Fifteen Year Results of Radiofrequency Ablation, Using VNUS Closure, for the Abolition of Truncal Venous Reflux in Patients with Varicose Veins.

OBJECTIVES: Endovenous thermal ablation (EVTA) of varicose veins was introduced in the late 1990s with radiofrequency ablation (RFA) using the VNUS Closure device. The results of the original VNUS Closure device for the abolition of truncal venous reflux at 15 years are reported. METHODS: A prospective audit of a group of patients treated with VNUS Closure 15 years previously was carried out, using clinical assessment and duplex ultrasound. A total of 189 patients were treated with VNUS Closure between March 1999 and December 2001 and were invited for clinical assessment (subjective and objective) and duplex ultrasonography (DUS) to assess treatment outcome and de novo disease progression. DUS outcome of the treated vein was graded: 1, complete success (complete atrophy); 2, partial success (> 1 patent section; none giving rise to recurrent varicose veins); 3, partial failure (≥ 1 patent sections giving rise to recurrent varicose veins); 4, complete failure. RESULTS: Fifty-eight patients (91 legs, 101 truncal veins) returned for follow-up DUS, giving a 31.5% response rate (many patients had moved or had died in the 15 years). Two truncal veins had been excluded following treatment elsewhere presumably for partial or complete failure. At a mean of 15.4 years post-procedure, 51 (56%) reported no varicose veins, 58 (100%) that they were pleased that they had the procedure and 57 (98%) that they would recommend the procedure. DUS showed 88% of patients achieved success with no clinical recurrence in the originally treated veins. De novo reflux was identified in 47 of 91 legs (51.6%), showing disease progression in veins that were originally competent. CONCLUSIONS: RFA with VNUS Closure achieved excellent long-term technical success in treating venous reflux in truncal veins 15 years post-procedure, demonstrated by DUS. This bodes well for the increased use of EVTA in treating truncal vein reflux.

Media Damage Following Detergent Sclerotherapy Appears to be Secondary to the Induction of Inflammation and Apoptosis: An Immunohistochemical Study Elucidating Previous Histological Observations.

OBJECTIVE/BACKGROUND: Traditionally, sclerotherapy has been thought to work by the cytotoxic effect of the sclerosant upon the endothelium alone. However, studies have shown that sclerotherapy is more successful in smaller veins than in larger veins. This could be explained by the penetration of the sclerosant, or its effect, into the media. This study aimed to investigate intimal and medial damage profiles after sclerosant treatment. METHODS: Fresh human varicose veins were treated ex vivo with either 1% or 3% sodium tetradecyl sulphate (STS) for 1 or 10 minutes. The effect of the sclerosant on the vein wall was investigated by immunofluorescent labelling of transverse vein sections using markers for endothelium (CD31), smooth muscle (α-actin), apoptosis (p53) and inflammation (intercellular adhesion molecule-1 [ICAM-1]). Polidocanol (POL; 3%) treatment at 10 minutes was similarly investigated. RESULTS: Endothelial cell death was concentration- and time-dependent for STS but incomplete for both sclerosants. Time, but not concentration, significantly affected cell death (p > .001). A 40% and 30% maximum reduction was observed for STS and POL, respectively. Destruction of 20-30% of smooth muscle cells was found up to 250 µm from the lumen after 3% STS treatment for 10 minutes. POL treatment for 10 minutes showed inferior destruction of medial cells. Following STS treatment and 24-hour tissue culture, p53 and ICAM-1 were upregulated to a depth of around 300 µm. This effect was not observed with POL. CONCLUSION: Inflammatory and apoptotic markers show the same distribution as medial cell death, implying that sclerotherapy with STS works by inducing apoptosis in the vein wall rather than having an effect restricted to the endothelium. Incomplete loss of endothelial cells and penetration of the sclerosant effect up to 250 µm into the media suggest that medial damage is crucial to the success of sclerotherapy and may explain why it is less effective in larger veins.

Changes in limb dynamics during the practice of rapid arm movements.

In our study we examined Bernstein's hypothesis that practice alters the motor coordination among the muscular and passive joint moments. In particular, we conducted dynamical analyses of a human multisegmental movement during the practice of a task involving the upper extremity. Seven male human volunteers performed maximal-speed, unrestrained vertical arm movements whose upward and downward trajectories between two target endpoints required the hand to round a barrier, resulting in complex shoulder, elbow, and wrist joint movements. These movements were recorded by high-speed ciné film, and myopotentials from selected upper-extremity muscles were recorded. The arm was modeled as interconnected rigid bodies, so that dynamical interactions among the upper arm, forearm, and hand could be calculated. With practice, subjects achieved significantly shorter movement times. As movement times decreased, all joint-moment components (except gravity) increased, and the moment-time and EMG profiles were changed significantly. Particularly during reversals in movement direction, the changes in moment-time and EMG profiles were consistent with Bernstein's hypothesis relating practice effects and intralimb coordination: with practice, motor coordination was altered so that individuals employed reactive phenomena in such a way as to use muscular moments to counterbalance passive-interactive moments created by segment movements.

Role of the NSs protein in the zoonotic capacity of Orthobunyaviruses.

The family Bunyaviridae contains over 350 named isolates, classified into five genera: Orthobunyavirus, Hantavirus, Nairovirus, Phlebovirus and Tospovirus. The Orthobunyavirus genus contains some 170 isolates that are mainly transmitted by mosquitoes and are responsible for a range of disease syndromes in humans including self-limiting febrile illness, encephalitis and haemorrhagic fever. The viruses have a tripartite, negative-sense RNA genome. Analyses of viruses in four serogroups (Bunyamwera, California, Group C and Simbu) showed that the smallest (S) RNA segment encodes the nucleocapsid protein (N) and a non-structural protein called (NSs). The NSs protein of Bunyamwera virus (BUNV) has been shown to play a role in shut-off of host cell protein synthesis in mammalian cells, but no protein shut-off is observed in BUNVinfected mosquito cells (Aedes albopictus C6/36 cells). Protein shut-off in infected mammalian cells is achieved by global inhibition of RNA polymerase II-mediated transcription and enables the virus to overcome the host innate immune response. As innate defence mechanisms constitute a significant barrier to virus infection of different hosts, NSs would appear to play a key role in determining the zoonotic capacity of orthobunyaviruses.

