Ultrasonography of the lower limbs for deep vein thrombosis at the University Hospital of the West Indies

A study was conducted on all patients referred to the ultrasound service of the radiology department of the University Hospital of the West Indies, Kingston, Jamaica, for evaluation of a clinical diagnosis of thrombosis of the deep veins of the lower limb, during the period January 1, 1995, to December 31, 1999. The calf veins were not routinely examined; this study was limited to the popliteal, superficial and deep femoral veins. Two hundred and seventy-four females and 104 males were referred. Seventy females and 32 males had ultrasound findings of deep thrombosis (DVT). The significant findings were that the male: female ratio for confirmed DVT was approximately 1:2; 26 percent of referrals had DVT on ultrasound; DVT was more common on the left and the popliteal vein (48 percent) and the superficial femoral vein (47 percent) accounted for most documented cases of DVT but thrombosis of the profunda femoral vein was unusual accounting for only 5 percent of cases. (AU)

Surgical management of critical limb ischaemia in Guadeloupe, French West Indies - abstract

This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age, 71 ñ 15 years) admitted for critical limb ischemia. 145 (84 percent) had tissue loss at admission including toe gangrene or ischemic ulcer in 77 and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularizations were performed at iliofemoral (n=20), suprapopliteal (n=22) or infrapopliteal level. Postoperative mortality rate was not significantly different in the "Amputation" group (14 percent) and "Revascularizations" groups 9 percent. Infective complications were comparable in both groups although 5/14 deaths after amputations were were directly related to infections while all deaths after revascularizations resulted from cardiovascular complications. The early limb salvage after revascularizations was 82 percent. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p<0.03) and with significantly higher rates of heart diseases and non-ambulatory status (respectively 24 vs 17 percent, p<0.05 and 37 vs 13 percent, p<0.001) than patients in whom revascularizations were performed. The major findings were that ischemic rest pain and tissue loss confined to digit gangrene or ischemic ulcer were significantly more frequent in the group "Revascularizations" (p<0.0001), while extensive gangrene extending beyond the forefoot (p<0.0001) was significantly more frequent in group "Amputations". Therefore, late presentation of patients and enhanced tissue loss are very likely to play a role in our primary amputation rate, higher than those observed elsewhere. In patients amenable to revascularizations (56 percent), arterial reconstructiions for critical limb icshemia performed in the West Indies provide for a fair likelihood of limb salvage. (AU)

Infrapopliteal bypass for critical limb ischaemia: early experience in the French West Indies

From December 1992 to October 1995, 42 infrapopliteal arterial bypass operations for limb salvage were performed in 39 patients (including 22 diabetics) with limb ischaemia (mean age, 71 years). Thirty-four patients (87 percent) had tissue loss at admission (8 ulcers, 13 digit gangrenes and 13 extensive foot infections). Angiographic findings were consistent with artherosclerotic involvement of femroal and crural arteries. Outflow anastomic sites were the popliteal (n = 5); tibial (n = 14); peroneal (n = 14) and pedal artery (n = 9). Autogenous saphenous vein was suitable in 27 procedures and inadequate in 15 (<3 mm diameter, with gross fibrosis or segmental occlusion) requiring prosthetic or composite grafts. Postoperative mortality rate was 10 percent, related to concomitant cardiovascular diseases. Mean follow-up was 14 months (range, 3 - 35). Fourteen bypasses failed, 5 in the early period (8 - 30 days) and 9 within a mean interval of 7.6 months, resulting in 6 limb amputations. Overall life-table primary graft patency rates were 72 percent (ñ 8) at 12 months and 61 percent (ñ 9) at 2 years and were not significantly different in diabetic patients compared to those in non-diabetics. Primary graft patency rates were significantly lower in prosthetic or composite grafts compared to saphenous vein grafts (75 percent vs 32 percent at 2 years - p<0.01), respectively. Overall life-table limb salvage rates were 84 percent (ñ 7) and 76 percent (ñ 9) at 12 and 24 months respectively. Seventy-eight percent of patients with limb salvage were relieved of ischaemic symptoms, 57 percent regained the ability to ambulate with improved functional level and 85 percent of tissue loss healed within a mean interval of 55 days. Infrapopliteal bypass operations for critical limb ischaemia performed in Martinique provide a fair chance of limb salvage despite limitations of medical facilities. (AU)

The in-patient profile of lower limb neurovascular disease in a Trinidadian population - abstract

