Surgical treatment of Milroy disease.

BACKGROUND AND OBJECTIVES: Milroy disease is a form of congenital primary lymphedema affecting the lower limbs. When conservative management is ineffective, surgical treatment becomes necessary. The purpose of this study was to investigate the efficacy of vascularized lymph node transfer (VLNT) associated with extensive therapeutic lipectomy in the treatment of these patients. METHODS: In China Medical University Hospital, four patients have been diagnosed with Milroy disease and treated over an 8 year-period time. All patients presented with hereditary bilateral legs swelling since birth. All patients were treated with VLNT from the gastroepiploic region bilaterally associated with extensive therapeutic lipectomy. RESULTS: All procedures have been executed bilaterally and have been successful, without complications. The average follow-up of the patients was 20.2 ± 2.8 months. The limbs treated presented an average circumference reduction of a 4.0 ± 2.1 cm and patients did not experience cellulitis during follow-up. Patients expressed satisfaction with the procedure. CONCLUSIONS: VLNT together with therapeutic lipectomy proved to be a reliable technique in moderate cases of Milroy disease, providing an alternative path for lymph drainage, and reducing the lymph load and the excess of subcutaneous adipose tissues, thus improving patients' quality of life.

Imagery for Self-Healing and Integrative Nursing Practice.

Imagery has been used as a healing practice since ancient times. Its reemergence in modern medicine began in the second half of the 20th century, when research suggested that imagery could help reduce patients' pain and anxiety and improve their quality of life and outlook on their illness. While current evidence is insufficient to support claims that imagery affects disease progression, research suggests that this method of inducing relaxation encourages patients' healing process and gives them a greater sense of autonomy in relation to disease and its management. Because imagery is noninvasive, the risks associated with its use are minimal and it is now widely used in integrative nursing. The author discusses imagery's uses and benefits, as well as the potential pitfalls in its use, and describes an imagery technique she has found effective in practice, providing a sample script and explaining how the technique might be used to help patients in various settings.

Supramicrosurgical lymphatic-venous anastomosis for postsurgical subcutaneous lymphocele treatment.

Postsurgical subcutaneous lymphocele is caused by accidental lesion of a lymphatic vessel that keeps on flowing lymph under the scar. Traditional treatments include aspiration and compression, with probable recurrence, and sclerotherapy which destroys both lymphatic cyst and vessel, creating risk of lymphedema. We describe the case of a postsurgical subcutaneous lymphocele of the left leg that was treated by supramicrosurgical lympatic-venous anastomosis. A single anastomosis was performed end-to-end, between one lymphatic vessel, individuated through indocyanine green lymphography, and one subcutaneous vein, distally to the lymphocele, under sedation and local anesthesia. Postoperative course was uneventful; the lymphocele completely resolved and never recurred during the nine months followup. This technique may heal the lymphocele with no impairing of lymph drainage function.

Tri-length laser therapy associated to tecar therapy in the treatment of low-back pain in adults: a preliminary report of a prospective case series.

Low-back pain is very frequent, especially in active adult population. There are several different orthopaedic condition that can cause low-back pain, and the pain worsen the quality of life significantly. The treatments vary from drugs, physical therapies, kinesiology, local infiltrations, and so on. Laser therapy has an important role in the treatment of the inflammatory causes of pain, with several studies that demonstrate the efficacy of low and high energy laser therapy in the treatment of low-back pain. Sixty-six consecutive patients with low-back pain with or without leg pain were treated using a combination of Tri-length laser I-Triax® (Mectronic Medicale, Bergamo, Italy) and Pharon® tecar therapy (Mectronic Medicale, Bergamo, Italy). The patients were treated three times a week, every other day, for a total of 10 sessions. Clinical results were evaluated using visual analogic scale for individual pain (0 to 10) and the Oswestry disability scale (ODS). Tests started before the beginning of therapies and 8 weeks after the end of the therapies. Visual analogic scale (VAS) score significantly improved from an average value of 8.1 ± 1.58 pre-treatment to an average value 8-weeks post-treatment of 2.63 ± 2.74 (P < .01). ODS values start from a pre-treatment average value of 53.0 ± 13.0 to a post-treatment average value of 23.5 ± 19.8 (P < .01). A higher improvement both in VAS and in ODS was denoted in the group of patient with low-back pain and leg pain (respectively, VAS from 8.66 ± 1.58 to 2.86 ± 2.94 and ODS from 57.8 ± 15.5 to 23.7 ± 19.5). Low-back pain, associated or not with leg pain, is a very common clinical situation. The treatments of this condition are different, and an important role can be given to the laser therapy. The conclusion of this study is that the association between laser therapy iLux-Triax® and tecar therapy Pharon® in the treatment of low-back pain, with or without leg pain, can significantly reduce pain and improve the quality of life in patients with degenerative and inflammatory problems.

