An experimental study of prescribed walking in the management of venous leg ulcers.

OBJECTIVE: To determine the relationship between the level of patient activity in the form of walking and the rate of venous leg ulcer (VLU) healing. METHOD: Forty patients with newly diagnosed VLUs were recruited to the study a nd randomly allocated to either control or exercise groups. All patients were treated with multilayer compression bandaging for 12 weeks, or until their ulcer had fully healed. Daily stepping rate was recorded at initial assessment and following 4 weeks of treatment. Participants in the exercise group were encouraged to increase their daily steps with a target of 10 000 steps per day. The control group were n ot asked to change their daily steps. RESULTS: In total, 33% of the exercise group achieved an average of 10 000 steps per day. Participants who took more steps at both the baseline and 4-week assessment healed more quickly than those who took fewer steps (p=0.052 and p=0.008 for baseline and week 4, respectively). Sixty-seven per cent of the participants who increased their daily steps had venous ulcers, which were healed by week 8, compared with 35% of those who did not. CONCLUSION: Participants who took more steps per day showed faster venous ulcer healing times when compared with those who took fewer steps, emphasising the benefit of walking in this patient group. Further studies are necessary to confirm these early findings. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflict of interest to declare.

The management of right iliac fossa pain - is timing everything?

BACKGROUND: Right iliac fossa (RIF) pain remains the commonest clinical dilemma encountered by general surgeons. We prospectively audited the management of acute RIF pain, examining the relationship between symptom duration, use of pre-operative radiological imaging and patient outcome. METHODS: Over a six-month period, 302 patients, median age 18 years, 59% female, were admitted with RIF pain. Symptoms, clinical findings and laboratory results were documented. Patient management, timing of radiological investigations and operations, and outcome were recorded prospectively. RESULTS: Non-specific abdominal pain (26%), gynaecological (22%) and miscellaneous causes (14%) accounted for most admissions. Ultimately, 119 patients (39%) had appendicitis. Anorexia, tachycardia or rebound tenderness in the RIF significantly predicted a final diagnosis of appendicitis. Patients with perforated appendicitis (n = 29) had a longer duration of pre-hospital symptoms (median 50h) compared to those with simple appendicitis (median 17 h) (p<0.001). The use of pre-operative imaging resulted in an increased time to surgery but was not associated with increased post-operative morbidity or perforated appendicitis. CONCLUSION: The majority of patients presenting to hospital with RIF pain did not have appendicitis. Increased duration of pre-hospital symptoms was the main factor associated with perforated appendicitis. However, increased in-hospital time to theatre was not associated with perforated appendicitis or post-operative morbidity.

Management and outcome in patients following head injury admitted to an Irish Regional Hospital.

PRIMARY OBJECTIVE: Each year in Ireland, 11 000 patients are admitted to hospital with a traumatic brain injury (TBI) but there are no data on subsequent disability in such patients. The objective of this study was to assess the management and outcome in patients of working age admitted with TBI to the unit. METHODS: Two hundred and sixteen patients admitted with TBI aged 16-65 were identified. Self-reported incidence of disability and access to appropriate services was assessed using the Glasgow outcome scale and a problem-orientated questionnaire. RESULTS: Eighty-five per cent of patients eligible for review agreed to participate. The majority of injuries (86%) were mild. An intracranial injury was identified on 35% of CT brain scans performed. Patients with an abnormality on CT scanning were more likely to report difficulties with headache, concentration and memory at time of follow-up. When questioned, 34% of patients still perceived difficulties since their injury. Of this group, 60% didn't receive any input from rehabilitation services. One year post-injury, 11% of patients remained unfit for work. CONCLUSION: A significant number of patients, even with mild TBI, continue to suffer sequelae from their injury augmented by difficulty in accessing appropriate rehabilitation services.

Vascular trauma in an Irish regional hospital.

