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By: Y. Hengley, M.B.A., M.B.B.S., M.H.S.

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This condition, which Because of their superficial location and close appo is commonly referred to as “hypothenar hammer sition to the bones, the arteries of the limbs and syndrome,” results in intimal injury, thrombo extremities are particularly vulnerable to traumatic sis or aneurysm with subsequent digital ischemia, injuries. Based on its pathomechanism, arterial pain or a palpable mass in the hand (see also trauma can be arbitrarily subdivided into three main Chapter 10) (Okereke et al. Similar vascular abnor wound by a sharp object or blunt arterial lacerations malities may occur at the level of the dorsalis pedis related to major stretching or contusion trauma artery following repeated blunt trauma over the (including high-grade sprains, bruising, dislocated dorsum of the ankle and midfoot (Yamaguchi et al. Other uncommon causes of closed ing progressive damage to the vessel wall that may arterial damage associated with abnormalities of lead to pseudoaneurysms, aneurysms, and vessel the musculoskeletal system are related to anatomic occlusion; and iatrogenic injuries resulting in either variants, such as: injury to the popliteal artery due thrombosis or local hemorrhage. When major arte to osseous abnormalities in patients with heredi rial trunks of the limbs are involved, direct trau tary multiple exostoses (see Chapter 14) (Chamlou matic injuries are clinical emergencies and, in most et al. These operator-dependent, may be inadequate in the eval lesions are typically located at the puncture site, uation of arterial flow distal to an arterial injury, is including the groin for the femoral artery and its susceptible to confusion created by collateral ves divisional branches (see Chapter 12) (Roubidoux sels, and may be unsuitable in patients with open et al. Compression-based femoral and median identifying and monitoring minor arterial inju neuropathy is a well-established complication of ries occurring during trauma that do not require hematomas and pseudoaneurysms following arte specific immediate operative management – such rial catheterization (see Chapter 7) (Jacobs et al. Color Doppler imaging vessel occlusions – in order to assess whether they is useful in differentiating complications of femoral 128 M. Two different cases of manual workers – one a car mechanic, the other a weight lifter – who had occupational hammering in their right hands. Operative view demonstrates a thickened pale artery coursing ad jacent to the ulnar nerve. At color Doppler imaging (not shown), the vessel occlusion initiated at the point where the artery is closely apposed to the posteromedial corner of the medial femoral condyle (asterisk) and is, therefore, vulnerable to compression by the anomalous muscle. At Dop system only occasionally produces a vascular pler spectral analysis, blood flow in the neck exhib lesion, such as an aneurysm or a vein occlusion. Demonstration of the continuity of other hand, characteristic findings of arteriovenous the dilated venous segment with a superficial, even fistulas include: visible connection between artery small, vein and blood flow detected within the and vein, multicolored (mosaic pattern) speckled mass may help the diagnosis (Fig. When mass at the fistula site, spreading of color pixels into thrombosed, venous aneurysms may be a diagnostic the perivascular soft tissues, high diastolic flow in challenge because they appear as nonspecific solid the arterial waveform proximal to the fistula site, avascular masses (Fig. Post-traumatic vein decreased flow in the artery caudal to the fistula, and thrombosis may occasionally be encountered fol high-velocity turbulent flow, sometimes with a pul lowing muscle strains as a result of stretching of the satile component, in the efferent vein (Helvie and vessel walls. Color Doppler imag ing demonstrates continuity of the pseudoaneurysm cavity with a displaced brachial artery by means of a thin neck (curved arrow). Note the shrunken appearance of the graft surrounded by a fluid collection (asterisks). This sign, together with demonstration of the venous ends and of internal blood flow at color Doppler imaging, may avoid confusion with ganglion cysts. While releasing probe compression, blood flow (arrow) can be seen entering the aneurysm from the parent vein (arrowhead) to completely fill its cavity. After surgical resection, this mass proved to be a thrombosed varix longed absence of contracture of the calf muscles rounding collateral vessels (Murphy and Cronan as a result of local pain and post-traumatic immo 1990). In some instances, the head of the thrombosis and distinguish a vascular problem thrombus may float freely within the vessel lumen from other musculoskeletal conditions that may (Fig. This finding should be indicated in the mimic it, including a ruptured Baker cyst (see report as it relates to an increased risk of embolism. Chapter 14) or a post-traumatic hematoma (see Although many have tried to date the thrombus on Chapter 15). The classic description of venous throm the basis of its reflectivity, such attempts have been bosis is that of an enlarged vein with thickened walls ineffective (Murphy and Cronan 1990). In chronic containing echogenic material with multiple sur vein thrombosis, recanalization of the thrombus Nerve and Blood Vessels 131 a 2 1 c * * e * * a A g h i Fig. Note that part of the non-echogenic lumen (2) was also thrombosed indicating successive phases of thrombus apposition with time. During real-time observation, the thrombus could be seen knocking against the vessel wall. Tiny longitudinal hypoechoic channels with flow (curved arrow) are seen inside the thrombus reflecting a process of partial recanalization. Note the subfascial edema (arrowheads) involving the biceps brachii muscle as a result of venous stasis.

