Digital photoplethysmography in the diagnosis of suspected lower limb DVT: is it useful?

OBJECTIVE: to determine the role of digital photoplethysmography (D-PPG) in the diagnosis of deep-vein thrombosis (DVT), in comparison to the "gold standard" of either contrast ascending venography (ACV) or colour-flow duplex imaging (CFDI). METHOD: prospective study of 100 hospital inpatients (103 legs) referred to the X-ray department for ACV or CFDI with clinically suspected lower limb DVT in a district general hospital. Each patient was assessed by either ACV or CFDI, and D-PPG. RESULTS: thirty-seven limbs were found to have DVT as demonstrated by ACV or CFDI. All patients with a venous refilling time (RT) of greater than 20 s and venous pump (VP) of greater than 35 had a normal ACV or CFDI. Using RT of less than 21 s as the optimal cut-off point, D-PPG achieved a sensitivity of 100%, negative-predictive value of 100%, specificity of 47% and positive-predictive value of 51%. By using VP of less than 36 as the optimal cut-off point, a sensitivity of 100%, a negative-predictive value of 100%, a specificity of 35% and positive-predictive value of 46% were achieved. CONCLUSIONS: these results validate the use of portable D-PPG as a useful screening tool for the diagnosis of clinically suspected lower limb DVT. A positive test requires further confirmation by one of the "gold standard" methods, whereas a negative test effectively excludes DVT.     

Treatment of critical lower limb ischemia--where are we standing at the turn of the Millennium?

The treatment of chronic critical limb ischaemia (CLI) is a very important and constantly developing field of vascular surgery. The high incidence of CLI (50-100/100,000 inhabitants [10]) means that vascular surgeons at a district general hospital/county hospital, providing care for 250-300,000 people, see about 120-150 cases in a year, 70-75% of them needing elective or acute intervention. We have witnessed many important changes over the last 1-2 decades in the management of this substantial field of vascular surgery. The in situ technique, angioscopically assisted valvulotomy, venous cuffs and A-V fistulae at the distal anastomosis of an infrainguinal bypass, the intraluminal and subintimal angioplasty-technique in hand, graft-surveillance programmes and the more aggressive treatment of graft-infection all provide a potentially better chance for limb salvage. Do we follow the trends and seize them?     

Check radiography after fixation of hip fractures: is it necessary?

Technological advances in radiography in the form of image intensification has not only made internal fixation of femoral neck fracture much easier but these high resolution films can be saved as hard copies and can also be reversed into 'positives' at a later date. However, requesting routine post-operative check radiographs for these fractures are still a common practice. A retrospective study was carried out to compare the quality of image intensifier films with conventional post-operative radiographs. 79 sets of films were reviewed with particular reference to adequacy of fixation and possible joint penetration by the screws. No significant difference was noted between the two sets of films. We suggest that routine post-operative radiographs after femoral neck fracture fixation are unnecessary unless there is some clinical indication. This has significant implications in relation to patient discomfort, radiation exposure and cost-effectiveness.     

Tourniquet application and epinephrine injection to penile skin: is it safe?

Although a tourniquet is frequently used in penile surgery there is still no consensus on safe application time. The aim of the present study is to investigate the effect of malondialdehyde (MDA) levels and histological changes in skin flaps after penile tourniquet application and epinephrine injection. A total of 36 male white New Zealand rabbits were randomly divided into six groups each containing six animals. A Mathieu-like flap was raised in all of the groups and a tourniquet was applied and the penis was subjected to ischemia for 10, 20 and 40 min in groups 1, 2 and 3, respectively. The flaps were then allowed to reperfuse for 5 min. Biopsies for MDA measurement were harvested in these groups. Subcutaneous 1/200,000 epinephrine was injected into penile skin in group 4 and 5 rabbits and biopsies for MDA measurement were harvested 10 and 40 min after injection. The control group was anesthetized without tourniquet usage or epinephrine injection. Specimens taken from the harvested flaps of all groups were submitted for histological evaluation. The mean MDA levels in all experimental groups were higher than in the control group and the difference was statistically significant. Edema, congestion and extravasation were observed in groups 1, 2 and 3. Minimal congestion and edema were observed in group 4 and severe edema and extravasation in group 5. Tourniquet usage for a duration of less than 10 min is clearly safer than prolonged usage. Epinephrine injection to penile skin may show a deleterious effect on wound healing.     

Venous ulcers of the lower limb: Where do we stand?

