How to save a limb

The diabetic foot : how to save a limb : part I by Cassar, Kevin - URI: https://www.um.edu.mt/library/oar//handle/123456789/12576The age standardized incidence rate of lower limb amputations in diabetics is 13.1 times (95% Cl 9-17.2) greater than for the general population. The incidence of diabetes related lower limb amputations is 475 per 100,000 patients years or 10.2 per 100,000 patients per year. Extrapolating this to our own population, we would expect to have no more than 50 major amputations per year. If we take into account the higher prevalence of diabetes in our country we should not have more than 80 major amputations per year. As can be seen in this article, the number of major amputations per year in our country has been static at around 120 per year. Figure 2 in this article shows that there is also a considerable number of minor amputations carried out per year, the numbers of which have again remained relatively stable in the past five years. Clearly the numbers performed locally are far in excess of those recorder in other countries. This bags the question of why our amputation rates are so high and what can we do to try to reduce this avoidable tragedy?peer-reviewe

Diagnostic Peritoneal Lavage : an obituary?

Diagnostic peritoneal lavage (DPL) has been used as a diagnostic procedure in patients with blunt abdominal trauma for almost a century. Its accuracy and reliability are high. However DPL is an invasive procedure and carries a small but significant risk of iatrogenic intra-abdominal injury. Besides, false positive rates as high as 24% have been reported with DPL. This results in unnecessary laparotomies in patients least able to withstand further insult. Ultrasonography used for the diagnosis of patients with intra-abdominal injury from blunt trauma is at least as sensitive and specific as DPL. Its positive predictive value is better than that of DPL. Besides ultrasound provides more information and can be performed rapidly. More importantly, it is non-invasive and therefore free of the complication rate associated with DPL. It is therefore no surprise that the use of DPL is declining both in Europe and the United States. Ultrasonography should be used in preference to DPL in the context of blunt abdominal trauma. Institutions receiving patients with such injuries should have 24-hour ultrasonographic facilities.peer-reviewe

Implementation of a graft surveillance programme for infrainuginal vascular bypass surgery

Aim: Patients undergoing bypass graft placement in the lower limb are often entered into a graft surveillance programme using duplex scanning. The aim of this programme is to identify stenoses in vein grafts before they become symptomatic and treat these by angioplasty or surgery, thus prolonging the patency of the graft. This paper aims at reporting on the progress and viability of this programme at Mater Dei Hospital, Malta. Method: Infrainguinal bypass grafts carried out between July 2007 and May 2009 were enrolled. Scanning starts during the patient’s in-hospital stay at one week post-operation. It is then scheduled at 6 weeks, 3 months, 6 months, 12 months, 18 months, 24 months, and yearly afterwards. When a significant stenosis is encountered, the patient is referred for angioplasty. Surgery would be considered in cases when angioplasty is not an option. Results: During this period 56 patients were recruited. At one week post-op the patency rate was 100%. At 6 months the primary unassisted patency was 77.5% while the primary assisted patency was 87.5%. At 12 months the primary unassisted patency was 50% while the primary assisted patency was 77%. Secondary patency rates at 6 and 12 months were 95% and 82% respectively. Conclusion: The graft surveillance programme ensures that any problem detected in the post-operative period is dealt with as soon as possible. The study shows that this programme is being effective in that assisted rates (i.e. after angioplasty or surgery) are better than unassisted rates.peer-reviewe

Carotid endarterectomy : the Maltese experience

Introduction: Carotid endarterectomy significantly reduces the risk of cerebrovascular events in both symptomatic and asymptomatic patients with significant carotid stenosis. The recent American Heart Association/American College of Cardiology guidelines advise that carotid endarterectomy is only beneficial when the perioperative stroke or mortality rate is below 6%. The aim of this study was to review the results of carotid endarterectomy performed in Malta by one vascular surgeon. Methods: All patients undergoing carotid endarterectomy between July 2007 and June 2011 were included in the study. Data was entered prospectively into a vascular database. Retrospective review of the case notes of all patients undergoing carotid endarterectomy was also performed. Demographics of the patient cohort as well as information about perioperative mortality, cerebrovascular events, cardiac events as well as any other complications were recorded. Information was also collected about any deaths and cerebrovascular events during the follow up period. Results: 51 patients underwent carotid endarterectomy during the study period. 94% were symptomatic (65% CVA; 15% TIA; 10% amaurosis fugax; 4% TIA and amaurosis) and 6% asymptomatic. 46% had an internal carotid artery stenosis of 90% or more while the rest had a stenosis of 70% or more. 31% of patients also had significant contralateral carotid stenosis or occlusion. There was one postoperative mortality (1.9%) and one patient sustained a postoperative lacunar stroke (1.9%). There were no cranial nerve injuries and no bleeding requiring return to theatre. The combined perioperative mortality and stroke rate in this cohort was 3.9%. Conclusions: The combined perioperative mortality and stroke rate in this sutdy is better than that reported in the major randomised controlled trials. The perioperative death and stroke rate is well below the threshold level advised by the AHA/ACC.peer-reviewe

The Malta Foundation programme : one year on : part I

The Malta Foundation programme was launched in July 2009, In July 2010 the first group of foundation doctors were awarded their Foundation Achievement of Competence Document allowing them to proceed to the next step of their career, basic specialist training. The programme was set p with two main objectives: A. t improve the first two years of postgraduate training of doctors and to ensure that doctors achieved a level of competence enabling provision of safe patient care; and B. to reverse the exodus of Maltese medical graduates and retain an adequate proportion of doctors to allow the local health service to provide a good quality service. we present the results of the introduction of the Foundation programme to Malta and ask whether the main objectives have been achievedpeer-reviewe

