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Objectives We sought to determine the baseline demographic and clinical characteristics of patients with Chronic Venous Disease (CVD) across the Caribbean, and to evaluate patients’ compliance to conservative therapy and the effectiveness of such therapy in reducing patients’ CVD symptoms. Method Patients were enrolled into the VEIN Act Program, and their demographic data, CVD symptoms (and their intensity) and CEAP C-classification was recorded at the first visit. Patients were prescribed conservative therapy, and symptom intensity and patient compliance and satisfaction evaluated at a follow-up visit. Results We enrolled 193 patients into the study, most of which (76%) were female, between 39–78 years (80%) and within the C2-C4a classes (56.1%). Pain (61.1%) and heaviness (58.5%) were the most common symptoms. Patient compliance to the prescribed treatment was relatively high for all modalities (>75%) and most patients (92.1%) were at least somewhat satisfied with their treatment. Conclusions Patient compliance to conservative therapy for management of CVD is high across the Caribbean, and such therapy is effective in reducing intensity of CVD symptoms.

Thyroid Hemiagenesis (THA) is an uncommon, congenital anomaly defined by the absence of one thyroid lobe with or without the isthmus. Reports suggest it may be found more often in regions endemic for hypothyroidism. Genetic abnormalities are thought to have a role based on findings in monozygotic twins. Most cases are sporadic, however familiar clusters have also been documented. It is found more frequently in females. A majority of patients report no symptoms and THA is found incidentally during investigations or intraoperatively. THA is usually associated with normal thyroid function, but it can present with thyroid hypofunction.\ud \ud Since a majority of patients are asymptomatic, there are no specific recommendations for management. Ultrasound imaging and thyroid scintigraphy using technetium or iodine are useful in diagnosis. Its clinical importance occurs when the remnant thyroid lobe requires excision leading to the lifelong requirement for thyroxine supplementation.\ud \ud Published English literature (Medline, PubMed, and Embase databases) was searched. Medical subject headings (MeSH) terms used were “thyroid hemiagenesis,” “one thyroid lobe,” and “thyroid aplasia”. Case reports, case series, and original articles were selected to provide a framework for this review.\ud \ud Articles reviewed were published in the past 20 years. The association of THA with thyroid cancer was explored. In this group, the F:M ratio was 3.25:1. Left THA constituted 53% of cases, right THA in 29.4%, and isthmus absence in 17.6% of cases. Also, the authors investigated the link between THA and hyperparathyroidism, both left and right THA are seen in an equal number of cases in the hyperparathyroidism subgroup. In patients with THA and Grave’s disease, left THA was seen in a majority of cases (86.7%), while an equal number of left and right THA was observed in patients with Hashimoto’s thyroiditis. In addition, congenital abnormalities associated with THA were observed, the left THA was seen in 60% and right THA in 40% of cases of this subgroup.\ud \ud The summative review provided a detailed insight into the epidemiology, aetiopathogenesis, genetics, symptomatology, diagnosis, and treatment for THA by combining findings and results from almost a hundred research papers from around the world. THA remains a poorly understood, often incidentally detected, abnormality in euthyroid patients undergoing investigations and treatment for other thyroid disorders.

The aim of this study was to examine worldwide chronic venous disease (CVD) burden and evaluate effectiveness, adherence and satisfaction with conservative treatment. The VEIN Act Program (VAP) was an international, prospective, observational study that enrolled adult outpatients with lower-limb pain consulting for any CVD-related clinical presentation. Patients’ CVD symptoms, Clinical Etiological Anatomic Pathophysiologic (CEAP) classification, and symptom intensity were recorded. After prescribing conservative treatments, patients returned for a follow-up visit. A total of 567 physicians enrolled 7987 patients, 7397 of whom were included in the analysis. Patients were mainly female (79.3%), mean age was 54.0 ± 15.1 years and mean body mass index was 26.8 ± 4.8 kg/m2. CEAP clinical classifications were C0s (3.6%), C1 (19.4%), C2 (21.8%), C3 (32.0%) and C4–C6 (23.2%). Symptoms were reported by 89.6% of patients and were present across all CEAP classes. Mean intensity (10 cm visual analog scale) was > 5 cm for all symptoms. Only 30.7% of patients had previously consulted for leg problems, and 24.3% had previously received treatment. Conservative treatment alone was prescribed to 78.3% of patients, and in association with operative treatment in 21.6% of patients, and consisted mostly of venoactive drugs (VADs) [99.6%, mostly micronized purified flavonoid fraction] and compression therapy (63.4%) in combination with lifestyle changes such as weight loss. Adherence to prescribed duration was 65.2% for VADs, but only 29.1% wore compression therapy as prescribed. Symptom relief was high with VADs and compression therapy (> 96%), and the majority of patients were satisfied (94.1%). Conservative treatments were beneficial across the spectrum of CVD, highlighting the importance of identifying patients early in the disease course.

