment of epithelialization showed a strong correlation with digital image analysis (IC coefficient 0.80). In conclusion, subjective clinical evaluation of wound epithelialization is as good as an objective measure, in this study digital image analysis. Since digital image analysis is more time-consuming, we recommend the use of the subjective evaluation for daily practice.     

Guidelines for the use of digital tourniquets based on physiological pressure measurements

A potential complication of a digital tourniquet is neurovascular damage due to excessive tissue pressure. A technique for measuring digital tourniquet pressures was developed in our laboratory and was tested on fresh cadaver hands in order to establish guidelines for proper application of tourniquets. A saphenous vein from a fresh cadaver was laid subcutaneously along the neurovascular bundle of the test finger. Digital tourniquets consisting of Penrose drains or rolled surgical gloves were then applied in a standardized fashion. Saline solution was injected through the saphenous vein in a quasi-static fashion using a Harvard pump, and the pressure within the vein was monitored with a pressure transducer. When the pressure within the vein reached the closing pressure generated by the tourniquet, the pressure stabilized due to leakage of fluid beyond the tourniquet. Digital tourniquets applied in customary fashion by selected physicians and surgeons produced a wide range of closing pressures that did not exceed 360 millimeters of mercury. Rolled surgical gloves produced closing pressures ranging from 113 to 363 millimeters of mercury, depending on the relationship between the size of the glove and that of the hand. Penrose drains produced closing pressures of more than 800 millimeters of mercury, depending on the amount of stretch applied.     

脊柱真空现象临床研究进展

脊柱真空现象(vacuum phenomenon,VP)是指发生在椎体、椎间盘、关节间隙和椎管内的气体积聚。1%~3%的正常成人可发现椎间盘真空现象,在腰腿痛的老年患者中检出率可达20%。产生脊柱真空现象的病因多样,其与脊柱相关症状的疾病有密切联系,主要诊断依据来源于影像学检查。本文通过近年来国内外对于脊柱真空现象的临床研究总结,分析引起脊柱真空现象的病因、临床表现及相关影像学特点,进而为临床上与该现象相关疾病的诊断与治疗提供积极的参考。     

Outcomes in urinary incontinence: reconciling clinical relevance with scientific rigour

OBJECTIVES: To aid clinicians in selecting an outcome measure for the assessment of urinary incontinence (UI), from the perspective of both scientific rigour and clinical utility. METHODS: We conducted a comprehensive review of the literature on outcome measures for the assessment of UI in adults. Tools were classified by instrument type (ie, subjective measures, objective measures, clinical observations, quality of life, and combined instruments) and assessed for scientific rigour based on their psychometric properties (reliability, validity, responsiveness). The clinical relevance of each tool was considered in terms of current usage and practicality. RESULTS: The most rigorous validation processes were identified for quality-of-life questionnaires, including the Incontinence Impact Questionnaire, King's Health Questionnaire, Incontinence Quality of Life questionnaire, and Urogenital Distress Inventory. Bladder diaries, goal-attainment scales, and combined measures such as the International Consultation on Incontinence Questionnaire appear to be more practical for use in clinics. The Clinical Global Impression of Improvement is the outcome most widely used clinically, but least well validated. CONCLUSIONS: To elevate the level of outcome assessment for UI to meet that of other urology specialties, it is necessary to reconcile the realities of clinical practice with the scientific rigour of UI research, and to mainstream outcome measures that are reciprocally translatable between the two settings.     

Bilateral total knee replacement with tourniquets in a homozygous sickle cell patient

A 27-yr-old male patient, with homozygous sickle cell disease was scheduled for bilateral total knee replacement under tourniquet. The use of tourniquet in sickle cell patients is not without hazard. After preoperative exchange transfusion, total knee replacement was performed. The patient tolerated the procedure well. Patients with sickle cell disease should not be denied the benefit of a tourniquet if hematological correction has been undertaken. IMPLICATIONS: The use of a tourniquet in patients with sickle cell is controversial. The author describes a case of bilateral total knee replacement performed using a tourniquet in a patient with sickle cell disease.     

Ganglioglioma: a clinical study with long-term follow-up

Gangliogliomas are uncommon tumors of mixed neoplastic glial and neuronal elements. Because of their low incidence, few large series exist that fully describe the clinical characteristics of patients afflicted with this tumor. We have reviewed the medical records of 20 patients at Duke University Medical Center with histologically proven gangliogliomas. These patients typically presented within the first three decades of life and their most common presenting symptom was seizures. Therapies included surgical resection, either partial or total, radiation therapy, and/or chemotherapy. Long-term follow-up was achieved by chart review and by telephone interview. Patients who underwent gross total resection alone seemed to fare the best when comparing all treatment groups, and we therefore recommend this as the main form of treatment.