BACKGROUND: Vascular trauma is a common cause of mortality and morbidity worldwide. There are few accurate quantitative data available presently on the nature and outcome of these injuries. The aim of this study was to determine the incidence, aetiology, management and outcome of vascular injuries which required surgical intervention at a regional vascular unit. METHODS: All patients who suffered a vascular injury requiring surgical intervention between January 1992 and December 2005 were included. RESULTS: A total of 35 patients who underwent operative intervention for vascular trauma were reviewed. There were 26 men and 9 women with a median age of 26 years (range 3-80 years). Road traffic accidents accounted for 15 (43%) of all cases and 16 patients (47%) had an associated fracture. The brachial artery was most frequently injured, constituting 36% of all cases. Interposition grafting using the autogenous long saphenous vein was the most common procedure performed (11 patients). Eleven patients required a secondary procedure while the overall limb amputation rate was 8.5%. There was one mortality following an IVC injury. Seventy-four per cent of the cohort was asymptomatic at last follow-up. CONCLUSION: While vascular trauma is relatively uncommon in our catchment area it can be successfully managed. Most of the cases occur in young fit patients.

Popliteal-to-distal artery bypass for diabetic limb salvage.

BACKGROUND: Poor long-term survival and significant co-morbidity among diabetic patients with limb ischaemia makes the shortest, simplest revascularisation procedure desirable. AIM: Evaluate limb salvage, primary graft patency and peri-operative morbidity rates in diabetic patients undergoing popliteal-to-distal artery bypass for limb salvage. METHODS: Patients undergoing popliteal-to-distal artery bypass for critical limb ischaemia over a seven-year period were retrospectively identified. Patients operative and follow-up data were entered into a database and limb salvage and patient survival determined using Kaplan Meier survival analysis. RESULTS: During the study period 21 popliteal-to-distal artery bypasses were performed on 19 diabetic patients. Mortality rate after one year was 11%. Primary graft patency rates among surviving patients was 81%, 67% and 48% at 1, 2 and 6 years respectively. Amputation was required in three patients. CONCLUSION: Popliteal-to-distal artery bypass produces favourable results in high-risk diabetic patients with critical limb ischaemia.

Comparing the endothelialisation of extracellular matrix bioscaffolds with coated synthetic vascular graft materials.

INTRODUCTION: Existing synthetic vascular grafts have unacceptably high failure rates when replacing below knee arteries. In vitro endothelialisation is a technique, which has been shown to enhance the patency rates of below knee vascular grafts. Synthetic materials are however poor cellular substrates and must be combined with coatings to promote cellular growth and attachment. The most common coating clinically is fibrin-coated ePTFE. The aim of our study was to compare the endothelialisation of fibrin-coated ePTFE with novel extracellular matrix (ECM) biomaterials that we hypothesise will provide a superior substrate for cell growth. METHODS: Human endothelial cells were cultured on ECM scaffolds and fibrin-coated ePTFE. Uncoated Dacron and ePTFE acted as controls. The cells were examined for viability, phenotype, adhesion and proliferation. Cell morphology was accessed using scanning electron microscopy. RESULTS: Cells remained viable and produced von Willebrand factor on all substrates tested. ECM scaffolds and fibrin-modified ePTFE achieved statistically higher attachment efficiency when compared to both uncoated synthetic graft materials (p ≤ 0.001). At 90 min 80 ± 3.6% of cells had attached to the ECM scaffold compared to Dacron (30 ± 4.5%, n = 3) and ePTFE (33 ± 2.5%, n = 3). There was no difference in adhesion rates between ECM scaffolds and fibrin-coated ePTFE (p = 1.00). Endothelial cells proliferated fastest on ECM scaffolds when compared to all other materials tested (p < 0.001) and reached confluency on day seven. CONCLUSION: ECM bioscaffolds offer an improved substrate for promoting rapid endothelialisation compared to fibrin-coated ePTFE by combining firm cellular anchorage and superior cell expansion.

A review of technological approaches to venous ulceration.

Leg ulceration is a chronic condition affecting about 1-2% of the adult population. The main causes of leg ulceration are venous hypertension, arterial insufficiency, diabetes, or a combination of these aetiologies (causes) or malignancy. Venous ulcers account for approximately 80% of all leg ulcers and are a result of venous hypertension. The current mainstay of treatment of venous ulcers is the application of graduated compression bandaging to the limb. In spite of the application of the best evidence-based therapy, healing rates for venous leg ulcers remain disappointing, at 50-70% after 12 weeks of treatment, depending on initial size and chronicity of the ulcer. Thus, a large number of ulcers are unhealed by this time, and many patients suffer from long-term leg ulceration, some remaining for years, and those that heal often recur. There is an obvious need to develop new treatments that would improve healing rates. This review provides a complete overview of the anatomy of venous circulation and the physiology pertaining to it, the pathophysiology of venous disease, the pathogenesis of ulceration, and a review of treatments currently employed in healing venous leg ulcers and their supporting evidence. The aim of this article is to encourage a fresh look at this chronic problem and stimulate ideas on how healing rates can be improved.