Popliteal vein aneurysm (PVAs), though uncommon, can be a cause of pulmonary emboli. They can also result in pulmonary vein embolism despite the use of anticoagulation therapy.We report the case of an otherwise fit, 64-year-old male who had a history of sudden onset of dyspnea on exercise with near syncope.A computed tomography pulmonary angiogram confirmed filling defects in the lung bases in keeping with pulmonary emboli. He was anticoagulated and a venous duplex scan revealed a fusiform suprageniculate PVA with no evidence of thrombus in the lumen. He underwent resection of the aneurysm with lateral vein patch graft repair and was placed on anticoagulation for 6 months with no recurrence after 2 years of follow-up.PVAs are rare and can either be symptomatic or asymptomatic. We advise early surgical treatment to prevent the significant morbidity and mortality associated with thromboembolization.Written consent was obtained from the patient for publication of case and use of images.

Introduction Same-day discharge percutaneous coronary interventions (SDD-PCI) may be quite impactful on healthcare burden for small island developing states (SIDS) such as Trinidad and Tobago. Methods From June 2012 to November 2014, 11 patients underwent SDD trans-radial PCI and followed up at one-month and three months. Data was retrospectively reviewed from a prospectively entered unit-maintained cardiology database. Baseline patient characteristics, in-hospital expenditure, and complications were assessed. Descriptive statistical analysis was performed in Microsoft Excel. Results The mean age at SDD-PCI was 50.90±9.96 and nine were male. Nine patients were of East Indian Caribbean ethnicity. Six were diabetic and five were hypertensive. Procedural success was 100% with no major early complication or three-months complications; patient satisfaction was achieved with a potential in-hospital savings up to $1480 USD per patient. Conclusion This SDD approach for elective trans-radial PCI may be safe and cost-effective in properly selected patients and merits a review of relevant policy issues in Trinidad and Tobago.

The dogma for optimal arteriovenous fistula (AVF) creation is based on starting as distally as possible on the upper limb and progressing proximally. We herein present our findings of an AVF that is as distal as possible on the hand. To document primary patency rates of the distal-to-snuffbox AVF. A 10-year prospective study (2006–2016) involving 31 patients whose distal cephalic vein diameter was ≥3 mm with a normal Allen's test was conducted. Patients were excluded if the radial artery in the wrist was highly calcified, the cephalic vein did not dilate more than 3 mm with proximal compression, and there was previously failed AVF of the limb or previous trauma to the limb. The procedure was performed under local anesthetic, and the anastomosis performed with a 6.0 polypropylene suture in an end-to-side fashion. Thirty-one patients with end-stage renal disease underwent distal vascular access using the distal-to-snuffbox (Hitchhiker's) AVF (HAVF). During follow-up, eight patients died with an adequately functioning HAVF. The primary patency rates at 12, 24, 48, and 60 months were 90, 87, 85, and 82%, respectively. Failure occurred in six (19%) cases over the follow-up period, two in the first 2 weeks and four over a span of 60 months. Conclusion The creation of radiocephalic AVFs in the first web space, distal to the tendon of the extensor pollicis longus, serves as a viable option with acceptable success rates. This allows the surgeon more options with proper patient selection for this procedure.

Arteriovenous malformations (AVMs) of the lower limb typically occurs in the thigh, knees and very rarely on the foot, especially on the plantar aspect of the foot. Failure of recognition of this condition and prompt treatment results in complications such as pain, ulceration, bony abnormalities and limb length discrepancies in some cases. Treatment modalities vary in accordance with the institutional convention as well as the surgeon’s preference. These may range from open resection, sclerotherapy, embolization, and radiosurgery when the lesion is relatively smaller in size.

