Primary prevention of venous thromboembolism.

Venous thromboembolism (VTE) is the most common cause of preventable in-hospital mortality and all hospitalized patients should be VTE risk assessed. The VTE risk should be weighed up against risk of bleeding on an individualized basis to guide choice of prophylaxis. The most common method of mechanical thromboprophylaxis is graduated compression stockings, although others, such as intermittent pneumatic devices, are available. Stockings have the greatest benefit when used in combination with pharmacological prophylaxis. However, stockings are contraindicated in some patients, including those with stroke or peripheral arterial disease. Various options for pharmacological thromboprophylaxis are available. The most commonly used agents are the low-molecular-weight heparins, but newer orally active agents may play an increasing role in the future.

Management of soft tissue wounds of the face.

Since time, immemorial soft-tissue injuries to the face have been documented in literature and even depicted in sculptures, reflecting the image of society. In a polytrauma the face may be involved or there may be isolated injury to the face. The face consists of several organs and aesthetic units. The final outcome depends on initial wound care and primary repair. So one should know the "do's and don'ts". Disfigurement following trauma, becomes a social stigma and has the gross detrimental effect on the personality and future of the victim. Therefore, such cases are most appropriately managed by Plastic Surgeons who have a thorough knowledge of applied anatomy, an aesthetic sense and meticulous atraumatic tissue handling expertise, coupled with surgical skill to repair all the composite structures simultaneously.

An update on the management and treatment of deep vein thrombosis.

Deep venous thrombosis (DVT) with its associated complications of pulmonary embolism and postthrombotic syndrome are an important cause of morbidity and mortality. This review article provides an overview of the pathophysiology, risk factors and the guidelines for thromboprophylaxis. It also reviews the available modalities in the diagnosis and treatment of DVT. The newer methods of treatment are also discussed.

Electrophysiological and histological changes in extrinsic muscles proximal to post burn contractures of hand.

Burn scar hand contractures of variable degree are frequently encountered. Although the forearm is apparently spared, it was clinically observed that there was disuse atrophy in the unburnt extrinsic forearm muscles. Usually the clinicians do not give much importance to this fact. The girth at the midforearm was significantly reduced as compared to normal side. The flexion of the hand joints are governed by two components (a) intrinsic and (b) extrinsic muscles. The intrinsic muscles are directly involved in the contracted tissue. Therefore it was thought essential to evaluate the extrinsic group of muscles for their contribution in the final functional recovery following corrective surgery. Thirty patients having unilateral post thermal burn contracture sparing forearm were studied. A detailed clinical evaluation was made including grade of contracture and reduction in the forearm girth. The forearm unburnt muscles were evaluated by preoperative electrophysiological studies. Intraoperative biopsies were taken from these muscles for histopathological examination. On histopathological examination, there were significant abnormal changes in the form of muscle fiber atrophy, fibrolipomatous tissue replacement of atrophic muscle fibers and sarcolemmal changes. These changes were directly proportional to the severity of contractures. The electrophysiological studies showed proportionate changes in the form of reduction in amplitude, duration and interference. This study suggests that if these changes are mild and in reversible stage, they will favourably affect the functional recovery following surgery. However if these changes are of severe grade and irreversible, in spite of adequate surgery, splinting and physiotherapy, the functional recovery may not be complete.

V-Y gastrocnemius muscle slide with turnover fascial flap for compound Achilles defects: a simple solution.

BACKGROUND: Compound defects of the Achilles region pose a reconstructive challenge. Poor vascularity of the Achilles region predisposes to complications. Repair of the tendon with simultaneous soft-tissue cover gives the patient the best chance to recover. MATERIALS AND METHODS: Gastrocnemius musculotendinous V-Y slide for Achilles tendon defect with non-axial turnover fascial flaps based on the proximal end of the defect with a split-skin graft on the fascial flap was used in two patients. The vascular bases of such flaps and the technical details has been discussed. RESULTS: The functional and aesthetic results were highly satisfactory with minimal donor-site morbidity. The flap was thin enough to fit the contour of the Achilles region. The fascial flap with skin graft was durable and withstood footwear well. The flap also allowed tendon gliding beneath it, with near-complete movements at the ankle joint. CONCLUSION: Large flaps can sufficiently be raised with a wide base to cover small- to medium-sized defects. It is a good, rapid and cost-effective solution for a difficult clinical problem.

Combined aspirin and cilostazol treatment is associated with reduced platelet aggregation and prevention of exercise-induced platelet activation.