[Estimation of complex surgical treatment effectiveness of lower limbs infected ulcers in patients with diabetic foot syndrome].

In a comparative aspect studied outcomes infected ulcers of the lower limbs in 169 patients with diabetic foot syndrome II - IV degree (from Meggit-Wagner). Analyzed the effectiveness of comprehensive conservative and surgical treatment of patients based on the regression of neurological symptoms by performance scales Total Symptom Score and Neuropathy Impairment Score Lower Limbs, as well the results of operative wound healing.

Effect of Shenmai injection, a traditional Chinese medicine, on pulmonary dysfunction after tourniquet-induced limb ischemia-reperfusion.

BACKGROUND: Tourniquet has been considered as a recognized cause of lower limb ischemia-reperfusion injury in the orthopedic field. This study investigates pulmonary function after tourniquet deflation and the protective effect of Shenmai injection (SMI), a traditional Chinese medicine. METHODS: Twenty-eight patients undergoing lower extremity surgery were randomized into a control group (group C) and a SMI group (group S), 14 patients in each group. Blood gas and circulating indicators (malondialdehyde, interleukin [IL]-6, and IL-8) were measured immediately before tourniquet inflation and at 0.5 hour, 2 hours, 6 hours, and 24 hours after tourniquet deflation. RESULTS: Plasma levels of malondialdehyde, IL-6, and IL-8 in group C were significantly increased over baselines from 2 hours to 24 hours after tourniquet deflation and the levels reached their peaks at 6 hours after tourniquet deflation, when arterial partial pressures of oxygen and arterial-alveolar oxygen tension ratio were decreased, whereas alveolar-arterial oxygen difference was increased significantly. Both the changes in blood gas variables and plasma mediators were attenuated in group S. CONCLUSION: Pulmonary gas exchange is impaired after lower limb ischemia-reperfusion induced by clinical tourniquet application. Pretreatment with SMI, a traditional Chinese medicine, attenuates lipid peroxidation and systemic inflammatory response and mitigates pulmonary dysfunction.

[Clinical application of otopoint-pellet pressure combined with patient controlled intravenous analgesia to lower limb orthopedic operation].

OBJECTIVE: To observe the therapeutic effect of otopoint-pellet pressure (OPP) combined with patient controlled intravenous analgesia (PCIA) for lower-limb surgery of orthopedics. METHODS: A total of 120 lower-limb orthopedic operation patients were randomized into OPP + PCIA group (n = 60) and PCIA group (n = 60). The patient's pain degree was evaluated by visual analogue score (VAS). RESULTS: In comparison with the simple PCIA group, VAS levels were significantly lower in the OPP + PCIA group than in the PCIA group 2, 6, 24 and 48 h after operation. The number of patients with post-operative reactions of nausea, vomiting and urinary retention in the OPP+ PCIA group was remarkably lower than that of OPP group (P < 0.05). CONCLUSION: OPP + PCIA is superior to simple PCIA in post-operative analgesia and reducing post-operative adverse reactions in lower-limb orthopedic operation patients.

The lived experience of persons with lower extremity amputation.

AIM: The aim of this study was to describe and understand the lived experience of people with lower extremity amputation. BACKGROUND: The loss of a body part can cause physical, psychological and social disturbances. The majority of previous studies in this area focus on the impact of amputation or the effectiveness of rehabilitation programmes. This is the first study in Taiwan exploring the holistic experiences of persons with amputation. DESIGN: A phenomenological research design was used. METHODS: Semi-structured interviews were performed with 22 people with lower extremity amputation. Interviews were tape-recorded and transcribed verbatim. Data were analysed using Colaizzi's phenomenological analysis method. RESULTS: The lived experience of persons with lower extremity amputation could be categorised into the following four themes: 'lost in the dark woods', 'emotional collapse', 'difficulty in passing through the shadow' and 'igniting a gleam of hope'. CONCLUSIONS: Participants described suffering in physical, psychological and sociocultural realms and the ways they strived to cope with these challenges. The findings of this study provide an enhanced understanding of the experiences of people with lower extremity amputation and underscore the importance of truly listening and responding to their concerns. The need to appreciate cultural context and to develop the peer-based support programme was highlighted. RELEVANCE TO CLINICAL PRACTICE: Health professionals need to acknowledge the real needs of people with lower extremity amputation and provide them a clear explanation regarding the short-term and long-term health issues associated with amputation during the pre- and post-amputation phase. Health professionals also need to expand the scope of services beyond a physical and prosthetic focus. Supportive psychological and social interventions such as formal support groups and peer support programmes may provide a powerful and inexpensive addition to routine care. Currently, such programmes are unavailable in Taiwan.

