C. N. McCollum

Community clinics for leg ulcers and impact on healing.

OBJECTIVE--To evaluate the effectiveness of community clinics for leg ulcers. DESIGN--All patients with leg ulceration were invited to community clinics that offered treatment developed in a hospital research clinic. Patients without serious arterial disease (Doppler ankle/brachial index > 0.8) were treated with a high compression bandage of four layers. SETTING--Six community clinics held in health centres in Riverside District Health Authority supported by the Charing Cross vascular surgical service. PATIENTS--All patients referred to the community services with leg ulceration, irrespective of cause and duration of ulceration. MAIN OUTCOME MEASURES--Time to complete healing by the life table method. RESULTS--550 ulcerated legs were seen in 475 patients of mean (SD) age 73.8 (11.9) years. There were 477 venous ulcers of median size 4.2 cm2 (range 0.1-117 cm2), 128 being larger than 10 cm2. These ulcers had been present for a median of three months (range one week to 63 years) with 150 present for over one year. Four layer bandaging in the community clinics achieved complete healing in 318 (69%) venous ulcers by 12 weeks and 375 (83%) by 24 weeks. There were 56 patients with an ankle/brachial arterial pressure index < 0.8, indicating arterial disease. The 50 patients with pressure index < 0.8 > 0.5 were treated with reduced compression, and 24 (56%) healed by 12 weeks and 31 (75%) by 24 weeks. The figures for overall healing for all leg ulcers were 351/550 (67%) at 12 weeks and 417/550 (81%) at 24 weeks, compared with only 11/51 (22%) at 12 weeks before the community clinics were set up. CONCLUSIONS--Community clinics for venous ulcers offer an effective means of achieving healing in most patients with leg ulcers.

Sustained compression and healing of chronic venous ulcers.

STUDY OBJECTIVE--Comparison of four layer bandage system with traditional adhesive plaster bandaging in terms of (a) compression achieved and (b) healing of venous ulcers. DESIGN--Part of larger randomised trial of five different dressings. SETTING--Outpatient venous ulcer clinic in university hospital. PATIENTS--(a) Pressure exerted by both bandage systems was measured in the same 20 patients. (b) Healing with the four layer bandage was assessed in 148 legs in 126 consecutive patients (mean age 71 (SE 2); range 30-96) with chronic venous ulcers that had resisted treatment with traditional bandaging for a mean of 27.2 (SE 8) months. INTERVENTIONS--(a) Four layer bandage system or traditional adhesive plaster bandaging for pressure studies; (b) four layer bandaging applied weekly for studies of healing. END POINTS--(a) Comparison of pressures achieved at the ankle for up to one week; (b) complete healing within 12 weeks. MEASUREMENTS AND MAIN RESULTS--(a) Four layer bandage produced higher initial pressures at the ankle of 42.5 (SE 1) mm Hg compared with 29.8 (1.8) for the adhesive plaster (p less than 0.001; 95% confidence interval 18.5 to 6.9). Pressure was maintained for one week with the four layer bandage but fell to 10.4 (3.5) mm Hg at 24 hours with adhesive plaster bandaging. (b) After weekly bandaging with the four layer bandage 110 of 48 venous ulcers had healed completely within 12 (mean 6.3 (0.4)) weeks. CONCLUSION--Sustained compression of over 40 mm Hg achieved with a multilayer bandage results in rapid healing of chronic venous ulcers that have failed to heal in many months of compression at lower pressures with more conventional bandages.

Urgent carotid surgery for high risk patients

Carotid surgery was performed urgently on 22 occasions out of 300 (7%). Of 15 patients with progressing stroke, in all, progression of stroke was arrested. Six patients recovered virtually completely and eight had improving neurological deficit after surgery, i.e. 14 of 15 (93%) benefitted. The other patient had arrest of stroke for a week and then suffered ipsilateral stroke. Of the seven patients operated upon for crescendo transient ischaemic attacks, five had no deficit after surgery or further attacks. The sixth patient had no further attacks but was found to have a tiny, neurological deficit. In these six patients (87%), surgery was greatly beneficial. The remaining patient had a fatal stroke following operation.