A description of an accelerometer-based mobility monitoring technique.

Accurate monitoring of the mobility status of older adults, over the long-term, is important in rehabilitation medicine, as regular physical activity is central to maintaining both physical and mental health, as well as evaluating quality of life. This technical note describes an accelerometer-based mobility monitoring technique, which can distinguish between static and dynamic activities and can detect the basic postures of sitting, standing and lying. The technique allows thresholds for these postures to be set and two different posture threshold methods are described: mid-point and "best estimate". Preliminary results from using these methods are presented. This preliminary evaluation of the technique was carried out over the long-term (>29 h) in an uncontrolled environment and the method used to carry out the evaluation is described in detail. The two different posture thresholding methods were tested on long-term mobility data from one older adult subject. The subject did not have to follow a specific activity protocol during the recording period (4 days) and was shadowed by an observer in order to evaluate the accuracy of this technique. The monitoring hardware consisted of two accelerometer devices, one on the trunk and the other on the thigh and a pocket-sized ambulatory data-logger. Applying 'best estimate' thresholding, as opposed to mid-point thresholding, improved sitting detection accuracy by 18%, to 93% and lying detection accuracy by 5%, to 84%. Thus, based on these preliminary data, an accurate mobility monitoring system for older adults is described and it was observed that the actual posture threshold limits applied have a high impact on the mobility monitoring system's accuracy and are particularly important for accurately detecting postures when used over the long-term, in an uncontrolled environment.

Information leaflets for venous leg ulcer patients: are they effective?

OBJECTIVE: To validate the usefulness of written information for patients with venous leg ulcers and test the hypothesis that patients who receive written information retain more knowledge than those who receive verbal information alone. METHOD: Twenty patients newly diagnosed with venous leg ulcers were recruited into this prospective trial. Patients were randomised either to the control group (given verbal information on their condition) or the intervention group (same verbal information and an information leaflet). The verbal information was in the same format as in the leaflet. Patients' knowledge of the condition was ascertained at an initial interview and at follow-up four to six weeks later. RESULTS: At follow-up both groups showed an overall improvement in knowledge, with no statistical difference between them. CONCLUSION: The results indicate there is limited value in providing information leaflets to this patient group, who were predominantly older patients with low levels of education. The relatively small sample size may explain the disappointing results. Further research may reveal a benefit of providing these leaflets to carers.

Health-related quality of life during four-layer compression bandaging for venous ulcer disease: a randomised controlled trial.

BACKGROUND: Venous leg ulceration is a chronic debilitating condition which negatively impacts on patients' quality of life. Despite the application of gold standard treatment a number of patients suffer from 'slow to heal' ulcers, which can require treatment for years. AIMS: The aim of this study was to compare the effects of four-layer compression bandaging (4LB) for treating venous leg ulcers with other available treatments on health-related quality of life duringtreatment. METHODS: In this pragmatic trial, 200 patients with venous leg ulceration were randomised either to 4LB (intervention group; n = 100) or to continue their usual system of care (control group; n = 100). Analysis was by intention to treat; quality of life measurements were taken at randomisation and after six weeks of treatment. RESULTS: 4LB provided greater quality of life benefits than the control group particularly in the area of physical activity and social functioning. CONCLUSION: Due to the long-term nature of treatment for many of these patients, the effects on quality of life should be considered when prescribing treatment. This study has shown that 4LB significantly improves the quality of life of patients during treatment for venous leg ulceration.

Non-orthopaedic paediatric trauma in a regional hospital.