The Malta Foundation Programme : one year on : pt.II

Part 1 of this article can be found in this link : https://www.um.edu.mt/library/oar//handle/123456789/12739Part 2 of the article. The Malta Foundation programme was launched in July 2009, In July 2010 the first group of foundation doctors were awarded their Foundation Achievement of Competence Document allowing them to proceed to the next step of their career, basic specialist training. The programme was set p with two main objectives: A. to improve the first two years of postgraduate training of doctors and to ensure that doctors achieved a level of competence enabling provision of safe patient care; and B. to reverse the exodus of Maltese medical graduates and retain an adequate proportion of doctors to allow the local health service to provide a good quality service. we present the results of the introduction of the Foundation programme to Malta and ask whether the main objectives have been achieved.peer-reviewe

GP referral letters : time for a template?

Introduction: Referral of patients to the vascular clinic at Mater Dei Hospital by general practitioners requires the completion of the standard ticket of referral provided by the Department of Health (Form No DH22). The same form is used for referral to all clinics and all specialties and has remained unchanged for many years. The aim of this study was to assess the quality of information provided by the general practitioners completing the ticket of referral for patients referred to the vascular clinic. Methods: The referral tickets for 100 consecutive patients referred to the vascular clinic at Mater Dei Hospital between December 2007 and February 2008 were prospectively analysed. The referral tickets were assessed for completion of patient’s name, identity card number, address and telephone number. The tickets were also assessed for completion of the referring doctor’s name, registration number and address. Data were also collected on whether the indication for referral was stated and on whether relevant information was provided about risk factors for arterial disease and drug history. The referral tickets were also assessed as to whether the GP had commented on examination of pulses, and on advice given on smoking or exercise. Finally data were collected on whether the referral ticket was written, typed or printed and the legibility of the document. Results: The only data that were complete in all 100 referral tickets was the patient’s name. In 9% of cases there was no identity card number, in 13% no patient address and in 64% no patient telephone number provided. In 22% of referral tickets the referring doctor’s name was not included and the registration number of the referring doctor was only given in 34% of referrals. In 62% of cases no GP address was provided. In 16% of cases the indication for referral was not filled in. Information about diabetes, hypertension, hypercholesterolemia and cigarette smoking was only given in 46%, 28%, 15% and 20% respectively. In 60% of cases no mention of peripheral pulses was made. A comment about advice given to the patient regarding smoking cessation and exercise was made in 1% and 2% of cases respectively. 30% of referral tickets were only partly legible. Conclusion: The quality of completion of referral tickets by general practitioners to the vascular clinic is poor. Essential patient and doctor information is frequently lacking or incomplete. Basic relevant information regarding patient risk factors and examination findings is often missing. The use of a standard referral ticket for all specialties and the design of the current referral ticket probably contribute to the poor quality of completion of these forms.peer-reviewe

Swelling in the thigh

A 67 year old man, who had undergone a left femoro-popliteal bypass using the ipsilateral great saphenous vein 7 years previously, presented with a swelling in the thigh. Nine months post-operatively he had undergone angioplasty of a vein graft stenosis. Subsequent follow up graft scans up to 5 years had been satisfactory. An ultrasound scan revealed a 6 cm aneurysm of the bypass graft in the proximal thigh (proximal graft diameter 7 mm, distal diameter 6 mm; thus theoretically suitable for stent grafting).peer-reviewe

Foam sclerotherapy : the Maltese experience

Objectives: To describe demographics and outcomes of a new sclerotherapy service – Foam sclerotherapy (FS), for venous disease at Mater Dei Hospital, Malta Methods: The data of a consecutive series of patients undergoing FS were prospectively entered into a database and the results analysed. Medical notes of patients were also reviewed. Patients underwent detailed venous duplex scanning before and after each intervention and at follow-up visits. Results: 121 patients underwent a total of 204 FS procedures between November 2008 and October 2011. 22% were male and 78% of the procedures were done in female patients. 151 (74%) of procedures were done in patients above the age of 50 years. 74(37%) interventions were for recurrent varicose veins and 113(55%) for chronic venous insufficiency (CEAP4-6). 77 (38%) patients had active or healed venous ulceration as the indication for treatment. 83% of ulcers healed after foam sclerotherapy during the follow up period. 88.3% (143/162) of veins treated were completely occluded while 11.7% (19/162) were partially occluded. In the majority (64%) only one treatment session was required. One patient sustained an anaphylactic reaction to the sclerosant. No deep vein thromboses, cardiovascular events, pulmonary embolism or other major complications were reported. Skin staining was reported in 21.5% of cases. Conclusions: Foam sclerotherapy is a safe and cheap treatment modality resulting in high rates of venous ulcer healing and successful venous occlusion and a very low complication rate. The success rate of foam sclerotherapy in Malta is comparable to that reported in the literature.peer-reviewe

Autologous haemodialysis access in Malta

Chronic kidney disease is a worldwide problem which is rapidly increasing. In the United States the incidence and prevalence of end stage renal disease has doubled in the last ten years and is expected to continue rising in the future.In Malta the high prevalence of diabetes and the ageing population has similarly resulted in a significant increase in patients requiring haemodialysis over the last decade. Despite advances in dialysis and transplantation, prognosis has not improved worldwidepeer-reviewe