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It is contraindicated during the 1st trimester of pregnancy; safety during the 2nd and 3rd trimester is not known. The tablets should be taken with fatty food (tablets may be crushed and mixed with 1-2 tsp water, and taken with milk). In Southeast Asia, relative resistance to quinine has increased and treatment should be continued for 7d. Quinine should be taken with or after meals to decrease gastrointestinal adverse effects. Mefloquine should not be used for treatment of malaria in pregnancy unless there is not another treatment option (F Nosten et al, Curr Drug Saf 2006; 1:1). It should be avoided for treatment of malaria in persons with active depression or with a history of psychosis or seizures and should be used with caution in persons with any psychiatric illness. Mefloquine should not be used in patients with conduction abnormalities; it can be given to patients taking β-blockers if they do not have an underlying arrhythmia. Mefloquine should not be given together with quinine or quinidine, and caution is required in using quinine or quinidine to treat patients with malaria who have taken mefloquine for prophylaxis. Mefloquine should not be taken on an empty stomach; it should be taken with at least 8 oz of water. It has also been reported on the borders between Myanmar and China, Laos and Myanmar, and in Southern Vietnam. Adults treated with artesunate should also receive oral treatment doses of either atovaquone/proguanil, doxycycline, clindamycin or mefloquine; children should take either atovaquone/proguanil, clindamycin or mefloquine (F Nosten et al, Lancet 2000; 356:297; M van Vugt, Clin Infect Dis 2002; 35:1498; F Smithuis et al, Trans R Soc Trop Med Hyg 2004; 98:182). Relapses of primaquine-resistant strains may be retreated with 30 mg (base) x 28d. Chloroquine should be taken with food to decrease gastrointestinal adverse effects. If chloroquine phosphate is not available, hydroxychloroquine sulfate is as effective; 400 mg of hydroxychloroquine sulfate is equivalent to 500 mg of chloroquine phosphate. The loading dose should be decreased or omitted in patients who have received quinine or mefloquine. If more than 48 hours of parenteral treat Treatment Guidelines from the Medical Letter. Intrarectal quinine has been tried for the treatment of cerebral malaria in children (J Achan et al, Clin Infect Dis 2007; 45:1446). Travelers should be advised to seek medical attention if fever develops after they return. Insect repellents, insec ticide-impregnated bed nets and proper clothing are important adjuncts for malaria prophylaxis (Treat Guidel Med Lett 2009; 7:83). Malaria in pregnancy is particu larly serious for both mother and fetus; prophylaxis is indicated if exposure cannot be avoided. Beginning 1-2 d before travel and continuing for the duration of stay and for 1wk after leaving malarious zone. In one study of malaria prophylaxis, ato vaquone/proguanil was better tolerated than mefloquine in nonimmune travelers (D Overbosch et al, Clin Infect Dis 2001; 33:1015). Some Medical Letter consultants prefer alternate drugs if traveling to areas where P. Beginning 1-2 d before travel and continuing for the duration of stay and for 4wks after leaving malarious zone. Doxycycline can cause gastrointestinal distur bances, vaginal moniliasis and photosensitivity reactions. Not recommendedfor use in travel ers with active depression or with a history of psychosis or seizures and should be used with caution in persons with psychiatric illness. Mefloquine should not be used in patients with conduction abnormalities; it can be given to patients takingβ-blockers if they do not have an underlying arrhythmia. Beginning 1-2 wks before travel and continuing weekly for the duration of stay and for 4wks after leaving malarious zone.

