Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center: Value of tailored peri-pancreatectomy protocols

BACKGROUND

Pancreaticoduodenectomy (PD) is a technically complex operation, with a relatively high risk for complications. The ability to rescue patients from post-PD complications is as a recognized quality measure. Tailored protocols were instituted at our low volume facility in the year 2013.

AIM

To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality.

METHODS

A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1, 2013 and June 30, 2023. Standardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications, and the modified Clavien-Dindo classification was used to classify post-PD complications.

RESULTS

Over the study period, 113 patients at a mean age of 57.5 years (standard deviation [SD] ± 9.23; range: 30-90; median: 56) underwent PDs at this facility. Major complications were recorded in 33 (29.2%) patients at a mean age of 53.8 years (SD: ± 7.9). Twenty-nine (87.9%) patients who experienced major morbidity were salvaged after aggressive treatment of their complication. Four (3.5%) died from bleeding pseudoaneurysm (1), septic shock secondary to a bile leak (1), anastomotic leak (1), and myocardial infarction (1). There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores ≤ 2 (93.3% vs 25%; P = 0.0024).

CONCLUSION

This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD. Despite low volumes at our facility, we demonstrated that 87.9% of patients were rescued from major complications. We attributed this to several factors including development of rescue protocols, the competence of the pancreatic surgery teams and continuous, and adaptive learning by the entire institution, culminating in the development of tailored peri-pancreatectomy protocols.

Hypertrophic Cardiomyopathy with a Twist

Hypertrophic cardiomyopathy is a relatively common inherited cardiac disorder, with echocardiography still being the initial imaging method for its diagnosis. Cardiac fibroma is a primary neoplasm that most commonly presents in childhood. We present a patient who was investigated for typical cardiac symptoms who went on to have cardiac magnetic resonance imaging and was found to have both of these conditions.

Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres

Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery (MIS) because there are many factors that make laparoscopic pancreas resections difficult. The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries. However, this is not the environment that many surgeons in developing countries work in. These patients often do not have the opportunity to travel to high volume centres for care. Therefore, we sought to review the existing data on MIS for the pancreas and to discuss. In this paper, we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas. The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice. Low pancreatic case volume in the Caribbean, and financial barriers to MIS in general, laparoscopic distal pancreatectomy, enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment. This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.

Laparoscopic Completion Cholecystectomy: An Audit from the Americas Hepato-Pancreato-Biliary Association (AHPBA) Caribbean Chapter

Objective

Removal of a gallbladder remnant occasionally becomes necessary when retained stones become symptomatic. Although the laparoscopic approach has been described, it is not yet considered the standard of care. We sought to determine the outcomes after completion cholecystectomies in the resource-poor setting within the Caribbean. 

Methods

We carried out an audit of the databases from all hepatobiliary surgeons in the Anglophone Caribbean. We identified all patients who had completion cholecystectomy over the five-year period from July 1, 2012 to June 30, 2018. Retrospective chart review was performed to extract the following data: patient demographics, diagnoses, presenting complaints, operative details, morbidity, mortality, and clinical outcomes. Descriptive statistics were generated using Statistical Packaging for Social Sciences (SPSS), version 12.0 (SPSS Inc., Chicago IL)

Results

There were 12 patients who were subjected to laparoscopic completion cholecystectomy for acute cholecystitis (7), severe biliary pancreatitis (3), and chronic cholecystitis (2) secondary to stones in a gallbladder remnant. There were 10 women and two men at a mean age of 47.4 years (range 32-60; standard deviation (SD) +/-7.81; median 48; mode 52) and a mean body mass index (BMI) of 30.8 Kg/M² (SD +/-3.81; range 26-38; median 29.5). The mean interval between the index operation and the completion operation was 14.8 months (SD +/- 12.3; range 1-48; median 13; mode 18). Five (42%) patients had their original cholecystectomy using the open approach. Five (42%) index operations were done on an emergent basis and the gallbladder remnant was deliberately left behind in three (25%) index operations. The completion cholecystectomies were all completed laparoscopically in 130.5 minutes (SD +/- 30.5; range 90-180, median 125; mode 125) without any conversions or mortality. There were two minor bile leaks that resolved without intervention through an indwelling drain. 

