Capacities of ultrasound study in a follow-up of patients with lower extremity varicose veins after phlebectomy

The study was undertaken to estimate the capacities of triplex ultrasound angioscanning in patients with lower extremity varicose veins in the late period after phlebectomy. Seventy patients operated on for the underlying disease were examined. According to the duration of the underlying disease, all the patients were divided into 4 groups: 1) 4 (5.7%) patients had a 5-year history of lower limb varicose veins; 2) 16 (22.9%) had a 5-to-15-year history; 3) 42 (60%) had a 15-to-25-year history; 4) 8 (11.4%) had a more than 25-year history. The ultrasonic marker of recurrent lower limb varicose veins was the re-emergence of dilated saphenous and perforating veins, as well as valve apparatus failure in the operated leg. In groups 1, 2, and 3, a recurrence of the underlying disease was detected just 2 years after surgical treatment. Good results could be obtained with multimodality treatment: phlebosclerotherapy at early stages of the disease, followed by phlebectomy, or multiple phlebosclerotherapy from the earliest stages. Ultrasound study (USS) is the most rational method for screening diagnosis in case of abnormal veins of the lower extremities in the postoperative period. USS carried out at early disease stages and in the postoperative period permits prevention of recurrent lower limb varicose veins.     

Mastalgia: psychoneurosis or organic disease?

To test the traditional surgical view that pain in the breast is largely an expression of psychoneurosis, the Middelesex Hospital Questionnaire was given to 317 women with mastalgia and 170 controls with varicose veins. Their scores were compared with those of 173 women psychiatric outpatients tested by the designers of the questionnaire. The results were broadly similar in the mastalgia and varicose veins groups, and where there were significant differences women with varicose veins had a higher psychoneurotic score in each case. Within the mastalgia group no difference in scores was observed between patients with cyclical mastalgia and those with mastalgia due to periductal mastitis. Both groups of surgical outpatients had significantly lower scores in major traits than the psychiatric group, except for a small group of patients with breast pain who persistently failed to respond to treatment. Patients with mastalgia are therefore no more "neurotic" than those with varicose veins, and differ greatly from patients with recognized psychoneurosis. Most patients have a physiological or pathological basis for their breast pain, and they deserve an appropriate diagnostic and therapeutic approach.     

Surgery and anesthesia in Ontario.

Operative and case-fatality rates in Ontario for eight elective (discretionary) and seven nonelective (nondiscretionary) operations and the proportions of these operations and their anesthetic procedures performed by general practitioners were calculated. Cholecystectomy increased in frequency 32% from 1968 through 1973, tonsillectomy and adenoidectomy decreased 37%, and hysterectomy increased 41%. Except for colectomy the rates for nonelective operations changed only slightly over the 6 years. Case-fatality rates (hospital deaths per 10000 operations) for the discretionary operations in 1973 were as follows: extraction of lens, 23.1; tonsillectomy and adenoidectomy, 0.4 (2 deaths among 52938 operations); varicose vein stripping, 6.1; nonrecurrent inguinal herniorrhaphy, 21.9; cholecystectomy, 61.0; hemorrhoidectomy, 9.8; prostatectomy, 115.9; and hysterectomy, 9.6. In 1973 general practitioners did 32% of tonsillectomies and adenoidectomies (61% in 1971), 10 to 20% of inguinal herniorrhaphies, hemorrhoidectomies and appendectomies and 6% or less of the other operations. However, they performed 35% or more of the anesthetic procedures for these four operations as well as for varicose vein stripping, cholecystectomy and hysterectomy. Rates of general-practice surgery and anesthesia in an urban centre in Ontario were substantially less than those for the province as a whole.     

Four years' experience of an interim secure unit.

An interim secure unit of 14 beds (Rainford Ward) at Rainhill Hospital has been functioning for four years. During that period 78 patients were referred and 39 were admitted from various sources. Of those admitted, 40% were women, all had committed dangerous acts, and the most common diagnosis was schizophrenia. Only seven patients have stayed for one year or more, and only one seems set to stay indefinitely. Patients discharged are followed up in roughly equal numbers by their catchment area psychiatric teams and by the regional forensic psychiatric service. The number of patients in the ward has settled to about 12 for a population of one million. The unit now functions unobtrusively in a large psychiatric hospital, has a high morale, has had few recruiting problems, and has suffered extremely few disturbing incidents.     