In patients where anticoagulation therapy is contraindicated, Inferior Vena Cava (IVC) filters are used as an option to prevent Pulmonary Embolism (PE). There are many classifications of Vena Cava filters the two main groups are; those intended for permanent implantation and the other temporary (which are to be retrieved at a later date). Permanent IVC filters are not designed to be removed, unless unexpected clinical circumstances arise. We describe a complex case of retrieval of a permanent IVC filter, though well documented; it is the first of its kind to be recorded in the Caribbean.

Ablation of the great saphenous vein can be performed using endovascular technology and has replaced stripping as the procedure of choice to treat truncal varicosities. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

A 26-year-old man presented with a nonhealing ulcer on the plantar aspect of the left foot of five years duration. Initial investigations were unremarkable. It was only after careful neurological examination that an inherited neuropathy was suspected. This was confirmed by nerve conduction studies and serum electrophoresis. He subsequently underwent partial great toe amputation for the ulcer and underlying first phalangeal osteomyelitis with uneventful healing. Neuropathic ulcers are usually associated with several well-known disorders including diabetes mellitus, tabes dorsalis, pernicious anemia, and sickle cell disease. A rarer cause is Charcot-Marie-Tooth Disease (CMTD). The report gives a review of CMTD and emphasizes that when faced with a nonhealing ulcer in the younger age group, such an underlying hereditary neuropathic cause must be considered.

Background: Men with breast carcinoma have a poor prognosis, especially in the younger age group (30–40 years of age), because most breast enlargements in young men are dismissed as gynecomastia, resulting in an unnecessary delay in treatment. Objective: We describe the case of a young male patient with invasive ductal breast carcinoma. Case summary: In November 2005, a 30-year-old Afro-Caribbean man presented at St. Clair Medical Centre in Port of Spain, Trinidad, with a painless lump in the right breast. Diagnostic findings revealed that the patient had stage II invasive ductal carcinoma, for which he underwent a mastectomy with total axillary clearance. Conclusion: Surgeons investigating unilateral breast swellings in young males should not dismiss them simply as gynecomastia, and should be wary of cancer.

Patient: Male, 26 Final Diagnosis: Marihuana addiction Symptoms: Compulsive showering • nausea • vomiting Medication: — Clinical Procedure: — Specialty: Toxicology Objective: Unexpected drug reaction Background: The use or misuse of Cannabis is well recognized in the Caribbean region. Recently, the cannabinoid hyperemesis syndrome has been described. The triad is characterized by chronic marijuana use, cyclical vomiting, and compulsive bathing. With the extensive use to marijuana as a recreational drug and also the increased use as prescription medication, a patient presenting with this symptomatology needs to be assessed appropriately and this syndrome needs to be one of the differential diagnoses. Case Report: To our knowledge, we report the first such case in the Caribbean region. Here, we report on the case of a 26-year-old Caucasian male with a 3-week history of nausea and week of epigastric pain and vomiting. The patient was known to use marijuana daily for 2 years and had similar complaints for the last 6 months. Conclusions: Because this popular recreational drug is now being used with increased frequency as a prescribed medication, it is crucial that clinicians be aware of this condition, which can present as a diagnostic dilemma.

We report the case of a 33 year old female who presented with endometriosis of the anterior abdominal wall following Caesarean Section at the surgical incision site. Abdominal Incisional Site Endometriosis can pose a diagnostic dilema owing to its relative rarity and vagueosity of symptoms, vis-a-vis, cyclical abdominal pain and occasional palpable mass associated with menstruation. A greater index of suspicion should be prompted in such patients especially if symptoms occur following pelvic surgery such as Caesarean Sections, hysterotomy, and myomectomy.

Purpose. Several investigators have suggested a dismal prognosis of ruptured abdominal aortic aneurysm (rAAA) repair in the elderly. The purpose of this study is to evaluate the morbidity and mortality of rAAA repair in octogenarians and compare it to that of a younger population. Methods From 1980 to 2000, all patients undergoing emergent rAAA repair were divided into two groups based on their age; Group I: age Results Over a 20-year period, 323 patients underwent rAAA repair through a left retroperitoneal (74%) or standard transperitoneal (26%) approach. In Group I (age Conclusion Although the elderly patients have an increased risk of having cardiac and cerebrovascular events in the postoperative period, the treatment of rAAAs in these patients should not be any different than that of a younger population. The left retroperitoneal approach is feasible and beneficial for rAAA repair and is associated with a limited morbidity and mortality.