Discussion

Completions cholecystectomy can be completed via the laparoscopic approach with good outcomes and acceptable morbidity and mortality rates. The patients derive the same advantages as elective cholecystectomies. Therefore, the laparoscopic approach, when performed by hepatobiliary surgeons with advanced laparoscopic expertise in specialized centers, should be the new standard of care. 

P1729 Abnomral course of pulmonary vein causing right heart dilatation

Funding Acknowledgements

None

Introduction

Partial anomalous pulmonary venous return is a rare congenital cardiac anomaly that usually involves the right pulmonary vein and an atrial septal defect. It is accounted for 0.7%. Isolated partial anomalous pulmonary venous return with an intact atrial septum is even rarer, and this condition is usually treated surgically in younger patients.

We report a case of a young female, incidentally found to have a right upper pulmonary vein draining into the right atrium, confirmed by TOE and CT Venography pulmonary, with moderate right ventricular enlargement, without pulmonary hypertension, intra-cardiac shunt or accompanied congenital anomaly.

A decision of surgical correction was made. We conclude that it is important to suspect PAPVC in patients with right ventricular volume overload, even in absence of ASD.

Case presentation

A 26-year-old female, not known to have any chronic illness. She was referred because of poor appetite and low weight, to cardiology evaluation for accidental murmur finding during examination. She had no other symptoms.

The TOE was done which showed left pulmonary veins are normal, the right lower pulmonary vein is normal, and there is high suspicion of aberrant right upper pulmonary vein draining in the right atrium, no evidence of intra-cardiac shunt.

CT Venography pulmonary revealed anomalous (Giant) right superior pulmonary vein to the superior vena cava and draining to the right atrium. Figure 1. Patient was referred for surgical correction.

Discussion

Partial anomalous pulmonary venous return is a type of left to right shunt. It is a rare congenital abnormal cardiac defect in which the pulmonary veins draining into the right atrium (RA) directly or indirectly by venous connection. Its accounted for 0.4 to 0.7%. However, as this rate is based upon autopsy data, the true prevalence of PAPVR may actually be higher.

PAPVR is frequently associated with other congenital heart disease, most commonly ASD, in >75% of patients. It is estimated that 10% to 15% of patients with ASD and up to 85% of patients with sinus venosus ASD have PAPVC. Exclusive of ASD, other more complex cardiac malformations occur in ∼20% of patients. PAPVR can also be an isolated defect with intact atrial septum.

TOE is more sensitive than TTE in detecting PAPVR. A potential limitation of echocardiography is the availability of acoustic windows. If all four PVs are not identified emptying into the left atrium on TEE, CCT and CMR may provide complementary data .

CONCLUSION

In conclusion, missed diagnosis always occurs in PAPVR, the debauched and blood flow of pulmonary vein should be over-viewed carefully during TEE examination. In a patient with unexplained RV enlargement PAPVC (one or more pulmonary veins) should be considered in the differential diagnosis. Multi-modality cardiac imaging using echocardiography, CT angiography and CMR may provide a comprehensive noninvasive evaluation of PAPVC.

Abstract P1729 Figure. Fig1 TOE (Top),CT (Bottom) of RUPV

94 When the gut affects the heart

A 59-year-old man came to our attention with progressive shortness of breath associated with lower limb oedema. He complained also of recurrent malar flushing, diarrhea and weight loss (14 kg in the last 8 months). At physical examination, a holosystolic murmur best heard over the fourth left sternal border, intensified upon inspiration, and a palpable tender liver with irregular surface were noted.

Transthoracic and transesophageal echocardiogram revealed dilated right chambers. The tricuspid annulus was dilated and the leaflets thickened, shortened and retracted with restricted mobility and incomplete coaptation, leading to severe tricuspid regurgitation (Panels A-B). Moderate pulmonary regurgitation was also detected (Panel C). Cardiac MR confirmed the morphology of the tricuspid valve (Panels D-E, arrows) and the severity of the tricuspid regurgitation (regurgitant fraction 66%). The pulmonary valve leaflets were also thickened and fixed (Panel F, arrow), with moderate pulmonary regurgitation (regurgitant fraction 21%).