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The cessation of blood supply may be characterised by the following features: complete (complete ischaemia) or partial (partial ischaemia). Sudden respiratory distress and dyspnoea the adverse effects of ischaemia may result from 3 ways: Deep cyanosis 1. Hypoxia due to deprivation of oxygen to tissues; this is Cardiovascular shock the most important and common cause. It may be of 4 types: Convulsions i) Hypoxic hypoxia : due to low oxygen in arterial blood. The cause of death may not be obvious but can occur as a iv) Histotoxic hypoxia: low oxygen uptake due to cellular result of the following mechanisms: toxicity. Inadequate clearance of metabolites which results in liberation of thromboplastin by amniotic fluid. Atheroembolism these causes are discussed below with regard to different Atheromatous plaques, especially from aorta, may get eroded levels of blood vessels: to form atherosclerotic emboli which are then lodged in 1. These emboli consist of from heart block, ventricular arrest and fibrillation from cholesterol crystals, hyaline debris and calcified material, and various causes may cause hypoxic injury to the brain. The commonest and most impor tant causes of ischaemia are due to obstruction in arterial spleen, brain and heart. Notable examples are clear cell d) Polyarteritis nodosa carcinoma of kidney, carcinoma of the lung, malignant e) Thromboangiitis obliterans (Buerger’s disease) melanoma etc (Chapter 8). Blockage of venous drainage may Interarterial anastomoses in the 3 main trunks of the 125 lead to engorgement and obstruction to arterial blood supply coronary arterial system. Blood supply to some organs and i) Luminal occlusion of vein: tissues is such that the vitality of the tissue is maintained by a) Thrombosis of mesenteric veins alternative blood supply in case of occlusion of one. For b) Cavernous sinus thrombosis example: ii) Causes in the vessel wall of vein: Blood supply to the brain in the region of circle of Willis. The effect of occlusion of one set of a) Strangulated hernia vessels is modified if an organ has dual blood supply. For b) Intussusception example: c) Volvulus Lungs are perfused by bronchial circulation as well as 4. The Liver is supplied by both portal circulation and hepatic causes are as under: arterial flow. Some d) By precipitated cryoglobulins of the factors which render the tissues more vulnerable to e) By fat embolism the effects of ischaemia are as under: f) In decompression sickness. The extent of damage produced by ischaemia due compared to parenchymal cells of the organs. The following to occlusion of arterial or venous blood vessels depends upon tissues are more vulnerable to ischaemia: a number of factors. The extent of injury by ischaemia iii) Kidney (especially epithelial cells of proximal convoluted depends upon the anatomic pattern of arterial blood supply tubules). Sudden vascular obstruction results in more severe effects of ischaemia than if it is gradual i) Single arterial supply without anastomosis. Complete vascular Occlusion of such vessels invariably results in ischaemic obstruction results in more severe ischaemic injury than the necrosis. The effects of ischaemia are variable and range Interlobular arteries of the kidneys. No effects on the tissues, if the collateral channels blockage of one vessel can re-establish blood supply develop adequately so that the effect of ischaemia fails to bypassing the blocked arterial branch, and hence the occur. These result when collateral example: channels are able to supply blood during normal activity but Superior mesenteric artery supplying blood to the small the supply is not adequate to withstand the effect of exertion. The examples are angina pectoris and intermittent Inferior mesenteric artery supplying blood to distal colon. The cause of sudden death from ischaemia vi) Blood pigments, haematoidin and haemosiderin, liberated is usually myocardial and cerebral infarction. At this stage, the most important and common outcome of ischaemia most infarcts become pale-grey due to loss of red cells. There are a few other noteworthy Grossly, infarcts of solid organs are usually wedge features in infarction: shaped, the apex pointing towards the occluded artery Most commonly, infarcts are caused by interruption in and the wide base on the surface of the organ.