Contralateral stimulation, using TENS, of phantom limb pain: two confirmatory cases.

OBJECTIVES: This study aims to evaluate the effectiveness of trans-electric nerve stimulation (TENS) for phantom limb pain applied to contralateral limb (nonamputated limb). DESIGN: Two detailed single case studies using TENS on the contralateral limb are reported in a longitudinal study with one-year follow-up. Five variables were measured across this period. The study comprised of five sequential stages (Pre-assessment, Preliminary baseline, Start of intervention, Extended assessment, One-year follow-up). SETTING AND PATIENTS: Patients were identified at the Rookwood Hospital in Cardiff. They subsequently received regular home visits. The first patient was a 24-year-old male who had suffered a left below-elbow amputation following a car crash. The second patient was a 38-year-old male who had a transfemoral right amputation further to a viral infection. MEASURES: The following semistructured interview and questionnaires were used: McGill Comprehensive pain questionnaire part A and B; The Cambridge Phantom Limb Profile; The Groningen Questionnaire: Problems after Arm Amputation; and 13 Visual Analog Scales. CONCLUSIONS: Both patients showed a significant improvement in their perception of phantom limb pain and sensations that was maintained at one-year follow-up. A randomized blinded controlled trial to confirm these positive outcomes is required.

[Polyspecialistic treatment of a polytrauma. Case report]. / Politrauma complesso: gestione poli-specialistica. Caso clinico.

The Authors report the clinical course of M.L., a 22 years old man. He came to our observation after a road accident, in third care. In the former hospital admissions hemodynamic stabilization, surgical haemostasis of multiple hepatic lacerations with hemoperitoneum and right leg amputation were performed. He arrived to our department in a critical condition owing to mild respiratory insufficiency due to many rib fractures with sero-haematic spillage into the pleural cavity, in dialytic treatment for acute renal insufficiency consequent to right renal artery damage, soft tissues necrosis of the amputation stump with sepsis and persistent fever until 40 degrees C. The treatment and care of this patient required a team-work with the collaboration of many specialists, namely surgeons, nephrologists, anaesthetists, interventionist radiologists and hyperbaric oxygen therapy experts. Thanks to such collaboration we achieved an excellent quoad vitam result. The aim of this paper is to confirm and emphasize the central role of a Trauma Team, fed in a Trauma Center and in a Trauma System, in the management of complex traumas.

The successful use of peripheral nerve blocks for femoral amputation.

We present a case report of four patients with severe cardiac insufficiency where peripheral nerve blocks guided by either nerve stimulation or ultrasonography were the sole anaesthetic for above-knee amputation. The patients were breathing spontaneously and remained haemodynamically stable during surgery. Thus, use of peripheral nerve blocks for femoral amputation in high-risk patients seems to be the technique of choice that can lower perioperative risk.

The contralateral rectus abdominis musculocutaneous flap for treatment of lower extremity lymphedema.

Lymphedema is common after inguinal lymphadenectomy or resection of groin tumors. Animal studies have shown success using the rectus abdominis musculocutaneous (RAM) flap as a treatment for lymphedema. Four patients with acquired lower extremity lymphedema were treated with a contralateral RAM flap with an inferior cutaneous pedicle left intact to facilitate lymphatic drainage into the unaffected groin. One patient also had lymphaticovenous anastomoses performed during flap transfer. All flaps survived with no postoperative complications. With a mean follow-up of 31 months, the mean reduction in limb circumference from the preoperative excess was 81% at the thigh, 70% at the calf, and 71% at the ankle. None of the patients with recurrent cellulitis had further incidences of groin cellulitis. Two patients required future flap debulking. Lymphoscintigraphy was performed in 1 patient and demonstrated reconstitution of lymphatic flow from the affected leg through the flap. According to this preliminary study, transfer of a contralateral RAM flap to the groin of a lymphedematous leg improves lymphedema and decreases the incidence of cellulitis.

