No abstract

Patients with primary varicose veins were examined by a combination of the standard tourniquet test with detection of reflux by Doppler ultrasound. Results were compared with standard clinical tests: impulse or thrill at the saphenous opening on coughing, tap impulse at the groin, and the 'Trendelenburg' tourniquet test. The state of competence of the saphenofemoral junction was noted at operation. One hundred and sixty-one limbs of 105 patients were studied. The saphenofemoral junction was incompetent in 132/161 limbs (82 per cent) and was judged competent in 29/161 limbs (18 per cent). The combined Doppler and tourniquet test assessed the saphenofemoral junction correctly in 82 per cent of limbs and was more accurate than all the other tests. The test had good sensitivity (0.9) but poor specificity (0.45). Poor specificity was a feature of all the tests except for thrill which was a highly insensitive test. The combined Doppler and tourniquet test appears to be the most simple, rapid and accurate means of detecting saphenofemoral incompetence.

The aim of this current retrospective study was to assess postoperative mobility one year after above knee (AKA) or below knee amputation (BKA) in a district general hospital. Data on patient demographics, diabetic status, risks for peripheral vascular disease, mortality and mobility at one year were recorded from the vascular database. Seventy-five patients underwent lower limb amputation over a 70-month period (AKA n=31, BKA n=44). Operative mortality was 10% and mortality at one year 13.7%. Fourteen out of the 31 patients (45.1%) who underwent AKA were mobile independently or with a walking stick compared to 54.5% (24/44) in the BKA group (P=0.44). Fifteen patients (48.3%) were diabetic in the AKA group compared to 26 patients (59.1%) in the BKA group (P=0.49). In the under 60 years group and over 60 years group there was no significant difference in type of amputation (P=0.64) or mobility (P=0.69). In this current series, there was no significant rehabilitation benefits in patients undergoing BKA compared to AKA. With an ageing population who inherently have increasing significant medical problems, the perceived benefit in preserving the knee joint may not be as significant as previously reported.

No abstract

No abstract

the lungs 1 ,4, 5. Tuberculomas have usually shown themselves after about 3 months' treatment, though the interval has been as short as 30 days and as long as 12 months 1 ,3, Our patient showed the paradoxical response on two separate occasions, after 44 days and after 4 months, while on successful treatment for Pott's disease, and others have recorded such events even after completion of treatment". Any course of antituberculosis chemotherapy should be completed, and intracranial pressure should be controlled. The condition may eventually resolve with medical treatment alone", Until the results of medical treatment have been rigorously assessed, these patients should probably be kept under observation for several years.

A 54-year-old truck driver presented with a tender swelling in the palmar aspect of his right hand. He regularly used the right palm as a "hammer" to secure loads onto his truck. Examination showed a 2-cm pulsatile swelling at the hypothenar eminence. The clinical diagnosis of a distal ulnar artery aneurysm was confirmed with duplex ultrasound imaging. Contrast-enhanced computed tomography with three-dimensional reconstruction (A, Cover) was used for further anatomic assessment.The aneurysm (B) was surgically excised under general anesthesia with end-to-end anastomosis of the healthy artery (C) using 6-0 Prolene (Ethicon, Somerville, NJ). Postoperatively the hand was well perfused, with intact neurologic and motor function. The patient made an uneventful recovery, and histologic analysis of the specimen confirmed a true aneurysm. COMMENTRepetitive blunt trauma to the palm of the hand may result in obstruction or aneurysm formation in the distal ulnar artery where it lies against the hamate bone. 1 The latter pathology occurs much less frequently. The "hypothenar hammer syndrome" has been described as an occupational hazard in carpenters, butchers, mechanics, and others who use their hand as a hammer. Operative intervention is associated with low morbidity and can prevent sequelae such as Raynaud phenomenon, digital gangrene, or ulnar nerve compression that eventually occur in most aneurysms treated conservatively. 2 Opinion is divided about whether the artery should simply be ligated after excision of the aneurysm or whether revascularization should be done by end-to-end anastomosis or interposition vein graft. 3 Ligation without reconstruction is possible when there is an adequate collateral circulation. Most would advocate selective revascularization based on an Allen test, back bleeding, and perfusion of the hand observed after the ulnar artery is occluded at surgery. REFERENCES 1. Smith JW. True aneurysms of traumatic origin in the palm. Am J Surg 1962;104:7-13.

Recent experimental evidence has suggested that circulating suppressor leukocytes play an important role in mediating the suppression of immunity seen in burn patients. In order to shed further light on the relationship between suppressor cells and depressed cellular immunity 22 patients were studied (mean age 37) who had suffered severe burns of greater than 30% body surface area. Simultaneous studies were performed on 14 control laboratory personnel (mean age 32). Monoclonal antibodies were used to identify T-lymphocyte subsets known to have suppressor/cytotoxic (OKT8) and helper/inducer (OKT4) function, respectively. In addition, serial measurements were made of the response of circulating lymphocytes to the T-cell mitogen phytohemagglutinin (PHA). An inversion of the normal ratio between suppressor/cytotoxic and helper/inducer subsets (normal 0.55:1, postburn 1.4:1; p less than 0.001) occurred soon after burn injury, reached a peak in five to seven days and then returned gradually to normal levels by 14 days. A diminished response of patients' lymphocytes to PHA (57 +/- 10% SD suppression as compared with normal controls at five to seven days) corresponded with high suppressor to helper cell ratios and returned to normal at the same time. Functional assays, which recognize only high levels of activity, demonstrated circulating suppressor cells in nine patients during this same period but became negative by 14 days. These early immunologic modulations were not predictive of morbidity or mortality. Later in the postburn course, systemic sepsis in eight patients was associated with a return of increased suppressor to helper cell ratios and decreased mitogen (PHA) responsiveness. At this time functional assays demonstrated circulating suppressor cells in six patients. Five of these six patients died of sepsis. It was concluded that severe burn injury regularly induces an early transient increase in circulating suppressor cells accompanied by a depression of lymphocyte activation. A later (greater than 14 days postburn) increase in suppressor cells to levels detectable by functional assays is closely correlated with mortality from sepsis.