Venous ulcers are the most common ulcers of the lower limb. It has a high morbidity and results in economic strain both at a personal and at a state level. Chronic venous hypertension either due to primary or secondary venous disease with perforator paucity, destruction or incompetence resulting in reflux is the underlying pathology, but inflammatory reactions mediated through leucocytes, platelet adhesion, formation of pericapillary fibrin cuff, growth factors and macromolecules trapped in tissue result in tissue hypoxia, cell death and ulceration. Duplex scan with colour flow is the most useful investigation for venous disease supplying information about patency, reflux, effects of proximal and distal compression, Valsalva maneuver and effects of muscle contraction. Most venous disease can be managed conservatively by leg elevation and compression bandaging. Drugs of proven benefit in venous disease are pentoxifylline and aspirin, but they work best in conjunction with compression therapy. Once ulceration is chronic or the patient does not respond to or cannot maintain conservative regime, surgical intervention treating the underlying venous hypertension and cover for the ulcer is necessary. The different modalities like sclerotherapy, ligation and stripping of superficial varicose veins, endoscopic subfascial perforator ligation, endovenous laser or radiofrequency ablation have similar long-term results, although short-term recovery is best with radiofrequency and foam sclerotherapy. For deep venous reflux, surgical modalities include repair of incompetent venous valves or transplant or transposition of a competent vein segment with normal valves to replace a post-thrombotic destroyed portion of the deep vein.KEY WORDS: Compression therapy, surgery on veins, venous hypertension, venous ulcers Indian JouIn the course of a lifetime, almost 10% of the population will develop a chronic wound, with a wound-related mortality rate of 2.5%.[1] Of these, underlying venous pathology is the most common aetiology of lower extremity ulceration.[2] Even in the 21^st century, studies revealed the following effects of ulceration: pain, itching, altered appearance, loss of sleep, functional limitations, social isolation, depression and disappointment with treatment.[3,4] In 2011, an integrative review of previous studies on quality of life in patients with venous ulcers was published, which confirmed the negative impact of the disease on health-related quality of life.[5]Venous ulcers are the result of breakdown of skin due to failure of preventing the consequence of chronic venous insufficiency. The disease has been known for more than 3.5 millennia, with wound care centers established as early as 1500 BC. Unfortunately, still today, it is a very poorly managed clinical condition by most physicians despite acquiring a great deal of knowledge about the pathogenesis and treatment for venous ulcerations.[6]There is no available statistics related to the incidence of venous ulcers in India. But, an epidemiologic study on railway workers in 1972 found the incidence of varicose veins to be significantly higher in South Indians than in their northern counterparts.[7]The morbidity of the disease, inadequate management, necessary logistic support and prolonged continuous care makes this disease a financial burden both at a personal and at the Government level. In the US, 80% of the lower extremity ulcers are venous ulcers, and the financial burden is $2 billion per year.[8,9] Venous leg ulceration alone has been estimated to cost the NHS £400 m a year in the United Kingdom.[10] Studies in Germany calculated the mean total cost of a venous ulcer per patient per year to be €9569 (€8658-92% direct costs and €911-8% indirect costs).[11]     

Conservative management of exomphalos major with silver dressings: are they safe?

Historically, some dressings used in exomphalos major were associated with toxicity. These have been abandoned in favor of safer dressings. Silver toxicity has not been described following the use of silver dressings in infants. We, however, found disconcerting serum silver levels in 2 consecutive patients during treatment with silver salt containing dressings.     

Speed of sound in bone at the tibia: is it related to lower limb bone mineral density in spinal-cord-injured individuals?

STUDY DESIGN: A cross-sectional study evaluating BMD at the hip and tibia, and SOS at the radius and mid-tibia in individuals with spinal cord injury (SCI) and a subgroup of non-SCI individuals. OBJECTIVES: To investigate the speed of sound (SOS) in bone in relation to bone mineral density (BMD). SETTING: Kinesiology Department, McMaster University, Ontario, Canada. METHODS: In 14 individuals with SCI and 10 non-SCI individuals, proximal femur and tibia BMD were measured using dual energy X-ray absorptiometry, and radius and tibia SOS were measured with an ultrasonometer. T-scores were calculated using healthy reference databases. Inter-relationships between measurement techniques were determined using Pearson's correlation coefficients. P-values less than 0.05 were considered statistically significant. RESULTS:: The average ages of the SCI and non-SCI groups were 33+/-9 and 27+/-6 years, respectively. Lesion level ranged from C4 to T12 and average time postinjury was 12 years, with a range of 1.6-25 years. Using the WHO criteria for osteoporosis, nine of 14 SCI subjects were osteoporotic at the hip, with the remainder in the osteopenic range. Tibia SOS T-scores were in the osteoporotic range for one subject with SCI, and two were in the osteopenic range. Among non-SCI individuals, one male had a tibia SOS T-score of -1.4, all others were within the normal range. Hip BMD and tibia SOS were significantly correlated (r=0.46, P<0.01). Hip BMD and tibia BMD were more strongly correlated (r=0.80, P<0.0005). Tibia BMD was not significantly correlated with SOS at the tibia (r=0.35, P=0.09). Radius SOS T-scores were positive and not significantly correlated with any lower limb variable. CONCLUSION: Lower-limb bone mass is reduced in spinal cord-injured individuals, but SOS at the mid-tibia is not. It remains to be determined whether ultrasound measurements can predict fracture in the SCI population.     