Objective: Few will debate that infrainguinal arterial reconstruction increases limb salvage. However, numerous reports describe a difference in results in coronary and peripheral arterial reconstructions between men and women. In this study, we analyze the outcome of infrainguinal bypasses performed over 30 years and stratify the results by gender. Methods: We reviewed our vascular registry from 1968 to 1999 for all infrainguinal arterial reconstructions. Demographics, indications, and adverse outcomes were analyzed. Patency, limb salvage, and survival rates were determined with life-table analysis. The χ2, log-rank, and Student t tests were used to determine statistical significance. Results: Five thousand eight hundred eighty procedures were performed, with 2161 in women (37%). Women were significantly older (71 versus 66 years), more often diabetic (53% versus 50%), and less often smokers (27% versus 44%) and more often had surgery for limb salvage (89.8% versus 81.0%). Mortality, complications, and need for revision did not differ. Primary patency rate was 44% versus 47%, secondary patency rate was 55% versus 58%, and survival rate was 39% versus 34% in men and women, respectively, at 10 years (all P > .05). Limb salvage rate in women exceeded that in men (93% versus 88%) at 10 years. Subgroup analysis by conduit also revealed no difference in patency. Conclusion: Infrainguinal arterial reconstruction can be performed safely with comparable results in women and men. Although women may present older and more often for limb salvage, outcomes do not appear to be adversely affected. (J Vasc Surg 2003;37:399-402.)

Originally thought to be a disadvantaged outflow source, the dorsalis pedis artery is associated with excellent patency and limb salvage in the diabetic population. The aim of this study was to demonstrate that the dorsalis pedis artery is as durable in nondiabetics as in their diabetic counterparts. During a 21-year period from 1979 to 1999, 299 long lower limb bypasses to the dorsalis pedis artery were performed at our institution. Patient data and outcomes were reviewed from the vascular registry. Statistical analysis and patency rates were compared using chi-squared and log-rank analysis. This study confirms that the dorsalis pedis can be used as an outflow source with durability that is comparable in both diabetics and nondiabetics. No significant difference exists in morbidity, mortality and patency rates. In the nondiabetic, when the dorsalis pedis is the only patent distal vessel, amputation can be avoided if one considers this a suitable option as an outflow source.

The foot comprises 3 compartments bounded by bone and fascia, each compartment containing muscle and vascular and nervous structures. Infection leading to an increase in pressures in the compartments results in rapid necrosis, a pathologic process characteristic of diabetic feet. Treatment involves fasciotomy and complete debridement of devitalized tissue with possible amputation of the involved digits. Knowledge of the anatomic structure of the foot and its compartments is therefore essential in effectively managing the diabetic foot.

OBJECTIVE To describe the characteristic presentation of exertional leg pain in athletes and to discuss the diagnostic options and surgical management of exertional anterior compartment syndrome of the leg in this group of patients. METHODS Data from a series of athletes presenting with exertional leg pain were analysed and categorized according to aetiology. RESULTS Sixty-six athletes presenting with exertional leg pain in 102 limbs were analysed. Sixteen patients in a first group of 20 patients with a provisional diagnosis of exertional anterior compartment syndrome of the leg underwent a closed fasciotomy with complete resolution of symptoms. A second group of 42 patients were diagnosed as medial tibial stress syndrome and a third group of four patients had confirmed stress fracture of the tibia. CONCLUSION Exertional leg pain is a common presenting complaint of athletes to sports physicians and physiotherapists. Careful analysis can lead to an accurate diagnosis and commencement of effective treatment. Exertional anterior compartment syndrome can be successfully treated utilizing a closed fasciotomy with a rapid return to sport.