With the suspicion of carcinoid syndrome, 5-hydroxyindoleacetic acid (5-HITT) was tested by 24-hour urine sample and a value of 929.5 µmol/24h was found (n.v. 10.5-47.1).

Whole body 18-F DOPA PET was performed. Axial views and reconstructed images revealed a short segment of mural thickening (2.4 cm and 1.1 cm) in the jejunum with a moderate/high uptake (Panels G, arrow). Adjacent to this lesion, a mesenteric spiculated mass (4.0 x 2.8 cm) with moderate uptake was visible (Panels H, arrow). Multiple enhancing nodules with high uptake were present in the liver (Panel I).

One of the liver nodules was biopsied. The biopsy revealed extensive infiltration by well differentiated neuroendocrine tumor (Panel J, blue arrow). The tumor cells were arranged in nests and were composed of cells with round to oval nuclei and eosinophilic cytoplasm (Panel K). The neuroendocrine nature of the tumor was confirmed by strong diffuse positivity with synaptophysin (Panel L), chromogranin and CD 56. Ki-67 showed a proliferative index of less than 3%. The tumor morphology, combined with the immunohistochemical features, was in keeping with a well differentiated neuroendocrine tumor.

Carcinoid heart disease is a rare cause of primary tricuspid and pulmonary valve disease leading to significant morbidity and mortality caused by right heart failure. The characteristic pathological findings are endocardial plaques of fibrous tissue that may involve the tricuspid valve and, rarely, the pulmonary valve. The fibrous tissue in the plaques results in distortion of the valves leading to either stenosis, regurgitation, or both.

Abstract 94 Figure.

Single incision laparoscopic surgery from a caribbean perspective

Conventional laparoscopy with multiple ports has recently gained a strong foothold in the Caribbean, but single incision laparoscopic surgery (SILS) has lagged behind. In this paper, we compare the data on SILS and conventional multi-port laparoscopy in the English-speaking Caribbean.

Clinical outcomes after major hepatectomy are acceptable in low-volume centers in the Caribbean

BACKGROUND

Major hepatectomies are routinely performed because they are often the only curative treatment for metastatic liver disease. There has been a trend to concentrate major hepatectomies in referral hospitals that perform these operations at high volumes. These high volume referral centers are usually located in developed countries, but many patients in developing nations are not able to access these centers because of financial limitations, lack of social support and/or travel restrictions. Therefore, local hospitals are often the only options many of these patients have for surgical treatment of metastatic liver disease. This is the situation in many Caribbean countries.

AIM

To determine the clinical outcomes after major liver resections in a low-resource hepatobiliary center in the Caribbean.

METHODS

We prospectively studied all patients who underwent major liver resections over five years. The following data were extracted: patient demographics, diagnoses, ECOG status, operation performed, post-operative morbidity and mortality. Statistical analyses were performed using SPSS ver 16.0

RESULTS

There were 69 major liver resections performed by two teams at a mean case volume of 13.8 major resections/year. Sixty-nine major hepatic resections were performed for: colorectal liver metastases 40 (58%), non-colorectal metastases 9 (13%), hepatocellular carcinoma 8 (11.6%), ruptured adenomas 4 (5.8%), hilar cholangiocarcinomas 4 (5.8%), hemangiomata 2 (2.9%), trauma 1 (1.5%) and hepatoblastoma 1 (1.5%). Twenty-one patients had at least one complication, for an overall morbidity rate of 30.4%. There were minor complications in 17 (24.6%) patients, major complications in 11 (15.9%) patients and 4 (5.8%) deaths.

CONCLUSION

There are unique geographic, political and financial limitations to healthcare delivery in the Caribbean. Nevertheless, clinical outcomes are acceptable in the established, low-volume hepatobiliary centers in the Eastern Caribbean.

Abstract P5-08-16: Breast cancer in the Bahamas: Revisiting the adequacy of national screening guidelines

Background: The Bahamas is an island nation shown to have a high incidence of early onset breast cancer. In addition, recent research has revealed that the Bahamian population has a high prevalence of a founder mutation to the BRCA1 gene. Despite the population differences between the Bahamas and the United States, the screening guidelines for breast cancer in the Bahamas reflect those of the United States. This study provides data that suggests that the current breast cancer screening guidelines in the Bahamas do not capture cases in the age groups most at risk and are in need of revision.