Mucous cystadenoma of the appendix: is it safe to remove it by a laparoscopic approach?

Mucinous cystadenoma is an uncommon neoplasm of the appendix usually discovered intraoperatively. Its clinical significance lies in the possible rupture and consequent spillage of mucin into the peritoneal cavity, leading to pseudomyxoma peritonei. Even if laparoscopy has been successfully used to perform appendectomy, some concerns exist regarding its use in dealing with mucinous secreting lesions because of possible spillage of mucin during surgery. We report a case of mucous cystadenoma of the appendix, which was successfully removed using a laparoscopic approach. At a 12-month follow-up assessment, the patient was free of disease. We believe that the laparoscopic approach is safe if surgery can be performed without grasping the lesion, and if the specimen is removed through the abdominal wall using a bag. Conversion to laparotomy should be considered if the lesion must be traumatically grasped, or if the tumor clearly extends beyond the appendix.     

Postoperative delirium in patients with chronic lower limb ischaemia: what are the specific markers?

OBJECTIVES: we determined the incidence and specific markers of postoperative delirium in elderly patients with chronic lower limb ischaemia. PATIENTS AND METHODS: since April, 1995, 110 patients aged 60 years or older (mean: 71.6+/-6.6 years) who underwent bypass surgery were assessed regarding aetiological factors of delirium: age, sex, dementia, body-mass index, hypertension, diabetes, cerebral disease, laboratory test results, severity of limb ischaemia, type of arterial occlusion, operative time, and blood transfusion. RESULTS: discriminant analysis showed statistical significance in the following five variables: age >/=70 years; critical limb ischaemia (and/or ankle pressure <40 mmHg); dementia; duration of operation >/=7 hours; low serum albumin. The overall percentage of cases correctly classified was 78.2% (Wilks> Lambda=0.695, p<0.001); the standardized regression coefficients of the five variables were 0.648, 0.500, 0.329, 0.218, and 0.200, respectively. In logistic regression, the regression coefficients for old age and critical limb ischaemia were 2.646 (14.1 of odds ratio; 95% confidence interval, 2.7-72.0) and 1.337 (3.8; 1.3-10.9), respectively. CONCLUSIONS: the incidence of postoperative delirium in elderly patients with chronic lower-limb ischaemia was as high as 42.3%, and an age of over 70 years and critical limb ischaemia were identified as specific markers, with 14.1 times and 3.8 times the odds of suffering from delirium after bypass surgery.     

Single-use trocar: is it possible to reprocess it after the first use?

The aim of this study was to verify and describe the presence of microorganisms in the single-use trocar after its use in surgical procedures, and after this device was submitted to cleaning, conditioning, and sterilization by physicochemical processes (formaldehyde, ethylene oxide, and hydrogen peroxide plasma). Twenty-eight trocars of the Ethicon, Auto-suture, and Aesculap brands, were randomly selected and analyzed after laparoscopic cholecystectomy. The results have shown that cultures grown of the material collected from the trocars, immediately after its use and before its sterilization process, showed the presence of bacteria and fungi in 46.5% (13). In 53.5% (15) of the trocars, the presence of microorganisms was not detected, very likely due to niche's scarcity. In the cultures grown of the 28 trocars after being submitted to sterilization processes, the presence of microorganisms was not verified. We can therefore conclude that although trocars possess compartments not easily accessed for cleaning, these devices can be adequately cleaned and effectively sterilized, when well manipulated, in the institution where the study was carried out by the processes of steam sterilization at low temperature and formaldehyde, ethylene oxide, and hydrogen peroxide plasma.     

Robotic skeletonizing of the internal thoracic artery: is it safe?

