Response of the popliteal artery to treadmill exercise and stress positioning in patients with and without exertional lower extremity symptoms

ObjectiveFunctionally limiting exertional lower extremity pain and neurologic symptoms are commonly encountered in military and civilian settings. Exertional muscle compression of the popliteal artery (PA) and tibial nerve in the proximal calf (the “popliteal outlet”) can be associated with these symptoms but is rarely investigated as a cause. Exertional ankle-brachial index (EABI) and dynamic PA ultrasound imaging may be suitable to screen for this syndrome of “functional” popliteal entrapment, but neither has been rigorously studied. Our objective was to characterize the response of the PA to lower extremity exertion and dynamic ankle positioning in symptomatic and asymptomatic limbs.MethodsLimbs characterized as symptomatic (n = 29) or asymptomatic (n = 61) had duplex ultrasound PA diameter and peak systolic velocity measurements with the ankle neutral and maximally plantar flexed. EABIs were obtained at rest and 1 minute and 5 minutes after walking (5 minutes, 3 mph, 10-degree incline) and running (5 minutes, 6 mph, 0-degree incline). Significance was set at P ≤ .05. Data are expressed as mean ± standard error of the mean.ResultsPlantar flexion resulted in PA occlusion and changes in diameter and peak systolic velocity in symptomatic (three occluded, ?2.4 ± 0.34 mm, +49 cm/s) and asymptomatic (six occluded, ?1.6 ± 0.21 mm, +65 cm/s) limbs. The difference in percentage change was significant between groups only for diameter change. EABIs in both groups were similar at rest, decreased with running and walking at 1 minute, and were not fully recovered by 5 minutes. Symptomatic limbs had a greater decrease in ABI than did asymptomatic limbs with both running and walking. The decrease was greatest at 1 minute after running and significantly more pronounced in symptomatic (?0.18) than in asymptomatic (?0.02) limbs.ConclusionsEABI decrease at 1 minute after running and PA diameter decrease with dynamic ankle plantar flexion are significantly greater in limbs with than without exertional lower extremity symptoms. These noninvasive measurements may be valuable in the workup of such symptoms. PA and tibial nerve compression at the popliteal outlet may be a more frequent cause of functionally limiting exertional lower extremity pain and neurologic symptoms than previously recognized.     

A Simplified Method of Ligation of Patent Ductus Arteriosus in Premature Infants

A clip technique for ligation of the ductus arteriosus in premature infants is presented.     

A simple and effective left ventricular vent tube.

We have devised a simple, cheap, left ventricular vent that is relatively free from malfunction. It has further use in that it serves as a means of cooling the endocardium when hypothermic techniques are utilized.     

A Simple Method of Intraaortic Balloon Removal after Open-Heart Operation

A simple technique for intraaortic balloon removal is presented.     

Respiratory obstruction in the newborn associated with increased volume and opacification of the hemithorax

Respiratory obstruction in the newborn can be associated with retained fetal pulmonary fluid if the obstruction was present in utero. The chest roentgenogram demonstrates increased volume and radiopacity of the affected lung. Two patients in respiratory distress with these roentgenographic manifestations are presented. The diagnostic approach to this problem is discussed.     

Carcinoid tumors of the appendix

The data presented in this series support the premise that simple appendectomy is adequate therapy for appendiceal carcinoids less than 1 cm in diameter. However, little argument can be made against more radical surgery for gross lymph node metastases. When surgical margins after appendectomy are not free of tumor, additional surgery seems warranted, although in the present series there was a patient who was followed for 30 years who had residual microscopic disease in the appendiceal stump. Adequate treatment for tumors larger than 2 cm includes radical right hemicolectomy. What constitutes adequate therapy for tumors in the 1 to 2 cm range continues to be a point of controversy. From the data presented herein, it seems that appendectomy alone is sufficient except in those instances when both mesoappendiceal and subserosal lymphatic invasion is identified microscopically.     

Perioperative heparin prophylaxis of deep venous thrombosis in patients with peripheral vascular disease

Perioperative low dose heparin was administered to 24 patients who were compared with 19 control patients undergoing peripheral vascular surgical procedures. This prophylactic measure was ineffective in reducing the incidence of subclinical, post-operative deep venous thrombosis, as indicated by iodine-125 fibrinogen scanning. The data suggest that patients undergoing vascular surgery will not benefit from the routine application of this prophylactic regimen.     

A comparison of preoperative and intraoperative vein mapping sizes for arteriovenous fistula creation

Background

Duplex ultrasound (DUS) mapping of the veins and arteries of the upper extremity is a well-established practice in arteriovenous fistula creation for long-term hemodialysis access. Previous publications have shown that vein diameters varying from 2 to 3 mm are predictive of success. Regional anesthesia is known to result in vasodilation and thus to increase the diameter of upper extremity veins. This study compares the sizes of veins measured by preoperative DUS mapping with those obtained after regional anesthesia to determine whether intraoperative DUS results in increased vein diameters and thus changes in the operative plan. A second goal was to determine whether such changes resulted in functional access.