OBJECTIVE To report the experience in one centre of the efficacy and safety of open mini-access ureterolithotomy (MAU) and to discuss relevant current indications. PATIENTS AND METHODS MAU was undertaken in 112 patients (mean age 38 years, range 26-57) between 1991 and 2001; the details and outcomes are reviewed. The mean (range) stone size was 12 (8-22) mm, with 30 stones in the upper, 69 in the mid- and 13 in the lower ureter. In 15 cases the stones were impacted and there were signs of infection in the proximal ureter. RESULTS MAU was successful in 111 patients; the one failure was caused by proximal stone migration early in the series. The mean (range) operative duration was 28 (10-44) min and the hospital stay 42 (24-72) h; 33 patients were in hospital for 24 h, 72 for 48 h and seven for 72 h. The blood loss was minimal, at 50 (30-150) mL. The drain was removed after 5 (5-7) days. Patients reported using opioid or nonsteroidal anti-inflammatory analgesia for a mean of 4 (1-7) days after surgery. The mean time to resumption of work was 16 (8-35) days. CONCLUSIONS MAU is a safe and reliable minimally invasive procedure; its role is mainly confined to salvage for failed first-line stone treatments but in selected cases, where a poor outcome can be predicted from other methods, it is an excellent first-line treatment.

Obturator hernia is a rare condition with few reports in the world literature. There appears to be no consensus on the ideal approach and repair for such a condition. We report a simple, quick technique via a lower midline incision using an autogenous peritoneal fold. It is ideal for the contaminated case and in settings where mesh is not readily available.

As for the conventional transperitoneal approach – especially if juxtarenal, for reoperative aortic procedures, inflammatory aneurysms, aneurysms associated with a horseshoe kidney.

Carotid endarterectomy is performed for symptomatic and asymptomatic carotid disease. The eversion carotid endarterectomy is one technique for performing carotid endarterectomy that is gaining popularity. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

A 26-year-old man presented with a nonhealing ulcer on the plantar aspect of the left foot of five years duration. Initial investigations were unremarkable. It was only after careful neurological examination that an inherited neuropathy was suspected. This was confirmed by nerve conduction studies and serum electrophoresis. He subsequently underwent partial great toe amputation for the ulcer and underlying first phalangeal osteomyelitis with uneventful healing. Neuropathic ulcers are usually associated with several well-known disorders including diabetes mellitus, tabes dorsalis, pernicious anemia, and sickle cell disease. A rarer cause is Charcot-Marie-Tooth Disease (CMTD). The report gives a review of CMTD and emphasizes that when faced with a nonhealing ulcer in the younger age group, such an underlying hereditary neuropathic cause must be considered.

We report a rare case of bilateral congenital metatarsal synostosis of the first and second metatarsal bones in a 6-year-old female, who was initially referred with obscure swellings ofthesoles of the forefeet (at the heads of the 2nd metatarsals) and intermittent pain on weight-bearing. Clinical examination had raised suspicion of a bony connection between the first and second metatarsals. This was confirmed by radiographs. Surgical intervention in theform of bilateral osteotomies proved successful in establishing pain free and more natural weight-bearing.

Background Traditionally, left-sided colon obstruction is managed by a multistaged defunctioning colostomy and resection. However, there is growing acceptance of one-stage primary resection and anastomosis with on-table antegrade irrigation. This paper presents a series of patients managed prospectively by primary anastomosis without intraoperative colonic lavage. Methods Emergency resection of acutely obstructed left-sided colonic carcinomas was performed. This was followed by primary anastomosis without on-table lavage after bowel decompression using a new technique. Results Fifty-eight consecutive, unselected patients underwent bowel decompression, resection and primary colocolic anastomosis. Only one patient developed a leak at the anastomotic site, requiring pelvic abscess drainage and transverse loop colostomy. One death occurred 12 h following surgery. Autopsy confirmed that this was due to myocardial infarction. Mean hospital stay was 9·8 days. Conclusion Emergency surgery on the obstructed left colon can be carried out safely after decompression alone, without intraoperative colonic lavage.

The aqueous extract of C. papaya fruit (100 mg kg(-1) day(-1) for 10 days) was evaluated for its wound healing activity in streptozotocin-induced diabetic rats using excision and dead space wound models. Extract-treated animals exhibited 77% reduction in the wound area when compared to controls which was 59%. The extract treated wounds were found to epithelize faster as compared to controls. The wet and dry granulation tissue weight and hydroxyproline content increased significantly when compared to controls. The extract exhibited antimicrobial activity against the five organisms tested. Carica papaya promotes significant wound healing in diabetic rats and further evaluation of this activity in humans is suggested.