Methods: We performed a retrospective review of all cases submitted to the Princess Margaret Hospital cancer registry from 1998-2012. We divided the patients into 10 year age cohorts and determined the frequency of breast cancer in each group. For comparison, data for the United States was obtained using the Surveillance, Epidemiology, and End Results (SEER) 18 registries, including all cases of breast cancer from 1998-2012 further stratified into age groups and ethnicity.

Results: The average age of diagnosis of breast cancer in the Bahamas from 1998-2012 was 54 years, compared to an average age of diagnosis in the United States overall population of 61 years and among the black American ethnicity, 58 years (2008-2012 data). The age group with the highest percentage of incidence in the Bahamas is the 40-49 age group consisting of 27% of those diagnosed from 1998-2012. During the same time period, the age group with the highest incidence of breast cancer in the United States was the 50-59 age group in the overall population (24.8%), as well as in the black population (26.7%). By beginning screening at age 40, according to screening guidelines during the study period, the United States was able to capture 95.3% of breast cancer cases in the overall population and 92.8% of breast cancer cases in the black population. Using similar guidelines, the Bahamas captured only 83.6% of breast cancer cases. For comparison, if screening began at age 30 in the Bahamas during the study period, 97% of breast cancer cases would have been captured.

Conclusions: The data in this study demonstrates significant differences in the incidence of breast cancer between age group cohorts in the population of the Bahamas compared to the population of the United States. Furthermore, it suggests that the screening guidelines in place in the Bahamas may be insufficient at capturing an adequate percentage of the population at risk for breast cancer. A significant increase in capture of those with breast cancer in the Bahamas may be achieved by reducing the age to begin screening below the age of 40.

Citation Format: Deleveaux S, Curling D, Francis W. Breast cancer in the Bahamas: Revisiting the adequacy of national screening guidelines [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-16.

Prevalence of founder mutations in the BRCA1 and BRCA2 genes among unaffected women from the Bahamas

Population-based testing for BRCA1/2 mutations detects a high proportion of carriers not identified by cancer family history-based testing. We sought to determine whether population-based testing is an effective approach to genetic testing in the Bahamas, where 23% of women with breast cancer carry one of seven founder mutations in the BRCA1 or BRCA2 gene. We determined the prevalence of founder BRCA mutations in 1847 Bahamian women without a personal history of breast or ovarian cancer, unselected for age or family history. We found that 2.8% (20/705) of unaffected women with a family history of breast/ovarian cancer and 0.09% (1/1089) of unaffected women without a family history carry a BRCA mutation. A total of 38% of unaffected women with a known mutation in the family were found to carry the familial mutation. We previously suggested that all Bahamian women with breast or ovarian cancer be offered genetic testing. These current data suggest that additionally all unaffected Bahamian women with a family history of breast/ovarian cancer should be offered genetic testing for the founder BRCA mutations.

Clinical outcomes of single incision laparoscopic cholecystectomy in the anglophone Caribbean: a multi centre audit of regional hospitals

INTRODUCTION

There has been no report on Single-Incision Laparoscopic Surgery (SILS) cholecystectomy outcomes since it was first performed in the Anglophone Caribbean in 2009.

METHODS

A retrospective audit evaluated the clinical outcomes of SILS cholecystectomies at regional hospitals in the 17 Anglophone Caribbean countries. Any cholecystectomy using a laparoscopic approach in which all instruments were passed through one access incision was considered a SILS cholecystectomy. The following data were collected: patient demographics, indications for operation, intraoperative details, surgeon details, surgical techniques, specialized equipment, conversions, morbidity and mortality. Descriptive statistics were generated using SPSS 12.0.

RESULTS

There were 85 SILS cholecystectomies in women at a mean age of 37.4 ± 8.5 years with a mean BMI of 30.9 ± 2.8. There were 59 elective and 26 emergent cases. Specialized access platforms were used in the first 35 cases and reusable instruments were passed directly across fascia in the latter 50 cases. The mean operative time was 62.9 ± 17.9 minutes. There was no mortality, 2 conversions to multi-trocar laparoscopy and 5 minor complications. Ambulatory procedures were performed in 43/71 (60.6%) patients scheduled for elective operations.