BACKGROUND: In the Republic of Ireland there are no paediatric surgeons outside Dublin. Most paediatric trauma is managed in general hospitals by general or orthopaedic surgeons. AIM: In this study we audited our experience with paediatric trauma in a regional setting. METHODS: We carried out a retrospective review of all non-orthopaedic paediatric trauma patients admitted to our institution over a two-year period.The method of injury, management and outcome were recorded and the TRISS (revised trauma injury severity score) method was used to calculate the probability of survival. RESULTS: One hundred and fifty four paediatric patients were admitted following trauma. Falls, RTAs and burns were the commonest reasons for admission. Twenty nine of these patients (19%) required surgical procedures. There were no unexpected deaths. CONCLUSION: The majority of paediatric trauma admissions were for minor injuries. A number of seriously injured children were successfully treated with no unexpected deaths.

Conservative management of mesh-site infection in hernia repair surgery: a case series.

PURPOSE: The aim of this study is to assess the outcome of conservative management of infected mesh grafts following abdominal wall hernia repair. METHODS: This study retrospectively examined the charts of patients who developed mesh-site infection following surgery for abdominal hernia repair to determine how effective conservative management in the form of antibiotics and wound management was on the resolution of infection and wound healing. RESULTS: Over a period of 30 months, 13 patients developed infected mesh grafts post-hernia repair surgery. Twelve patients were successfully treated conservatively with local wound care and antibiotics if clinically indicated. One patient returned to theatre to have the infected mesh removed. Of the patients that healed eleven were treated with negative pressure wound therapy (VAC(®)). CONCLUSION: This series of case studies indicate that conservative management of abdominal wall-infected hernia mesh cases is likely to be successful.

A MultiCenter Pilot Randomized Controlled Trial of Remote Ischemic Preconditioning in Major Vascular Surgery.

A pilot randomized controlled trial that evaluated the effect of remote ischemic preconditioning (RIPC) on clinical outcomes following major vascular surgery was performed. Eligible patients were those scheduled to undergo open abdominal aortic aneurysm repair, endovascular aortic aneurysm repair, carotid endarterectomy, and lower limb revascularization procedures. Patients were randomized to RIPC or to control groups. The primary outcome was a composite clinical end point comprising any of cardiovascular death, myocardial infarction, new-onset arrhythmia, cardiac arrest, congestive cardiac failure, cerebrovascular accident, renal failure requiring renal replacement therapy, mesenteric ischemia, and urgent cardiac revascularization. Secondary outcomes were components of the primary outcome and myocardial injury as assessed by serum troponin values. The primary outcome occurred in 19 (19.2%) of 99 controls and 14 (14.1%) of 99 RIPC group patients (P = .446). There were no significant differences in secondary outcomes. Our trial generated data that will guide future trials. Further trials are urgently needed.

Cholecystectomy alters the hormonal response of the sphincter of Oddi.

We have previously described a cholecysto-sphincter of Oddi reflex whereby sphincter of Oddi (SO) motility is mediated in part by the degree of gallbladder distension. Therefore, we tested the hypothesis that cholecystectomy alters the response of the SO to endogenous and exogenous hormonal stimulation. Eight months after sham laparotomy (n = 8) or cholecystectomy (n = 10), prairie dogs were anesthetized with alpha-chloralose. The common bile duct was cannulated distally with a side-hole, pressure-monitored catheter perfused with degassed water at 0.15 ml/min. The duodenum was cannulated distal to the SO to allow perfusion of the proximal 30 cm of intestine with 20 mmol/L sodium oleate at 0.4 ml/min. In animals undergoing sham laparotomy the gallbladder was cannulated, aspirated, and kept empty throughout the experiment. SO phasic wave frequency (F), amplitude (A), and baseline pressure were measured for 60 minutes before and during intraduodenal (ID) perfusion of sodium oleate and then for 60 minutes before and 30 minutes during intravenous (IV) infusion of cholecystokinin-octapeptide (CCK-OP) at 10 ng/kg/min. A SO motility index (MI) (MI = F X A) was calculated for each 10-minute period. Common duct diameter and resting SO motility were unaltered 8 months after cholecystectomy. In animals that had sham laparotomy ID infusion of sodium oleate reduced SO MI by 46% (p = 0.06) and 75% (p less than 0.05) at 30 and 60 minutes, respectively, whereas in animals that had cholecystectomy the reduction in SO MI was only 6% and 25% (p less than 0.05) during the same periods. In animals that had sham laparotomy IV CCK-OP increased the SO MI by 175% (p less than 0.05), but in the animals that had cholecystectomy IV CCK-OP increased SO MI by only 60% (no significance). These findings indicate that after cholecystectomy resting SO motility is unaltered, but the response to ID sodium oleate and to IV cholecystokinin is blunted. We suggest that cholecystectomy alters neural pathways that mediate the normal response of the SO to endogenous and exogenous hormonal stimulation.