Femoral Hernia in the Female

A study of 384 consecutive femoral herniorrhaphies performed upon female patients admitted to Shouldice Hospital, Toronto, during a 19-year period was carried out. Its main purpose was to describe the techniques used and to evaluate the results obtained. A careful 10-year follow-up plan for all cases existed.Two hundred and ninety-three operations were performed for the repair of simple femoral hernia; 91 were performed for the repair of femoral hernia which had developed following an initial ipsilateral inguinal or femoral repair performed previously, either in this hospital or elsewhere.The basic repair was subinguinal. Four modifications are described, one entirely subinguinal and three combined with exploration of the inguinal canal.The recurrence rate for simple femoral hernia in the female was 1.3% and for “recurrent” femoral hernia in the female, 5.5%.     

Incidence of Incisional Hernia after Cesarean Delivery: A Register-Based Cohort Study

Objective

To estimate the incidence of incisional hernias requiring surgical repair after cesarean delivery over a 10-year period.

Methods

This population- and register-based cohort study identified all women in Denmark with no history of previous abdominal surgery who had a cesarean delivery between 1991 and 2000. The cohort was followed from their first until 10 years after their last cesarean delivery within the inclusion period or until the first of the following events: hernia repair, death, emigration, abdominal surgery, or cesarean delivery after the inclusion period. For women who had a hernia repair, hospital records regarding the surgery and previous cesarean deliveries were tracked and manually analyzed to validate the relationship between hernia repair and cesarean delivery. Data were analyzed with a competing risk analysis that included each cesarean delivery.

Results

We identified 57,564 women who had had 68,271 cesarean deliveries during the inclusion period. During follow-up, 134 of these women had a hernia requiring repair. Of these 68 (51% [95% CI 42–60%]) were in a midline incision although the transverse incision was the primary approach at cesarean delivery during the inclusion period. The cumulated incidence of a hernia repair within 10 years after a cesarean delivery was 0.197% (95% CI 0.164–0.234%). The risk of a hernia repair was higher during the first 3 years after a cesarean delivery, with an incidence after 3 years of 0.157% (95% CI 0.127–0.187%).

Conclusions

The overall risk of an incisional hernia requiring surgical repair within 10 years after a cesarean delivery was 2 per 1000 deliveries in a population in which the transverse incision was the primary approach at cesarean delivery.     

改良曲张静脉点式剥除术治疗中老年下肢静脉曲张的临床疗效

目的:探究改良曲张静脉点式剥除术在治疗中老年下肢静脉曲张的临床疗效。方法:收集我院已确诊为下肢静脉曲张的中老年患者37例,分成实验组与对照组。对照组18例行传统曲张静脉点式剥除术,实验组19例行改良曲张静脉点式剥除术。对比两组患者手术后的下肢静脉曲张的治疗效果。结果:实验组有效率(94.7%)显著高于对照组(72.2%),差异具有统计学意义(P0.05);与对照组相比,实验组患者手术时间较短、术中出血量较少、下床活动时间较早,术后并发症总治愈率较高,复发率、术后并发症发生率较低,其差异均有统计学意义(P0.05)。结论:采用改良曲张静脉点式剥除术治疗中老年下肢静脉曲张的患者能够更彻底的剥除曲张额静脉,有效的改善患肢症状,明显降低复发率。     

Duplex-Doppler ultrasonography in the detection of lower extremities deep venous thrombosis and in the detection of alternative findings

The diagnoses observed in patients referred for the Doppler ultrasonographic examination of peripheral and iliac veins for suspected deep venous thrombosis (DVT) are presented in this study. During 48 months 2,610 patients were examined by duplex Doppler ultrasonography (US). Among these, 1,879 were women (72%) and 731 men (28%), with the age-range 16-91 (mean 56, 2) years. Ultrasonic scanners Acuson 128 XP 10, ATL HDI 5000, GE Logiq 7, and GE Logiq 9 were used, with transducers in the frequency range from 2.5-14 MHz. Findings were categorized into four main categories: (1) deep venous thrombosis (DVT); (2) pathology predominantly related to superficial veins without DVT, (3) pathology of adjacent structures; (4) normal findings. 562 patients had DVT (21.5%). 1,108 patients (42.5%) had predominant pathology of superficial veins: postthrombotic syndrome, superficial thrombophlebitis and varicose veins. 390 patients (14.9%) had pathology of surrounding structures, unrelated to veins, the most common pathology being popliteal cysts and muscular hematomas. These lesions must be properly diagnosed by US to avoid erroneous anticoagulant treatment.     