CONCLUSION

In the Caribbean setting, SILS cholecystectomy is a feasible and safe alternative to conventional multi-trocar laparoscopic cholecystectomy for gallbladder disease.

The quality of life trajectory of resected gastric cancer

BACKGROUND

Few studies describe quality of life (QoL) outcomes following gastrectomy for gastric cancer using a validated instrument. The gastric cancer module for the Functional Assessment of Cancer Therapy system of QoL measurement tools (FACT-Ga) was utilized to determine the changes in QoL following gastrectomy, and during the disease course.

METHODS

In 43 patients undergoing gastrectomy for gastric cancer, outcome such as complications, recurrence, and survival were annotated. Karnofsky performance status (KPS) and QoL were determined preoperatively and at each follow-up visit.

RESULTS

Nineteen (44%) patients and 24 (56%) patients underwent partial gastrectomy (PG) and total gastrectomy (TG), respectively. Complications occurred in 30%, and one mortality (2.3%) occurred. Median survival was 23 months. KPS, FACT-G, and FACT-Ga scores all decreased after surgery, and normalized by 6 months. There was no significant difference in QoL in patients who had a PG or TG, although the type of gastrectomy did affect KPS. QoL dropped on average 4.4 ± 3.6 months prior to death.

CONCLUSIONS

Surgery adversely affects QoL for up to 6 months. Thereafter, QoL mirrors changes in disease status. More studies are required to document the QoL cost-benefit ratio in gastric cancer, which often is accompanied by short survival benefits.

Detection of fecal and serum antibodies against enterotoxigenic Escherichia coli toxins and colonization factors in deployed U.S. military personnel during Operation Bright Star 2001--Egypt

Infection caused by enterotoxigenic Escherichia coli (ETEC) poses a significant health problem in children and adults residing in endemic developing countries. Acute and convalescent paired stool and serum samples were obtained from 27 U.S. military personnel with ETEC-induced diarrhea during a military exercise in Egypt. In general, the concentration of total fecal and circulatory anti-LT IgA was significantly increased in convalescent specimens than in the paired acute ones in almost 65 % of the cases. The pattern of specific antibody responses in fecal and serum samples from cases with ETEC expressing the antigens coil surface 1 (CS1), CS2, CS3 and CS6 were, on the other hand, not conclusive due to the small numbers of the study cases. Further research is still required to understand the immunologic responses during the natural course of disease. The data obtained, nevertheless, may help current research efforts on the development of vaccines for humans against ETEC infection.

Induction of systemic antifimbria and antitoxin antibody responses in Egyptian children and adults by an oral, killed enterotoxigenic Escherichia coli plus cholera toxin B subunit vaccine

We assessed serologic responses to an oral, killed whole-cell enterotoxigenic Escherichia coli plus cholera toxin B-subunit (ETEC-rCTB) vaccine in 73 Egyptian adults, 105 schoolchildren, and 93 preschool children. Each subject received two doses of vaccine or placebo 2 weeks apart, giving blood before immunization and 7 days after each dose. Plasma antibodies to rCTB and four vaccine-shared colonization factors (CFs) were measured by enzyme-linked immunosorbent assay. Immunoglobulin A (IgA) antibodies to rCTB and CFA/I were measured in all subjects, and those against CS1, CS2, and CS4 were measured in all children plus a subset of 33 adults. IgG antibodies to these five antigens were measured in a subset of 30 to 33 subjects in each cohort. Seroconversion was defined as a >2-fold increase in titer after vaccination. IgA and IgG seroconversion to rCTB was observed in 94 to 95% of adult vaccinees, with titer increases as robust as those previously reported for these two pediatric cohorts. The proportion showing IgA seroconversion to each CF antigen among vaccinated children (range, 70 to 96%) and adults (31 to 69%), as well as IgG seroconversion in children (44 to 75%) and adults (25 to 81%), was significantly higher than the corresponding proportion in placebo recipients, except for IgA responses to CS2 in adults. IgA anti-CF titers peaked after one dose in children, whereas in all age groups IgG antibodies rose incrementally after each dose. Independently, both preimmunization IgA titer and age were inversely related to the magnitude of IgA responses. In conclusion, serologic responses to the ETEC-rCTB vaccine may serve as practical immune outcome measures in future pediatric trials in areas where ETEC is endemic.