Intermittent pneumatic compression acts synergistically with manual lymphatic drainage in complex decongestive physiotherapy for breast cancer treatment-related lymphedema.

The application of intermittent pneumatic compression (IPC) as a part of complex decongestive physiotherapy (CDP) remains controversial. The aim of this study was to investigate whether the combination of IPC with manual lymph drainage (MLD) could improve CDP treatment outcomes in women with secondary lymphedema after breast cancer treatment. A randomized study was undertaken with 13 subjects receiving MLD (60 min) and 14 receiving MLD (30 min) plus IPC (30 min) followed by standardized components of CDP including multilayered compression bandaging, physical exercise, and skin care 10 times in a 2-week-period. Efficacy of treatment was evaluated by limb volume reduction and a subjective symptom questionnaire at end of the treatment, and one and two months after beginning treatment. The two groups had similar demographic and clinical characteristics. Mean reductions in limb volumes for each group at the end of therapy, and at one and two months were 7.93% and 3.06%, 9.02% and 2.9%, and 9.62% and 3.6%, respectively (p < 0.05 from baseline for each group and also between groups at each measurement). Although a significant decrease in the subjective symptom survey was found for both groups compared to baseline, no significant difference between the groups was found at any time point. The application of IPC with MLD provides a synergistic enhancement of the effect of CDP in arm volume reduction.

Acute neonatal arterial occlusion: is thrombolysis safe and effective?

PURPOSE: We report our experience of the management of arterial occlusion in the newborn. METHODS: A case note review was carried out after ethical approval. Doppler ultrasonography confirmed the occlusion. Thrombolysis was the primary intervention. Surgery was used selectively. A good outcome was one without tissue loss or functional impairment or minimal tissue loss without functional impairment. Data are presented as medians with ranges. RESULTS: Ten patients (9 male; median gestational age, 35.5 weeks [range, 28-39 weeks]) presented on day 1 (range, 1-8 days). Initial management included systemic tissue plasminogen activator (8 patients) and surgery (2 infants in whom thrombolysis was contraindicated). Improvement was noted in 7 of 8 infants treated medically and in both who underwent surgery. Three infants had significant tissue loss. Outcome at 29 months (range, 1.3-95.4 months) was good in the remaining 7. CONCLUSIONS: A multidisciplinary approach, thrombolysis and selective surgery achieved tissue preservation and function in the majority while minimizing complications. Early referral to centers with multidisciplinary teams is recommended.

The effectiveness of inpatient rehabilitation in the acute postoperative phase of care after transtibial or transfemoral amputation: study of an integrated health care delivery system.

OBJECTIVE: To compare outcomes between lower-extremity amputees who receive and do not receive acute postoperative inpatient rehabilitation within a large integrated health care delivery system. DESIGN: An observational study using multivariable propensity score risk adjustment to reduce treatment selection bias. SETTING: Data compiled from 9 administrative databases from Veterans Affairs Medical Centers. PARTICIPANTS: A national cohort of veterans (N=2673) who underwent transtibial or transfemoral amputation between October 1, 2002, and September 30, 2004. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: One-year cumulative survival, home discharge from the hospital, and prosthetic limb procurement within the first postoperative year. RESULTS: After reducing selection bias, patients who received acute postoperative inpatient rehabilitation compared to those with no evidence of inpatient rehabilitation had an increased likelihood of 1-year survival (odds ratio [OR]=1.51; 95% confidence interval [CI], 1.26-1.80) and home discharge (OR=2.58; 95% CI, 2.17-3.06). Prosthetic limb procurement did not differ significantly between groups. CONCLUSIONS: The receipt of rehabilitation in the acute postoperative inpatient period was associated with a greater likelihood of 1-year survival and home discharge from the hospital. Results support early postoperative inpatient rehabilitation following amputation.

Duration of spinal anesthesia with bupivacaine in chronic opium abusers undergoing lower extremity orthopedic surgery.