Risk of severe outcomes among patients admitted to hospital with pandemic (H1N1) influenza

Background

We describe the disease characteristics and outcomes, including risk factors for admission to intensive care unit (ICU) and death, of all patients in Canada admitted to hospital with pandemic (H1N1) influenza during the first five months of the pandemic.

Methods

We obtained data for all patients admitted to hospital with laboratory-confirmed pandemic (H1N1) influenza reported to the Public Health Agency of Canada from Apr. 26 to Sept. 26, 2009. We compared inpatients who had nonsevere disease with those who had severe disease, as indicated by admission to ICU or death.

Results

A total of 1479 patients were admitted to hospital with confirmed pandemic (H1N1) influenza during the study period. Of these, 1171 (79.2%) did not have a severe outcome, 236 (16.0%) were admitted to ICU and survived, and 72 (4.9%) died. The median age was 23 years for all of the patients, 18 years for those with a nonsevere outcome, 34 years for those admitted to ICU who survived and 51 years for those who died. The risk of a severe outcome was elevated among those who had an underlying medical condition and those 20 years of age and older. A delay of one day in the median time between the onset of symptoms and admission to hospital increased the risk of death by 5.5%. The risk of a severe outcome remained relatively constant over the five-month period.

Interpretation

The population-based incidence of admission to hospital with laboratory-confirmed pandemic (H1N1) influenza was low in the first five months of the pandemic in Canada. The risk of a severe outcome was associated with the presence of one or more underlying medical conditions, age of 20 years or more and a delay in hospital admission.The first cases of pandemic (H1N1) influenza in Canada were reported on Apr. 26, 2009. Retrospective case-finding determined that the onset of symptoms in the first Canadian case, involving a traveller returning from Mexico, occurred on Apr. 12, 2009. The first patient admitted to hospital began to experience symptoms on Apr. 18.During the first few weeks of the outbreak, in-depth follow-up and reporting of cases was conducted in keeping with the World Health Organization’s pandemic plans for each country to comprehensively assess its first 100 cases.¹ By mid-May, many Canadian jurisdictions moved away from this approach because it became increasingly taxing on both public health human resources and laboratory capacity. It was decided that reporting of individual cases would continue nationally only for patients who were admitted to hospital or who died. We provide a detailed review of the disease characteristics and outcomes, including risk factors for admission to intensive care unit (ICU) and death, of patients admitted to hospital in Canada during the first five months of the pandemic.     

Blocked beds.

In a cross-sectional survey of 325 surgical and orthopaedic beds 43 (16%) of the 265 occupied beds were filled by patients who had no medical need to be in an acute ward. They had been in hospital for a median time of 40 weeks up to the survey date. Of the 43 patients, 11 were awaiting transfer to a geriatric ward; 13 to community residential care; and seven to their homes. There was no plan for discharge or transfer for the remaining 12 (28%). Those "at risk" of becoming long-stay patients for social reasons on these wards were women, over 75, living alone or with one relative, who had been admitted to hospital in emergency with a fractured femur, head injury, or other trauma. Action necessary to reduce the number of social long-stay patients includes (a) changing attitudes to the solving of social case problems; (b) revising procedures of assessment and planning of future care; (c) improving teamwork and record keeping within the hospital and the community services; (d) providing a better balance of acute, medium and long-stay hospital beds; and (e) putting more resources into rehabilitation.     

Nursing role to improve care to infarct patients and patients undergoing heart surgery: 10?years’ experience

Background

The nurse practitioner may be the ideal healthcare worker to create a new environment and may facilitate in the process of expediting discharge and improving patient safety. They can play an intermediary role between the consultants, nurses and patients, thereby combining the aspects of care (nursing) and cure (physicians).

Method

We describe the contribution and role of the nurse practitioner in a teaching hospital and provide an overview of the changes in care and cure that were facilitated by two nurse practitioners in the treatment of cardiac surgery patients or non-complicated acute coronary syndrome patients.

Results

The nurse-led clinic for postoperative patients has registered 1967 patients in the past 10 years. These patients were transferred at a mean of 5.5 days after their bypass operation. All patients had an uneventful clinical course in our hospital and were discharged alive. The period between discharge and outpatient clinic visit could be set at 4 weeks.The post-acute coronary syndrome (ACS) group included 1236 patients. Mortality in this patient cohort was 4% while 0.4% of these patients experienced a re-myocardial infarction. Additional surgery was needed in only 2% of these stable post-infarction patients. The mean length of stay was 5.9 ± 14.5 days.