BACKGROUND: The advantages of internal thoracic artery skeletonization include early high blood flow, a longer conduit, and less bleeding than pedicle internal thoracic artery grafts. Longer conduits are needed for complete endoscopic arterial revascularization. Therefore this study was designed to determine the feasibility and safety of internal thoracic artery skeletonization using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA). METHODS: Nine dogs underwent bilateral robotic internal thoracic artery harvesting through three ports placed in the left chest. One internal thoracic artery was harvested as a pedicle in each dog, and the other was skeletonized. Internal thoracic artery blood flow was measured in each graft, and comparative endothelial histologic studies were performed. Data are mean +/- the standard error of the mean. RESULTS: All 18 internal thoracic arteries were harvested successfully. Skeletonized internal thoracic artery harvests required more time (48.0 minutes +/- 1.8) than pedicle internal thoracic artery harvests (39.0 minutes +/- 1.4; p < 0.05). Internal thoracic artery flows during the final intervals were similar (skeletonized = 30.0 mL/min +/- 2.4 vs pedicle = 31.5 mL/min +/- 1.8; p = 0.9). Free internal thoracic artery bleeding flow was similar in both groups (skeletonized = 162.0 mL/min +/- 3.0 vs pedicle = 189.0 mL/min +/- 2.4; p = 0.4). Histologically, both groups were similar with minimal endothelial damage. CONCLUSIONS: Robotically skeletonized harvesting is safe, but it requires more time (48.0 minutes +/- 1.8) than pedicle internal thoracic artery harvesting. Despite muted tactile feedback with robotics, neither technique was associated with histologic or functional damage. These encouraging results may represent an advantage for complete arterial revascularization in robotic coronary bypass patients.     

Changing from analog to digital images: Does it affect the accuracy of alignment measurements of the lower extremity?

Background and purpose

Medical imaging has changed from analog films to digital media. We examined and compared the accuracy of orthopedic measurements using different media.

Methods

Before knee arthroplasty, full-length standing radiographs of 52 legs were obtained. The mechanical axis (MA), tibio-femoral angle (TFA), and femur angle (FA) were measured and analyzed twice, by 2 radiologists, using (1) true-size films, (2) short films, (3) a digital high-resolution workstation, and (4) a web-based personal computer. The agreement between the 4 media was evaluated using the Bland-Altman method (limits of agreement) using the true-size films as a reference standard.

Results

The mean differences in measurements between the traditional true-size films and the 3 other methods were small: for MA –0.20 to 0.07 degrees, and for TFA –0.02 to 0.18 degrees. Also, the limits of agreement between the traditional true-size films and the three other methods were small.

Interpretation

The agreement of the alignment measurements across the 4 different media was good. Orthopedic angles can be measured as accurately from analog films as from digital screens, regardless of film or monitor size.During the last 15 years a gradual change from traditional, analog film radiographs to digital imaging has occurred. This has implemented a change not only in the way images are obtained, but also in the way images are archived and, above all, evaluated. The image transition time in daily clinical practice has decreased (May et al. 2000). Traditional film evaluation has changed to image reading on monitor screens; this change affects not only radiologists, but also orthopedic surgeons. In addition to the change in the visual analysis of images, there has also been a change in how measurements are performed. Light boxes, rulers, and grease pencils have been exchanged for computers using graphics software.In knee surgery, it is common to assess the alignment of the whole lower extremity with a hip-to-ankle radiograph from which the mechanical axis (MA), the tibio-femoral angle (TFA), and femur angle (FA) are measured. Excellent intra- and interobserver reproducibility of analog MA measurements has been reported in several studies (Henderson and Kemp 1991, Sharma et al. 2001, Rauh et al. 2007, Gordon et al. 2009). In osteoarthritis, the tibio-femoral joint space narrowing is often unsymmetrical, leading to angular deformity of the lower extremity, more commonly of varus type. In order to be able to restore the alignment, knowledge of the preoperative malalignment is crucial. A malalignment of the knee prosthesis not only increases the likelihood of postoperative malfunction, but also affects the lifespan of the prosthesis (Sorrells et al. 2007).We investigated the accuracy of alignment measurements performed using 4 techniques: analog true-size films, films of reduced size, high-resolution workstations, and web-based personal computers (PCs). Before that, we assessed the intra- and interobserver reliability of these 4 techniques, separately for each technique.     

Evidence-based medicine and the management of the chronic wound: is it enough?

Evidence-based medicine has become ubiquitous in modern-day medicine, including wound care. However, the application of evidence-based medicine into the arena of chronic wounds has not been uniformly performed and measured. Most wound care studies are plagued by inconsistencies in inclusion criteria, data measurements, and endpoint reporting. Furthermore, the small sample sizes prohibit drawing effective conclusions. However, that does not imply that the current guidelines of treatment are substandard. Instead, one must rely more heavily on current evidence and experts in the field until larger, more consistent studies can establish good practice patterns.