BACKGROUND: It has been demonstrated that chronic opium abusers have lower thresholds for pain. Spinal anesthesia is a common procedure in anesthesia, which is performed through administration of drugs (usually local anesthetics) in the intrathecal space, to produce temporary pain relief. The aim of this study was to determine whether chronic opium abuse could have any possible effect on the duration of spinal block by bupivacaine. METHODS: In a case-control study, 50 opium abusers and 50 nonabusers undergoing lower extremity orthopedic operations were selected from the patients admitted in Taleghani Hospital in Tehran for elective surgery. The study parameters were assimilated as much as possible, including the method of anesthesia. RESULTS: No statistically significant difference was noted between the two groups regarding the age, sex, and duration of surgery; while, the duration of sensory block was much shorter in the opium abusers (86.6+/-15.7 minutes) compared with the nonabusers (162+/-22.1 minutes) (P<0.0001). CONCLUSION: The study suggests a shortened duration of spinal block with bupivacaine in opium abusers. The results can propose a number of possible mechanisms including cross-tolerance mechanisms between local anesthetics and opioid compounds at the level of spinal neurons. Further molecular studies at the level of spine are suggested.

[Medical treatment of critical leg ischemia: current status and future perspectives of gene and cell therapy]. / Ischémie critique des membres inférieurs: traitement médical actuel et perspectives de la thérapie génique et cellulaire.

Critical limb ischemia (CLI) is associated with a high risk of amputation and death. For patients who cannot be surgically revascularized, medical options include prostanoids, spinal cord stimulation and lumbar sympathectomy, but none of these treatments has a demonstrated impact on the amputation rate at six months. Gene and cell therapy, aimed at stimulating angiogenesis, have mainly been tested in phase I and II clinical trials. These approaches appear to be feasible and safe in the short-term, but large randomized studies are necessary to demonstrate their clinical benefits and long-term safety.

Age and sex may significantly interact with diabetes on the risks of lower-extremity amputation and peripheral revascularization procedures: evidence from a cohort of a half-million diabetic patients.

OBJECTIVE: Using the National Health Insurance claim data, we prospectively investigated the age- and sex-specific incidence density and relative hazards of nontraumatic lower-extremity amputation (LEA) and peripheral revascularization procedure (PRP) of the diabetic population in Taiwan. RESEARCH DESIGN AND METHODS: A total of 500,868 diabetic patients and 500,248 age- and sex-matched control subjects, selected from the ambulatory care claim (1997) and the registry for beneficiaries, respectively, were linked to inpatient claims (1997-2002) to identify hospitalizations due to nontraumatic LEA and PRP. Incidence density was calculated under the Poisson assumption, and the Kaplan-Meier analysis was used to assess the cumulative event rates over a 6-year follow-up period. We also evaluated the age- and sex-specific relative hazards of nontraumatic LEA and PRP in relation to diabetes with Cox proportional hazard regression model adjusted for demographics and regional areas. RESULTS: The estimated incidence density of nontraumatic LEA and PRP for diabetic men was 410.3 and 317.0 per 100,000 patient-years, respectively. The corresponding data for diabetic women were relatively low at 115.2 and 86.0 per 100,000 patient-years. Compared with control subjects with the same age and sex, diabetic patients consistently suffered from significantly elevated relative hazards of nontraumatic LEA. Young and female patients were especially vulnerable to experience increased risks of nontraumatic LEA, but such effect modification by age and sex was less apparent for PRP. CONCLUSIONS: Multidisciplinary diabetes foot care systems, including the provision of revascularization procedures, should be further enforced to reduce subsequent risks of nontraumatic LEA, especially in young and female diabetic patients.

Necrotising fasciitis and traditional medical therapy-- a dangerous liaison.

INTRODUCTION: Necrotising fasciitis is a disease associated with high morbidity and mortality, and multi-focal necrotising fasciitis is uncommon. We present 2 cases of concurrent necrotising fasciitis of contralateral upper and lower limbs. CLINICAL PICTURE: Both presented with pain, swelling, bruising or necrosis of the affected extremities. Traditional medical therapy was sought prior to their presentation. TREATMENT: After initial debridement, one patient subsequently underwent amputation of the contralateral forearm and leg. The other underwent a forearm amputation, but refused a below-knee amputation. OUTCOME: The first patient survived, while the second died. CONCLUSION: Traditional medical therapy can cause bacterial inoculation, leading to necrotising fasciitis, and also leads to delay in appropriate treatment. Radical surgery is needed to optimise patient survival.