Conclusion

This observational study confirms that a nurse-led postoperative care unit and post-ACS care unit is feasible and effective for the treatment of patients returning from cardiac surgery or transferred after uncomplicated ACS to a general cardiology ward.     

Perceived noise in surgical wards and an intensive care area: an objective analysis.

An investigation of noise levels in a hospital ward, a cubicle off the ward, and an intensive therapy unit (ITU) showed that the noise levels in all three areas were higher than internationally recommended levels at all times of day. Loud noises above 70 dB(A) were common in all areas but especially the ITU. The noise pollution levels reached annoying values during the day in the ward and cubicle and during both the day and the night in the ITU. Equipment and conversations among the staff were the main causes of noise in the ITU. These noisy environments are unlikely to help patients recover. Although measures designed to eliminate noisy surfaces will help, making staff aware of the noise they create and the effects it has may be much more effective in reducing noise pollution.     

Psychogeriatric Ward for Mentally Disturbed Elderly Patients

The operation is described of a special psychogeriatric ward of 23 beds set up in 1967 to provide treatment for mentally disturbed elderly patients who could not be kept in a general ward or at home. The unit is in a predominantly geriatric hospital which serves a population of 340,000 and in the four and a half years reviewed 600 patients were admitted. Half of the admissions were emergencies. A consultant geriatrician was in charge and the nursing staff were general trained. The number of beds was found to be adequate for the demand. Few patients had to be transferred to a psychiatric hospital, but, since the mental disturbance was often associated with severe illness and the patients were old, the death rate was high. The nursing staff have found the work interesting and stimulating.     

Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. Stroke Unit Trialists' Collaboration.

OBJECTIVES: To define the characteristics and determine the effectiveness of organised inpatient (stroke unit) care compared with conventional care in reducing death, dependency, and the requirement for long term institutional care after stroke. DESIGN: Systematic review of all randomised trials which compared organised inpatient stroke care with the contemporary conventional care. Specialist stroke unit interventions were defined as either a ward or team exclusively managing stroke (dedicated stroke unit) or a ward or team specialising in the management of disabling illnesses, which include stroke (mixed assessment/rehabilitation unit). Conventional care was usually provided in a general medical ward. SETTING: 19 trials (of which three had two treatment arms). 12 trials randomised a total of 2060 patients to a dedicated stroke unit or a general medical ward, six trials (647 patients) compared a mixed assessment/rehabilitation unit with a general medical ward, and four trials (542 patients) compared a dedicated stroke unit with a mixed assessment/rehabilitation unit. MAIN OUTCOME MEASURES: Death, institutionalisation, and dependency. RESULTS: Organised inpatient (stroke unit) care, when compared with conventional care, was best characterised by coordinated multidisciplinary rehabilitation, programmes of education and training in stroke, and specialisation of medical and nursing staff. The stroke unit care was usually housed in a geographically discrete ward. Stroke unit care was associated with a long term (median one year follow up) reduction of death (odds ratio 0.83, 95% confidence interval 0.69 to 0.98; P < 0.05) and of the combined poor outcomes of death or dependency (0.69, 0.59 to 0.82; P < 0.0001) and death or institutionalisation (0.75, 0.65 to 0.87; P < 0.0001). Beneficial effects were independent of patients'' age, sex, or stroke severity and of variations in stroke unit organisation. Length of stay in a hospital or institution was reduced by 8% (95% confidence interval 3% to 13%) compared with conventional care but there was considerable heterogeneity of results. CONCLUSIONS: Organised stroke unit care resulted in long term reductions in death, dependency, and the need for institutional care. The observed benefits were not restricted to any particular subgroup of patients or model of stroke unit care. No systematic increase in the use of resources (in terms of length of stay) was apparent.     

Evaluation of the smooth muscle cell component and apoptosis in the varicose vein wall

This study was designed to evaluate the role of the smooth muscle cell and the apoptosis in the pathogenesis of the varicose vein. Segments of saphenous vein were obtained from healthy subjects and from those with varicose veins. The vein specimens were subdivided according to subject age (younger or older than 50 years) and according to the varicose vein source (distal or proximal). Morphological, ultrastructural, cell proliferation (anti-PCNA method) and cell death (TUNEL method) analysis were performed. The walls of healthy, control vein specimens acquired a more collagenous and papillomatous appearance with age. A slight increase in the number of TUNEL-positive cells was also observed in specimens from older subjects. The proportion of apoptotic cells was much greater in the varicose veins than in control specimens. Most cellular alterations were seen in proximal varicose segments obtained from young subjects. These specimens showed hypertrophic areas with a high degree of cellularity (both in the media and in the thickened intima). The highest proportion of apoptotic cells and collagenisation were also observed in these areas. The enhanced number of apoptotic cells in varicose veins observed mainly in proximal/young vein specimens could be responsible, at least in part, for the acceleration of the final fibrosclerotic process characteristic of the varicose vein wall.     