BACKGROUND: Cilostazol has proven efficacy in increasing walking distance in claudicants, but it has not been demonstrated to be more effective than placebo in secondary cardiovascular prevention. The direct effect of exercise on platelet function remains less well defined. We have investigated the effect of combination treatment with aspirin and cilostazol on platelet activity in claudicants subjected to repeated treadmill exercise. METHODS: Nineteen claudicants completed a double-blind, randomised, controlled, cross-over trial. Each subject received a 2-week course of aspirin (75mg) and placebo and aspirin and cilostazol (100mg twice daily). Following each 2-week treatment period, patients participated in a standardised treadmill test (3.2kmh(-1), 10 degrees incline) walking to maximal claudication distance. The exercise was repeated thrice in total, and blood was sampled before and after exercise. Platelet activation was measured using free platelet counting aggregation, flow cytometry for surface markers of platelet activation and soluble P-selectin assay. RESULTS: Compared to aspirin and placebo, combination treatment with aspirin and cilostazol was associated with reduced arachidonic-acid-induced platelet aggregation (p<0.01, Wilcoxon signed-rank test). Aspirin and placebo treatment were associated with elevated P-selectin expression, platelet-monocyte aggregation and reduced CD42b expression (p<0.05, Wilcoxon signed-rank test) post-exercise. No difference was seen in spontaneous platelet aggregation whilst soluble P-selectin was reduced post-exercise with combination treatment with aspirin and cilostazol (p<0.05, Wilcoxon signed-rank test). CONCLUSIONS: Combination treatment with aspirin and cilostazol results in suppression of platelet activation and reduces the effect of exercise on platelets. The benefit seen may be a result of cilostazol enhancing the inhibitory effect of aspirin on the cyclo-oxygenase pathway.

Logistics and supply management system of drugs at different levels in Darbhanga District of Bihar.

OBJECTIVES: To understand the logistics and supply management system of drugs at different levels within the district health care delivery system of Dharbanga in Bihar. METHOD: This was a cross-sectional study in 3 Primary Health Centres (PHCs), 3 Additional Primary Health Centres (APHCs) and 6 Subcentres (SCs) during September-December 2008. The study subjects were Civil Surgeon, Pharmacists, Medical Officers, ANMs. Data was collected using qualitative and quantitative techniques from different stakeholders. RESULT: The health centers were severely understaffed and drug stores are managed by unqualified/untrained pharmacists. Drug list available was not fully matching with the need/requirement of the population. The vital and essential drugs required for various health centers were of short supply or unavailable in medical stores. MOs were unaware of budget allocation/allotment for their centers. Demand estimation of the drug items were not done scientifically hence quantity of drugs supplied was not in consonance with community needs. The existing guidelines were not followed as a result drugs like Zinc, Misoprostol and Magsulf were not available at the PHCs or APHCs. The storage and transportation facilities of drugs were found to be poor. Community members were not satisfied with the availability of drugs. CONCLUSION: The logistic and supply system of drugs in Darbhanga district is very weak, hence the needs of the catering population related to medicines was not fully met.

Cleft palate associated with hamartomatous bifid tongue. Report of two cases.

Congenital tumours of the tongue may have a detrimental effect on the simultaneously developing adjacent structures. Palate formation may be affected as it develops in the same period of organogenesis as the tongue. We present two such rare cases of cleft palate with tumour of the dorsal tongue as the probable causative factor. To analyse such an entity, it is necessary to understand the embryogenesis of the palate and tongue. The management and possible elucidation of the occurrence with respect to the developmental phases of tongue and palate are detailed in brief.

Endovascular Treatment of a Ruptured Splenic Artery Aneurysm using Amplatzer(®) Vascular Plug.

Splenic Artery Aneurysms are commonly detected incidentally and can present acutely as a source of intra-abdominal catastrophe. Management options include both surgical and endovascular repair. The role of endovascular repair in an haemodynamically stable acute rupture is undefined and the use of Amplatzer(®) Vascular Plug has not to our knowledge been reported.

Evaluation of the role of ultrasonography in diagnosis of autoimmune thyroiditis in goitrous children.