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Serotonin synthesis and uptake in symptomatic patients with Crohn’s disease in remission. A wide diversity of bacteria from the human gut produces and degrades biogenic amines. Quantitative risk-benefit analysis of probiotic use for irritable bowel syndrome and inflammatory bowel disease. Because antimicro bial prophylaxis for endocarditis has been a standard and routine part. There are Pediatric Infectious Diseases Society, and because there is an increas other arguments against the practice of antimicrobial prophylaxis. Infective endocarditis is more likely to result from exposure to random Nonetheless, there are still concerns regarding these new guidelines bacteremias occuring with activities of daily living than from bac from physicians and patients, despite the fact that the 2007 guidelines teremias due to dental, gastrointestinal or urinary tract procedures. In this brief com Antimicrobial prophylaxis likely prevents an exceptionally small mentary, we summarize the major changes since the 1997 guidelines number of cases of endocarditis, if any, in persons undergoing dental, and provide suggestions on incorporating these changes into clinical gastrointestinal or urinary tract procedures. This was heralded as a sig and recommended that “despite the lack of evidence of the benefit for nificant modification because it eliminated the postprocedure dose. Antimicrobial prophylaxis was recom be reluctant to accept the radical, but logical step of withholding mended for patients at moderate or high risk. It was therefore agreed to were considered to be of such negligible consequence that antimicro compromise and recommend prophylaxis only for those patients in bial prophylaxis was not recommended (5). The key principles underpinning all the previous dures to not providing any at all. Accepted June 2, 2008 Can J Cardiol Vol 24 No 9 September 2008 ©2008 Pulsus Group Inc. Data from reference 1 high-risk patients include individuals with previous endocarditis, car patients with high-risk cardiac lesions, antibiotic prophylaxis with the diac valve replacement surgery (mechanical or biological prosthetic regimens in Table 2 may be considered for those undergoing proce valves), and surgically constructed systemic or pulmonary shunt or dures that involve incision or biopsy of the respiratory mucosa, such as conduit (2). Dental procedures that require antibiotic prophylaxis tonsillectomy or adenoidectomy (1). Antibiotic prophylaxis for bron included those involving dentogingival manipulation. However, if the invasive respiratory tract pro societies, which, not unexpectedly, refused to accept the guidelines, cedure is to manage an established infection, such as drainage of an resulting in confusion among physicians and patients. The arguments for modifying the guidelines are per should be the drug of choice (1). In with regard to endocarditis prophylaxis for persons undergoing gas both guidelines, ‘high risk’ refers to the very high likelihood of severe trointestinal or genitourinary tract procedures. The administration of adverse outcome should the patient develop endocarditis, and not to prophylactic antibiotic solely to prevent endocarditis in persons under the patient’s lifetime risk of developing the disease. The rationale for this better defined, and transplant valvulopathy is included as a high-risk recommendation is based on the relative absence of data demonstrat feature. Neither guideline recommends prophylaxis in patients with ing a conclusive link between these procedures and the development of valvular heart disease with or without regurgitation. In addition, the administration of antimicrobial this guideline alone will lead to a considerable reduction in the use of prophylaxis has not been shown to prevent endocarditis in association antimicrobial prophylaxis. Enterococci are part of the normal gastroin mended for prophylaxis in dental procedures are listed in Table 2. However, no published reports have result in infective endocarditis than bacteremias from dental procedures demonstrated that such therapy may prevent enterococcal endocarditis. Vancomycin or clindamycin may be administered in increased lifetime risk of developing endocarditis patients unable to tolerate beta-lactam agents or in situations when. Prophylaxis of infective endocarditis is recommended only in patients with methicillin-resistant S aureus is speculated. Table 3 summarizes the highlights of the new 2007 recommen forms of cardiac conditions not listed in Table 1 dations. Antibiotic prophylaxis is recommended only for the dental procedures that restrictive in not recommending antimicrobial prophylaxis in many patients with cardiac lesions, they provide a pragmatic and reasonable involve manipulation of the gingival tissues or periapical tissue of teeth or approach supported by the best available evidence. The guidelines are perforation of the oral mucosa in patients with underlying high-risk based on consensus and compromise, balancing the absence of solid cardiac conditions (Table 1) evidence with the catastrophic consequences of endocarditis in the. Antibiotic prophylaxis is recommended for procedures involving the high-risk patients. We may only know with time whether these rec respiratory tract or infected skin, skin structures or musculoskeletal ommendations have appropriately targeted the correct risk groups and tissues only in patients with the underlying cardiac abnormalities outlined procedures.

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