Real-patient evaluation of communication skills teaching for GP registrars

BACKGROUND

Five thousand eight hundred and eighty-five patient-completed questionnaires were used to evaluate the effectiveness of an interpersonal skills module designed for a vocational training programme for GPs.

OBJECTIVES

It was anticipated that patient-based assessments would detect a significant improvement in the interpersonal skills of GP Registrars who undertook the module.

METHOD

A quasi-experimental design using an intervention and control group (comprising 68 GP Registrars) was used to monitor the outcomes of the interpersonal skills module.

RESULTS

Patient ratings of interpersonal skills were significantly higher for those GP Registrars who participated in the interpersonal skills module.

CONCLUSIONS

Patient-based assessments are a useful evaluation method for assessing the quality of the doctor-patient relationship.

Venous stasis complications of the use of the superficial femoral and popliteal veins for lower extremity bypass

PURPOSE

The widely accepted durability of autogenous vein for infrainguinal arterial bypass has led the authors to use the superficial femoral and popliteal vein in selected cases. The results of this experience are presented.

METHODS

From January through December 1991, during which 92 lower extremity bypass procedures were performed, deep vein bypass was attempted in seven patients (three femoral-popliteal grafts, two femoral-peroneal grafts, one femoral-deep femoral bypass, and one popliteal-posterior tibial bypass). In all cases the saphenous vein was absent or inadequate for use as a bypass conduit. The superficial femoral vein was harvested to below the knee in five patients.

RESULTS

At last follow-up six of seven patients had patent grafts with relief of their original symptoms. All the procedures were complicated by venous stasis; acute postoperative phlegmasia developed in two cases. In one of these cases the limb was salvaged by below-knee fasciotomy and deep venous bypass (distal popliteal vein to common femoral vein with polytetrafluoroethylene). In the other case an above-knee amputation was required. Of the five remaining patients three had moderate venous stasis edema unresponsive to limb elevation and compression stockings after operation, and two have had resolution of minimal postoperative venous stasis with simple limb elevation. All cases of severe and moderate venous stasis occurred in patients with popliteal vein harvest to below the knee.

CONCLUSIONS

The authors conclude that the use of the deep veins of the lower extremity for bypass is effective but is associated with a significant increase incidence of venous stasis edema. Two instances of phlegmasia were associated with popliteal vein harvest below the knee, and the authors caution against harvest of the popliteal vein to this level.

Micronuclei in cytokinesis-blocked lymphocytes of cancer patients following fractionated partial-body radiotherapy

We applied the cytokinesis-block micronucleus assay to measure chromosome damage in lymphocytes of 11 cancer patients undergoing fractionated partial-body irradiation. Measurements performed before, during and after cessation of radiotherapy showed a dose-related increase in micronucleus frequency in each of the patients studied. When the results for micronucleus frequency (Y) were plotted against the estimated equivalent whole-body dose (X) the dose-response relationship obtained was Y = 75.8X + 49.5 (r = 0.783, P less than 0.0001). A general decline in MN frequency was observed during the post-treatment period down to 57 per cent (+/- 10) after 12 months but there was considerable variation between individuals. The advantages and disadvantages of the application of the cytokinesis-block micronucleus assay as a biological dosimeter for lymphocytes irradiated in vivo are discussed.

Mobility after major limb amputation for arterial occlusive disease

This study is concerned with the degree of mobility achieved by patients following major amputation for arterial occlusive disease of the legs and its relationship to the level of amputation. Eighty-four out of a possible 85 consecutive amputees form the basis of the study and the degree of mobility was assessed and graded in survivors six months after amputation. Of the 69 survivors 74% were mobile to some degree and 57% walked daily with a prosthesis. Sixty-five per cent of all the amputations were below-knee. Seventeen per cent of below-knee stumps in patients surviving two weeks failed to heal. In amputees who attained a unilateral mobile healed stump 78% with below-knee amputations and 50% with above-knee amputations walked daily with a prosthesis. To obtain maximum mobility the knee should be retained whenever practical even though this results in some unhealed stumps requiring revision.