OBJECTIVES: To evaluate the role of thyroid ultrasound in children with autoimmune thyroiditis diagnosed either on cytopathology or by the presence of thyroid peroxidase antibodies. DESIGN AND SETTINGS: Children presenting for the first time to the Thyroid Clinic at the Institute of Nuclear Medicine and Allied Sciences for the complaint of goiter over a two year period (January 2005-December 2006) were studied. SUBJECTS: 695 school children (244 boys and 451 girls) aged 5-18 year were studied. METHODS: Children were subjected to thyroid ultrasound, cytopathology, thyroid peroxidase antibody and thyroid function tests. RESULTS: Overall, 16% of goitrous children had hypoechogenicity on ultrasound, 15.2% had cytopathological evidence of thyroiditis, 10.6% had positive thyroid peroxidase antibodies and 25.2% had abnormal thyroid function tests. Subjects with hypoechogenicity had higher percentage of thyroiditis on cytopathology (41.4% vs. 10.3%; P<0.01), thyroid peroxidase antibody positivity (30.6% vs. 6.8%; P<0.01) and thyroid dysfunction (46.8% vs. 21.2%; P<0.01) than those with normal echogenicity. CONCLUSION: Thyroid USG has a useful, though limited, role in excluding thyroid disease in children. The sensitivity of echogenicity for the diagnosis of autoimmune thyroiditis in children is less than that reported in adults.

Increased platelet-monocyte aggregation in male claudicants with the Pl(A1/A2) polymorphism of Gp IIb/IIIa.

OBJECTIVES: To investigate the relationship between the Pl(A1/A2) polymorphism and platelet activation and aggregation in patients with Peripheral Arterial Disease (PAD). DESIGN: A prospective single-centre cohort study. METHODS: 45 patients with PAD on aspirin 75mg were recruited and phenotyped/genotyped for the Gp IIb/IIIa Pl(A1/A2) polymorphism. Platelet-Monocyte Aggregation (PMAs) was evaluated using flow-cytometry. RESULTS: The formation of PMAs in the Pl(A2) group was higher but not statistically significant (p=0.17). However, when males were analysed separately, the formation of PMAs was significantly higher in the Pl(A2) group (p=0.0192). No difference was seen in the females. CONCLUSIONS: In this study we show that the Pl(A1/A2) polymorphism primarily affects the aggregation of platelets to monocytes in males. The effect is not observed in females and understanding the mechanism behind this may help elucidate the way the polymorphism alters platelet function in the presence of aspirin.

Distally based tenosynovial sheath flap of peroneal tendons for exposed tendo Achilles: preliminary report of five cases.

A distally based tenosynovial sheath of peroneal tendons was used as a flap with skin graft to cover the exposed tendo Achilles. The flap has a reliable blood supply being perfused by a constant sizeable musculofascial perforator. Cadaveric dissection with methylene blue dye study has been conducted to prove the rationality and reliability of blood supply. The position of the perforator had been confirmed prior to surgery by a hand-held Doppler. The flap used to cover the exposed Achilles tendon in five cases yielded positive results. To our knowledge, a retrograde flap of this nature is unprecedented though an antegrade flap of similar composition has been described.

Skeletonised retrograde distal perforator island fasciocutaneous flaps for leg and foot defects.

Defects involving the distal leg and foot are frequently encountered following various aetiological factors. Paucity of local tissue causes surgeons to resort to the retrograde peninsular flap, the cross leg flap or the free flap. With specific knowledge of perforators, the fasciocutaneous flap from the calf area can be transferred to the defect in a single stage based on skeletonised distal perforators. The surgical anatomy, flap planning and procedure have been detailed. Nineteen patients were treated during the period 1995 to 2005. The perforators were identified preoperatively by audio Doppler. The flaps were marked and dissected proximal to the defect skeletonising the distal perforators under loupe magnification and transferred to the defect in a single stage. The donor site was skin grafted. Out of 19 cases, 16 flaps healed uneventfully, one flap necrosed completely and in two cases there was marginal necrosis. The cases were followed up for 2-10 years with an average of 6 years. With detailed knowledge of perforators one can safely reconstruct distal moderate-size defects of the lower limb in a single stage, thus having the benefits of free tissue transfer without resorting to microsurgery. This technique has proved to be an advancement in the reconstructive repertoire allowing flaps of non conventional dimensions to be perfused by skeletonised perforators.

Platelet monocyte aggregates and monocyte chemoattractant protein-1 are not inhibited by aspirin in critical limb ischaemia.

OBJECTIVES: Platelet monocyte aggregates (PMA) and monocyte chemoattractant protein-1 (MCP-1) play a significant role in atherosclerotic disease but the effect of aspirin and their role in peripheral arterial disease (PAD) requires further investigation. We have compared p-selectin, PMA and MCP-1 in patients with PAD treated with aspirin (75 mgs daily), with age matched controls not treated with aspirin. MATERIALS AND METHODS: Using flow cytometry and ELISA, P-selectin, PMA and MCP-1 were compared in 3 populations; healthy controls (n=12), intermittent claudication (n=19) and critical limb ischaemia (CLI), (n=10). RESULTS: P-selectin was significantly higher in CLI patients (3.48% positive) compared to the claudicants (1. 36% positive) and the controls (1.76% positive). PMA levels were significantly higher for CLI population (44.5% positive) compared to the claudicants (20.48% positive) and the controls (28.33% positive). MCP-1 levels expression was significantly higher for the CLI patients (175.4 pg/mL) compared to the claudicants (76.1 pg/mL) and the controls (117.0 pg/mL). CONCLUSION: Despite aspirin treatment CLI patients have higher platelet activation and MCP-1 expression than controls and claudicants. With increasing severity of disease aspirin is unable to suppress markers of platelet activation and pro-atherosclerotic chemokine expression which may represent another form of aspirin resistance.