Platelet kinetics following carotid endarterectomy: The effect of aspirin and patch angioplasty

Platelet deposition on the subintimal surface of the arterial wall following endarterectomy has been implicated in the development of postoperative thrombosis, intimal hyperplasia and may be important in recurrent stenosis. Autologous radiolabelled platelet deposition has been measured in 51 patients following carotid endarterectomy. The effect of platelet inhibitory drugs and patch angioplasty on early postoperative platelet accumulation at the site of endarterectomy has been investigated. In patients undergoing direct suture of the arteriotomy, platelet deposition measured as the Carotid Uptake Ratio was significantly reduced from 1.44 +/- 0.03 to 1.11 +/- 0.35 in those receiving aspirin and dipyridamole (P less than 0.002). Carotid Uptake Ratio was greater following patch angioplasty at 1.41 +/- 0.07 when compared to 1.14 +/- 0.07 with direct suture of the arteriotomy (P less than 0.002).

Microfilters in fluid resuscitation

Summary Surprising numbers of particulate contaminants are present in small-volume parenteral products, while large-volume infusion fluids have far fewer. Patients on the intensive care unit will frequently receive at least 10 7 particles > 2 μm, of which small-volume drugs and medications account for over 90%. The consequences from these remain uncertain, and the evidence is only convincing clinically for infusion phlebitis and experimentally for reducing transient changes in blood pressure and platelet numbers. From such evidence the use of 0.2 μm in-line filtration is not recommended for the large-volume infusions used during emergency resuscitation. In patients receiving multiple small-volume medications or intra-arterial infusions filtration would seem appropriate. Microaggregates in blood or blood products may cause pulmonary dysfunction, but the evidence that microfiltration of blood reduces the incidence of dysfunction remains only partly convincing. On balance, it would seem justifiable to fit in-line screen filters for patients where large-volume blood transfusions may be anticipated.

Radiolabeled platelets in detecting the source of recurrent pulmonary emboli. A case report

Multiple pulmonary emboli are recognized to be the cause of progressive pulmonary failure. In these patients, the source of emboli may be difficult to detect, even by venography. The authors describe the use of autologous Indium 111-labeled platelets to locate the origin in a patient with progressing right heart failure.

The Diagnosis of True and False Aneurysms With 111-Indium Labelled Platelets

Thrombus formation within arterial aneurysms may lead to embolisation and distal ischaemia. We have investigated the use of 111-indium labelled plate lets in the diagnosis of atherosclerotic and false aneurysms. Autologous platelets labelled with 111-indium oxine were injected into patients with eleven proven aneurysms (8 atherosclerotic, 3 false) . Gamma camera imaging performed be tween 24 and 72 hours later was positive for 10 of the aneurysms. In every case there was increased uptake of label over the aneurysm when compared to undis eased blood vessels (p < 0.05). Most aneurysms could be demonstrated within 24 hours of labelling platelets. 111-indium labelled platelets may prove useful in identifying the source of peripheral arterial emboli.

Haemodilution Improves III-in-Platelet Labelling Efficiency

Since the original description of radiolabelling of platelets with III-Indium Oxine by Thakur in 1976 (9), the applications of this technique have widened. Radiolabelled platelets have been used to assess platelet uptake on atheromatous tissue (2), in prosthetic grafts (3, 4, 7), models of surgical shock (8), transplanted organs (1), platelet vessel wall interaction following arterial surgery (6) and platelet inhibitory therapy (5). However, the preparation of platelets for radiolabelling requires an adequate platelet harvest from anticoagulated blood and at times this has been impaired by a high haematocrit. It has been suggested that haemodilution may improve platelet harvest and we have applied this to our platelet labelling technique in a canine model measuring thrombogenicity in prosthetic grafts in greyhounds.

Use of 111-in-Fragmented Platelets in the Detection of Occult Sepsis

Delay in reaching the diagnosis of localising pus is the major cause of morbidity and mortality in abdominal sepsis (1).

Intravascular Permeation of Uterine Stromal Endometriosis: Case Report

A case of inferior vena caval (IVC) tumor penetration and obstruction, twenty years after treatment of uterine stromal endometriosis (low-grade stro mal sarcoma) is presented.