Peptide YY inhibits cholecystokinin-stimulated sphincter of Oddi activity in the prairie dog.

Peptide YY (PYY), a recently discovered gut peptide, has been shown to have a number of actions that are antagonistic to the effects of cholecystokinin. This study was designed to determine whether PYY would inhibit cholecystokinin-stimulated sphincter of Oddi activity in the prairie dog. In 12 prairie dogs PYY was infused intravenously at 1, 10, and 100 ng/kg/min, and arterial blood samples were obtained. A dose-response curve was obtained, with the 10 ng/kg/min dose producing serum levels of 725 pg/ml. In seven additional prairie dogs a side-hole, pressure-monitored perfusion catheter was passed into the duodenum through a choledochotomy and positioned in the sphincter of Oddi. A perfusion catheter was also placed in the gallbladder fundus. Sphincter of Oddi and gallbladder pressures were recorded before and during 20-minute infusions of cholecystokinin and then cholecystokinin plus PYY at 10 ng/kg/min. PYY significantly inhibited cholecystokinin-stimulated sphincter of Oddi phasic wave frequency (3.8 +/- 0.2 vs 3.3 +/- 0.4; p less than 0.05) and sphincter of Oddi motility index (26.2 +/- 4.3 vs 18.7 +/- 4.8; p less than 0.025) but did not affect the increase in gallbladder pressure induced by cholecystokinin. These findings are consistent with other known anticholecystokinin effects of PYY. We conclude that PYY may also inhibit sphincter of Oddi activity in the prairie dog by an anticholecystokinin effect, thus reducing flow through the sphincter.

Decreased morbidity and mortality after pancreatoduodenectomy.

In two 5 year periods (1975 to 1979 and 1980 to 1984), 96 patients underwent pancreatoduodenal resection, which included 74 partial pancreatic resections and 22 total pancreatectomies. Thirty-seven of these patients had resections with preservation of the pylorus. Substantial reductions in perioperative mortality (2 percent versus 10 percent) and morbidity (26 percent versus 49 percent) (p less than 0.05) were achieved in the latter period. Pylorus preservation, with a mortality and morbidity of 3 percent and 27 percent, respectively, did not increase operative risk or compromise long-term survival in patients with malignant disease. In comparison, relatively high mortality and morbidity rates (14 percent and 59 percent) accompanied total pancreatectomy without improved long-term survival. Five year actuarial survival for nonpancreatic periampullary adenocarcinomas was 58 percent. Thus, we recommend pancreatoduodenectomy with preservation of the pylorus for resection of periampullary tumors. These patients, whose only possibility for cure is a major pancreatic resection, should not be denied this opportunity on the basis of reports from a previous era.

An investigation of the effect of electrode size and electrode location on comfort during stimulation of the gastrocnemius muscle.

The use of surface neuromuscular electrical stimulation (SNMES) in medicine is well established. However, discomfort has been identified as limiting the use of SNMES in these applications. This pilot study investigated the influence of various electrode sizes and their positioning on perceived pain and discomfort during neuromuscular electrical stimulation (NMES) of the gastrocnemius muscle using surface electrodes. This study formed part of a research project to develop a therapeutic device for calf muscle blood flow assist applications. Twelve healthy subjects (n=12) participated in this pilot study. Each participant attended the trial centre for testing which consisted of SNMES to four different electrode stimulation sites using two electrode sizes (round with areas 19.63 and 38.48 cm2). Comfort was assessed by asking the subjects to indicate the stimulation amplitude corresponding to the onset of discomfort (pain threshold) and the amplitude at which the discomfort became unbearable (pain tolerance). Of the four stimulation sites tested, two were deemed unsuccessful as it was very difficult to obtain a muscle contraction using these sites, while the remaining two sites elicited good muscle contraction. The most comfortable stimulation was achieved by placing the cathode electrode high on the calf, below the proximal end of the muscle heads and the anode electrode towards the end of the muscle belly and when the 19.63 cm2 electrodes were used at these sites (p=<0.001).