Outcomes of intra-arterial thrombolysis for acute limb ischemia.

Intra-arterial thrombolysis is an alternative treatment to surgery for acute limb ischemia. We report our own experiences by retrospectively assessing initial and long-term outcomes using this strategy. Patients (n = 48; 50 events) underwent thrombolysis according to our protocol (64.6% male, median age 68.5 years). Using thrombolysis as an initial treatment strategy, overall limb survival on index admission was 84%. Of this group who had successful limb salvage, 76% was attributable to thrombolysis alone, and 24% had limb salvage attributable to subsequent surgery after failed thrombolysis or anticoagulation. Significant complications occurred in 8% of cases, and no deaths were attributed to thrombolysis. Patients alive at 6 and 24 months after index admission who had limb salvage attributable to thrombolysis alone had limb survival rates of 89% and 82%, respectively. The majority of these patients had not required subsequent secondary procedures to maintain limb survival. Thrombolysis is an acceptable and less invasive treatment of acute limb ischemia, with many patients not needing subsequent surgery.

Intraabdominal desmoid tumour presenting with perforation.

We present a rare case of a desmoid tumour presenting with perforation of the small bowel. Although desmoid is classified pathologically as a benign tumour, its infiltrative nature leads to a locally aggressive mass, which can invade surrounding structures and organs making surgical resection difficult. Some unresectable tumours show oestrogen receptor positive cells and can be managed with tamoxifen. The aetiology, investigation and management options are briefly described.

Angiographic evaluation of fasciocutaneous flaps.

Extensive studies have been carried out to understand the vascular anatomy of fasciocutaneous flaps both in human cadavers and in experimental models. Seldom has angiographic study been undertaken in clinical cases. Before peroperative clinical angiography, microangiographic study was performed on rabbits to understand the vascular supply of the skin and deep fascia. Major vascular dominance could be seen in the deep fascia compared with the skin. Thereafter, peroperative angiography was carried out to visualize the vascular network of fasciocutaneous flaps. The study was conducted in 10 patients who required antegrade fasciocutaneous flap for exposed upper two thirds of the tibia. It showed longitudinally oriented rich vascular network in the flap. This study provided peroperative objective assessment of the nature of vascularity and an explanation for the viability of fasciocutaneous flaps of nonconventional dimensions. The procedure did not have any detrimental effect on the physiology of the flap.

Treadmill exercise in claudicants on aspirin results in improved antioxidant status but only minimal platelet activation.

The consequence of exercise on platelets remains controversial and adverse effects may result from repeated ischaemia reperfusion injury. We investigated platelet activation (platelet P-selectin (PS), and activated glycoprotein (Gp) IIb/IIIa), platelet-monocyte aggregates (PMA) and total plasma antioxidant status (TPAS) in claudicants after exercise. Twenty claudicants, taking 75 mg of aspirin daily, were subjected to repeated treadmill testing (3 km/h, 10% inclination). Blood was sampled before and after exercise. Activated GpIIb/IIIa, PS and PMA were quantified with flow cytometry. TPAS was quantified using a decolourisation assay. Percent positive cells for PS (pre-exercise 3.76% vs. 40 min post-exercise 4.10%; P < 0.05) and platelet-monocyte aggregates (pre-exercise: 25.31% vs. 40 min post-exercise 26.99%; P < 0.05) were significantly higher after exercise. Relative median fluorescence (RMF) for activated GpIIb/IIIa was significantly higher 40 min after exercise (pre-exercise: 3.04 vs. 40 min post-exercise: 4.01; P < 0.05). TPAS was significantly higher post-exercise (pre-exercise: 1.31 mmol/l vs. 1 min post-exercise: 1.40 mmol/l and 40 min post-exercise: 1.38 mmol/l; P < 0.01). Following moderate exercise, 'aspirin treated claudicants' show marginal platelet activation, PMA formation and a favourable improvement in antioxidant status. Further studies are required to assess the effect of additional antiplatelet agents and the significance of platelet-monocyte interactions. The possibility that aspirin contributes to the TPAS changes following exercise needs to be investigated.