Iatrogenic metatarsal coalition: a postoperative complication of adjacent V-osteotomies.

The authors present a case report of iatrogenic metatarsal coalition, a postoperative complication of adjacent V-osteotomies. The paper also includes a discussion of surgical considerations of multiple adjacent osteotomies contributing to such a sequela, including adequate irrigation, instrumentation, anatomy, and the use of corticosteroids.

Diabetic osteoarthropathy versus diabetic osteomyelitis.

The differentiation between diabetic osteoarthropathy and osteomyelitis is a very difficult one to make, even in the presence of a pedal ulceration. However, considering present medical costs, the incorrect diagnosis of osteomyelitis can be a costly one, not only for the hospital, but also for the patient. In light of a normal white blood cell count, a benign 67Ga-citrate scan, and two noncontiguous areas of bone destruction, the diagnosis of diabetic osteoarthropathy can be made without the necessity of a bone biopsy.

Opening base wedge osteotomy with first metatarsophalangeal joint implantation arthroplasty--a retrospective study.

The authors present a retrospective study of the opening base wedge osteotomy with first metatarsophalangeal joint implant arthroplasty, for the correction of long-standing hallux abducto valgus deformity. Twenty cases involving 23 feet were performed, and the results are discussed. The indications and procedure are described, as well as an in-depth discussion.

Surgical management of plantar von Recklinghausen neurofibroma.

Clinical manifestations of von Recklinghausen's disease on the plantar aspect are very rare. Most of the neurofibromas involving the skin are asymptomatic, but when they occupy an unusual position or attain a large size, they lead to significant disability. A case report and the surgical treatment of a 39-year-old female with the pathognomonic clinical characteristics, along with a symptomatic plantar neurofibroma, are presented. The pathogenesis, clinical manifestations, diagnosis, complications, and treatment of this progressive disease are described in this report.

Diabetic foot amputations. Part II: Metatarsal amputations.

Part II of this series of articles on diabetic foot amputation represents case studies, along with appropriate metatarsal amputation procedures. Misdiagnosis or delayed treatment of these patients can lead to loss of limb and, in some cases, can be life threatening. Diabetic feet have varying degrees of neurovascular compromise, but this should not result in traditional below-the-knee or above-the-knee amputations.

Surgical management of the deep plantar abscess in the diabetic patient.

The authors report the case of a deep plantar abscess in a diabetic patient. The pathophysiology of diabetic foot lesions as well as classification is discussed. The philosophy of local radical debridement involving ray resection, as well as postdebridement management is discussed in detail.

Dengue seroepidemiology in Singapore.

The resurgence of dengue in Singapore since 1986 had been associated with an adult predominance and a very low incidence in children. No study had been carried out to investigate this finding. Here we report a serological study of 1068 children aged 0 to 15 years. There is a significant rise in seroconversion in children aged 6 years and older coinciding with the start of formal schooling. This suggests that there may be a change in the location where dengue is acquired.

Diagnosis and treatment of the ruptured Achilles tendon.

The authors review the basic principles of tendon healing and repair as they apply to a ruptured Achilles tendon, and discuss its diagnosis and treatment. The treatment, either surgical or conservative, is a controversial subject. Both forms have their problems. The authors conclude that while surgical repair is the treatment of choice in most cases, conservative management should be considered an effective alternative.

A perspective study using bleomycin sulfate in the treatment of plantar verrucae.

The authors present a perspective study using bleomycin sulfate in the treatment of plantar verrucae. Also, they review the literature concerning this modality. Although the effective cure rate obtained in this study was less than that reported previously, the authors found bleomycin to be particularly effective in the treatment of mosaic verrucae.

Heterogeneous mechanical response of rat knee menisci to thermomechanical stress.

Thermodilatometric, dynamic thermomechanical, and light-microscopic analyses were done on the anterior and posterior regions of the rat knee menisci to correlate regional differences in morphology and extracellular matrix composition with regional mechanical behavior. Following the administration of a general anesthetic, menisci were excised from 12 young female Sprague-Dawley rats. During thermodilatometric and thermomechanical testing, tissue temperature was increased at a constant rate of 3.5 degrees C/min from 30 to 100 degrees C. Light microscopy revealed regional differences in cell density and proteoglycan content. The anterior horn was significantly heavier (greater than 87%) and thicker (greater than 60%) than the posterior region. During thermal analyses, both the anterior and posterior horns decreased in tissue thickness as the temperature increased from 30 to 73 degrees C. After 73 degrees C, however, the posterior horn expanded significantly, whereas the anterior remained in a comparatively contracted state. The rates of linear contraction and expansion of the posterior horn were seven times those of the anterior horn, and the stiffness of the anterior horn was significantly greater than the posterior horn.

Diabetic foot amputations. Part III: Midfoot.

Recently, the approach in management of diabetic foot disorders has undergone critical re-evaluation. Major foot infections, such as plantar space infections and osteomyelitis do not automatically result in Syme's or below-the-knee amputations. When indicated, midfoot amputations should be attempted because of the functional and psychologic advantages compared with more proximal amputation levels of the lower extremity. In Part III of this series of articles concerning diabetic foot amputations, the authors present case studies along with midfoot amputations and muscle-balancing procedures.