MANAGEMENT OF VARICOSE VEINS DURING PREGNANCY

The incidence of recurrences after radical venous operations done during pregnancy or where pregnancy has occurred subsequently is much higher than it is in cases in which pregnancy is not a factor. These discouraging results are due to increased venous pressure, obstruction to the venous drainage of the lower extremities and hormonal factors. The management of varicose veins during pregnancy should be by conservative means consisting of proper elastic support, elevation of the extremities at night and during rest periods in the day, avoiding static dependency of the legs, and control of body weight. In event of venous stasis and severe symptoms of varicosis that cannot be controlled by conservative measures, limited surgical intervention is indicated. This should consist of high ligation and division of the involved venous trunk and the immediate tributaries. Radical extirpation of varicose veins should be reserved until further pregnancy is not contemplated.     

Identification and definition of long-stay mental hospital population.

In a study to identify and define a central group of long-stay psychiatric patients who are resistant to discharge 422 were found who had been in hospital for eight to 23 years. These "problem" patients represented 40% of all long-stay patients. The total number of years that they had spent in hospital was nearly double that of the remaining patients. They were mostly unvisited, unoccupied, and single, and most were suffering from schizophrenia or organic psychosis. Half were in a good or reasonably good state of mental health, and three-quarters were in a good or reasonably good state of physical health. The findings have implications for the rehabilitation and treatment of these patients and also for the provision of community aftercare facilities.     

Comparison of mortality of patients with heart attacks admitted to a coronary care unit and an ordinary medical ward.

During a 32-month period 2047 patients suspected of having heart attacks were admitted to hospital and were followed up prospectively. Out of 1480 eventually found to have definite or probable myocardial infarction, 483 had initially been admitted to an ordinary medical ward because of the shortage of coronary care unit (CCU) beds. More patients aged over 65 had been admitted to a ward than to a CCU, and more patients aged 65 or less had been admitted initially to a CCU. Within each age group, however, patients admitted initially to a CCU were clinically similar to those admitted initially to a ward. There was a higher proportion of successful resuscitations among patients admitted to a CCU, but there was no significant difference in mortality in either age group between patients admitted to a CCU and a ward.     

Trauma services requirements in a district general hospital serving a rural area.

OBJECTIVE--To assess the demands made on a regional trauma centre by a district trauma unit. DESIGN--Two part study. (1) Prospective analysis of one month''s workload. (2) Retrospective analysis of one year''s workload by using a computer based records system. Comparison of two sets of results. SETTING--Accident unit in Gwynedd Hospital, Bangor. PATIENTS--(1) All patients who attended the accident unit in August 1988. (2) All patients who attended the accident unit in the calendar year April 1988-April 1989. MAIN OUTCOME MEASURE--Workload of a district trauma unit. RESULTS--In August 1988 there were 2325 attendances; 2302 of these were analysed. In all, 1904 attendances were for trauma; 213 patients were admitted to the trauma ward and 103 required an operation that entailed incision. Patients who attended the unit had a mean (range) injury severity score of 2-13 (0-25). Only two patients had injuries that a district general hospital would not be expected to cope with (injury severity score greater than 20). In the year April 1988-April 1989, 21,007 patients attended the unit. In all, 17,958 attendances were for orthopaedic injuries or injuries caused by an accident; 1966 patients were admitted to the unit. CONCLUSIONS--Most trauma is musculoskeletal and relatively minor according to the injury severity score. All but a few injuries can be managed in district general hospitals. In their recent report the Royal College of Surgeons has overestimated the requirements that a British district general hospital would have of a regional trauma centre.     

Sequelae of an 125I-Fibrinogen Detected Thrombus

Forty-four patients who had a deep vein thrombosis detected with the fibrinogen uptake test were followed up three to four years later. The mild aching pains and ankle swelling that were present at the time of the thrombosis persisted or got worse in many, but there was no increase in the incidence of varicose veins. The minor self-limiting thrombosis detected with the fibrinogen uptake test should not be considered innocuous, for it can cause long-lasting symptoms.