Gross anatomy of the liver, biliary tree, and pancreas in the black-tailed prairie dog (Cynomys ludovicianus).

The gross anatomy of the liver, extrapetatic biliary tree, sphincter of Oddi, and pancreas in the black-tailed prairie dog (Cynomys ludovicianus), a widely used animal model for investigations into biliary physiology, pathophysiology, and pathology, was studied in 10 animals. The liver consists of 4 lobes, the left lateral, median, right lateral, and caudate. The gallbladder lies on the ventral surface of the right lobule of the median lobe. The cystic and hepatic ducts unite to form the common bile duct which enters the duodenum approximately 5 mm distal to the pylorus. The lower end of the common duct dilates forming an ampulla which is surrounded proximally by a band of circular muscle fibres which constitute the choledochal sphincter. The pancreatic duct opens separately into the duodenum approximately 80 mm from the pylorus. Earlier physiologic studies have demonstrated that the choledochal sphincter has intrinsic motility distinct from the duodenum.

Normal inspiratory muscle strength is restored more rapidly after laparoscopic cholecystectomy.

Respiratory complications after laparotomy cholecystectomy may result from generalised muscle weakness and fatigue, or from reduced respiratory muscle function secondary to an upper abdominal incision. In a prospective study we compared maximal inspiratory effort (Pimax/mmHg) and dominant hand grip strength (kPa) (expressed as a percentage of zero hour value) in patients undergoing open cholecystectomy (OC) (n = 12), laparoscopic cholecystectomy (LC) (n = 25) and a control group of patients undergoing lower limb surgery (n = 12). Of the 12 OC patients, three suffered respiratory complications: two had atelectasis and one a chest infection, compared with no such complications in the other two groups (P < 0.05). Pimax decreased postoperatively in all groups (P < 0.05) and had returned to normal by 48 h in the LC and control groups. In contrast, in the OC group Pimax fell from 112.5 +/- 17.8 mmHg to as low as 81.3 +/- 16.5 mmHg at 72 h and only returned to preoperative levels at 120 h. The hand grip strength fell significantly in all groups at 24 h (P < 0.05) but normal levels were achieved again by 48 h in all groups, and there was no significant difference in the hand grip strength between the groups over the 5 days. These results suggest that generalised muscle fatigue after surgery is similar after open and laparoscopic cholecystectomy. Open cholecystectomy does, however, cause a more prolonged reduction in respiratory muscle function and this is likely to contribute to the higher incidence of respiratory complications in this group of patients.

Post-cholecystectomy symptoms after laparoscopic cholecystectomy.

Abdominal symptoms persist in up to 40% of patients after laparotomy cholecystectomy and biliary lithotripsy. Laparoscopic cholecystectomy is now the treatment of choice for symptomatic gallstone disease. However, no data exist as to the influence of laparoscopic cholecystectomy on symptoms. We analysed 100 patients who had undergone laparoscopic cholecystectomy at a median of 12 months (range 10-19 months) previously. Pre- and postoperative symptoms were compared and patient satisfaction was graded from 1 (best) to 5 (worst). Time to resumption of full activity (mean +/- SD) was recorded. All patients had more than two symptoms preoperatively. Postoperatively, 61 patients had complete absence of symptoms, 14 patients complained of only one symptom during the postoperative period and 25 patients continued to have at least two symptoms. The mean time taken to return to full activity was 2.4 +/- 1.7 weeks. In patients without any symptoms postoperatively, time taken to return to full activity was 2.3 +/- 1.5 weeks, 2.7 +/- 1.4 weeks for patients with one symptom postoperatively, while patients with two or more symptoms returned to full activity in 2.3 +/- 1.3 weeks and 2.6 +/- 1.7 weeks, respectively. Notwithstanding that 25% of patients reported two or more symptoms postoperatively, most patients (n = 84) considered the procedure to be a complete success. A further 10 patients had significant improvement after laparoscopic cholecystectomy. Five patients considered themselves only slightly improved, while a single patient was no better off postoperatively. These data indicate that after laparoscopic cholecystectomy most patients return to full activity within 3 weeks. Thus, the incidence of post-cholecystectomy symptoms is similar after laparoscopic and laparotomy cholecystectomy and biliary lithotripsy.Patients should be advised of the risk of persistent symptoms after these procedures.