Lower limb neurovascular disease is an extremely common problem in Trinidad, accounting for about 55 per cent of the surgical in-patient population. Because detailed information on the profile of these patients is not documented a prospective survey of lower limb disease was carried out among all patients admitted to 116 adult surgical beds over a 3-month period. A form was designed to collect demographic data, diagnosis, operations dressings, antibiotics and risk factors, and completed for each patient on admission and updated till discharge. Of a total of 203 patients with lower limb disease 7 with varicose vein as the underlying pathology were excluded. There were 100 males in the 196 cases and Afro-Trinidadians (75.5 per cent) were predominant over Indo-Trinidadians (21.4 per cent). Wet gangrene accounted for 36 per cent, other infections 30 per cent, non-healing ulcer 19 per cent, dry gangrene 9 per cent and rest pain 7 per cent. Trauma initiated 35 per cent of the septic lesions. Forty-two (21.4 per cent) patients had major amputations. Patients stayed in hospital for a long time (average 22.2 days), used dressings frequently (15.1 dressings per patient) and required considerable antibiotic medication (20.7 days). Diabetes mellitus was the commonest associated disease (63 per cent). Lower limb ischaemia and gangrene result in considerable cost to our medical institutions. Foot care especially in diabetics could reduce the incidence of these problems since trauma is often a precipitating factor (AU)

Preserving the lower limbs

Preservation in medicine is seen against a background of loss. Loss of the lower limbs in Barbados and the Caribbean is at present a major health problem, which is made worse by the lack of good rehabilitative for those who suffer from this disability. The problem is illustrated in Barbados by the fact that there are some 126 amputations of lower limbs each year sixty percent are in diabetics. The underlying diseases which threaten the loss of lower limbs are diabetes and occlusive atherosclerosis. The combination of the two is particularly difficult. The precipitating factors which put vulnerable limbs at risk can be categorised as trauma and infection

Femoral shaft fractures in children: when bone shortening is desirable in healing - abstract

Fractures of the femoral shaft are common injuries in growing children. Road traffic accidents, falls from furniture at home and falls from trees account for the majority of cases. Apart from cases of child abuse which should be suspected in toddlers with multiple injuries to the body, pathological fractures are uncommon in this age group. Open fractures are also uncommon. Whereas in the conservative treatment of adult femoral fractures, every attempt must be made to reduce the fragments as accurately as possible and, in particular, restore normal length, in growing children such degree of accuracy in reduction is not necessary. In fact, some degree of bone shortening is desirable in displaced fractures. Accurate reduction of the fragments end to end will result in an overgrowth of the affected limbs amounting to 1" in the femur and this is permanent. This poster presents our experience based on 80 cases treated over an eight-year period. The ages of the children ranged from 3 months to 12 years. All cases were treated conservatively except one eleven-year old who had to be operated on. The only complication observed was a refracture, but this proceeded to proper healing. We believe treatment of fractures of the femoral shaft in growing children, based on certain well deformed principles, should be within the reach of every practitioner. In children approaching adolescence, the potential for growth is limited. Therefore, in these children, the fracture should be managed as for adults (AU)

Pregnancy and progeny in rats treated with the pyrrolizidine alkaloid fulvine

The pyrrolizidine alkaloids are naturally-occurring plants toxins which are considered significant in the etiology of certain liver diseases, particularly in some tropical and sub-tropical regions. Fulvine, a hepatotoxic alkloid present in the medicinal herb Crotolaria fulva, was observed to be fetotoxic and highly teratogenic in rats. The occurrence of fetal resorptions showed a dose-effect relationship. The highest incidence of developmental defects was induced by fulvine at a dose-level of 80 mg/kg which in other studies produced significant chromosomal damage. Microscopic examination of fetal liver, following maternal exposure of fulvine, did not reveal hepatic lesions.(Summary)

Volume changes in forearm and hand following release of obstruction to venous return

Observations were made on the changes that occur in the volume of the forearm and hand following the release of an obstruction to the venous return. The presence of three phases has been confirmed: a) a rapid primary decrement (P.D.) followed occasionally by b) an increase in volume (Hump), and finally c) a secondary decrement (S.D.) as the limb volume gradually returned to normal. It is suggested that the primary decrement in limb volume (P.D.) is largely venous in origin and is probably due to the rapid initial ejection of blood from the limb as the large veins recover their normal size and calibre. An index of venous distensibility is suggested which might provide a means of indirectly measuring venous tone.(AU)