Linking hand therapy outcome measures used after carpal tunnel release to the International Classification of Functioning,Disability and Health: A systematic review

IntroductionThe goal of hand therapy after carpal tunnel release (CTR) is restoration of function. Outcome assessment tools that cover the concepts contained in the International Classification of Functioning, Disability and Health (ICF), a framework for describing functioning and disability, are appropriate for hand therapy treatment of this diagnosis.Purpose of the StudyTo identify and review outcome measures used in studies on rehabilitation after CTR and link these to the concepts contained in the ICF.MethodsA comprehensive literature search was conducted. Outcome measures in the included studies were linked to the ICF. For data calculation purposes, outcome measures were linked to the specific ICF category, which matched the majority of assessment items if there were components that fit into more than 1 category. The quality of the studies was evaluated, and effect sizes for the treatment interventions were calculated for a comprehensive systematic review.ResultsSeven studies met the inclusion criteria. Eleven outcomes (68.75%) were linked to body function, 1 (6.25%) to body structure, 3 (18.75%) to activity and participation, and 1 (6.25%) to environmental factors. No outcomes were associated with environmental factors or personal factors. Structured Effectiveness for Quality Evaluation of Study scores of the included studies ranged from 23 to 43/48.DiscussionThe predominant outcome tools in the current research on rehabilitation after CTR are impairment measures and are linked to the category of body structures and body functions.ConclusionsFunctional measures, associated with the activity and participation category, are only modestly represented, and there is a lack of representation of environmental and personal factors for outcome measures used following CTR.     

Outcomes of tibial endovascular intervention in patients with poor pedal runoff

Objective

Tibial interventions for critical limb ischemia are now commonplace. The aim of this study was to examine the impact of pedal runoff on patient-centered outcomes after tibial endovascular intervention.

Feasibility and pilot efficacy of a brief smoking cessation intervention delivered by vascular surgeons in the Vascular Physician Offer and Report (VAPOR) Trial

Background

This study determined the feasibility and potential efficacy of an evidence-based standardized smoking cessation intervention delivered by vascular surgeons to smokers with peripheral arterial disease.

Vascular surgery residents spend one fifth of their time on electronic health records after duty hours

ObjectiveElectronic health records (EHR) have largely replaced paper-based medical records. Academic institutions have adapted EHR successfully and technological innovations now allow remote access. Thus, self-reported resident duty hours may not accurately reflect the actual time that is spent on patient care-related activities.MethodsThis retrospective observational study quantified vascular surgery resident EHR activities between January 2016 and June 2016 at a tertiary care hospital. Use time was tracked from user login to logout, divided by day of the week, and separated by EHR tasks performed. Each 24-hour time period was further divided into on-duty (6:00 am to 6:00 pm) and off-duty (6:00 pm to 6:00 am) hours. On-call weekdays and rotations that occurred off campus were excluded. The following EHR activity data were requested: total time, chart review time, documentation time, electronic order entry, patient discovery, and electronic messages.ResultsA total of 11,812 charts were accessed: 80.5% on weekdays and 19.5% on weekends. Total time spent (hours:minutes:seconds, weekday percentage, weekend percentage) on EHR during this time period was 634:33:36 (81.2%, 18.8%). On weekdays, 79% of the EHR time was during the work hours and 21% after hours. On weekends, 78% of the EHR time was during work hours and 22% after hours. Time spent on different EHR tasks was as follows: chart review 278:58:34, documentation 66:33:07, electronic order entry 120:50:24, electronic messaging 2:16:48, problem list modification 1:49:26, electronic messages 4:30:43, patient discovery 151:14:53, and other 164:05:17. Overall, postgraduate year 1 residents spent the most number of hours on EHRs and during the weekdays. There was serial decrease in the total number of EHR hours and the number of weekday hours with the seniority of the residents, with postgraduate year 5 residents spending the least number of overall hours and weekday hours on the EHR. When EHR access was compared with self-reported duty hours, resident compliance was 58% on average.ConclusionsEHR use after hours constituted one-fifth of a vascular surgical trainee's total EHR time. Despite self-reported duty-hour compliance, a good proportion of their daily time is still spent on patient care. This pilot study sets the stage for larger studies to be conducted in future to address this issue.     

Measuring common outcome measures and their concepts using the International Classification of Functioning, Disability and Health (ICF) in adults with burn injury: a systematic review

Purpose

To identify and quantify the health related concepts contained in the most common outcome instruments used in adult burn care, and to compare the content of these instruments based on their linkage to the International Classification of Functioning, Disability and Health (ICF). The ICF has been validated as a reference tool by the World Health Organization and is a framework that incorporates physical, emotional, environmental and social aspects of daily functioning.

Methods

Electronic searches of MEDLINE, EMBASE CINAHL, PsychINFO and the Cochrane Library from 2003 onwards were carried out using a predetermined search strategy. Specific characteristics of the included studies and data pertaining to the outcome instruments were extracted. Two reviewers independently categorised the underlying concepts contained in the most commonly used outcome measures and linked them to ICF categories using standardised linkage rules.

Results

Out of a total 132 included studies, 151 outcome instruments were identified. Of these, 14 frequently used generic and burn-specific instruments were selected for linkage to the ICF. From the 381 items contained in the 14 instruments, 356 concepts were extracted and subsequently linked to 99 ICF categories. Nearly 46% of the concepts were linked to body function and 20% to activities and participation, whereas only a few concepts were formally linked to health condition, body structures and personal or environmental factors.

Conclusion

The ICF proved highly useful for the content comparison of frequently used generic and burn-specific instruments. The results may provide clinicians and researchers with new insights when selecting health-status measures for clinical studies in those with burn injury.