Objective Patients with end-stage renal failure and upper-extremity arterial occlusive disease sometimes have painful digital ulceration. We evaluated the efficacy of distal bypass grafting from the brachial artery for limb salvage in this setting. Methods All patients with end-stage renal disease with painful digital ulceration or gangrene of the hand seen from 1992 to 2002 were evaluated with clinical examination and noninvasive studies. Those with evidence of occlusive disease underwent conventional angiography. Individuals with forearm occlusive disease underwent bypass grafting, from the brachial artery to either the distal radial artery or ulnar artery at the level of the wrist or proximal hand. Follow-up was scheduled at regular intervals, and included duplex scanning. Limb salvage and bypass graft patency were determined with life table analysis. Results Over 10 years, 18 forearm bypass procedures were performed in 15 patients. The outflow artery was the radial artery in 15 procedures and the ulnar artery in 3 procedures. Bypass conduit was autogenous in all patients. No patient had a functioning arteriovenous fistula at bypass grafting; six limbs had previously occluded fistulas. Two bypass grafts (11%) occluded in the early postoperative period, with resultant progression of gangrene. In the remaining 16 grafts patency was maintained (mean follow-up, 18 months), with pain control and tissue healing. Conclusion Treatment in patients with renal failure with upper extremity occlusive disease may be facilitated with brachiodistal bypass grafting. Pain control and reversal of progression of hand necrosis can be achieved.

Rectus muscle haematoma is a well documented clinical entity, but its diagnosis remains elusive. A haematoma within the rectus sheath produces a painful, tender swelling that can mimic an intraperitoneal mass with features of an acute abdomen. Two patients with rectus haematomas presenting after bouts of prolonged coughing are reported. In both cases, clinical features and ultrasound findings suggested the presence of intraperitoneal pathology. However, in both cases consistent findings in the history and examination pointed towards the diagnosis of a rectus haematoma. It is proposed that these simple clinical criteria are diagnostic of a rectus sheath haematoma, and can thereby avert an unnecessary laparotomy.

Axillary vein thrombosis, or Paget von Sch- roetter syndrome, is a rare clinical condition. It is as- sociated with several thrombogenic states and numerous sporting activities involving excessive use of the arm. We report one such case associated with exotic dancing. In societies where dancing involves excessive arm move- ment, the physician must be aware of this condition to permit early diagnosis and effective treatment.

Midline laparotomy incision is generally closed as a continuous single layer with monofilament suture. To achieve safe abdominal closure, it is advised to have a suture:wound length (SL:WL) ratio of more than 4:1. The importance of a high SL:WL ratio led us to standardise a safe abdominal closure technique. We calculated the subsequent SL:WL ratio and support our finding with a mathematical model. Between March 1996 and February 1997, 100 consecutive patients undergoing elective or emergency laparotomy through a midline incision were entered into this prospective study. The wounds were closed with a single layer continuous suture to approximate the abdominal muscles. Suture and wound lengths were recorded. Patients were followed for one year. Five patients developed incisional hernia at 12 months postoperatively. There was no burst abdomen. The mean SL:WL ratio: was 6.2:1. A mathematical model confirms that a SL:WL ratio of 6:1 should be achieved with this suture technique. We recommend an optimal SL:WL ratio: greater than or equivalent to 6:1 to achieve safe closure of midline laparotomy incision.

A 52-year-old male weighing 74 kg presented with a twoday history of colicky pain in the supra-umbilical region. He complained of nausea and anorexia. On the day of presentation, his pain migrated to the right iliac fossa and became constant. Examination revealed a pulse of 90 bpm with a temperature of 98.7 F. He was found to be tender in the right iliac fossa with voluntary guarding and rebound. His white cell count was found to be 11.3 per m with a shift in the neutrophils to the left. His MANTREL score was estimated at 9. A mini-Lanz incision approach for appendicectomy was performed. Serosanguineous peritoneal fluid was noted on entering the cavity. The appendix was macroscopically noninflamed. Intraperitoneal ischemia was suspected at this time, and on mobilization of the intraperitoneal contents, a 1080 torsion of a 8 10 cm lip of omentum was noted (Fig. 1). The ischemic segment was excised between ligatures. An incidental appendicectomy was performed. The patient recovered uneventfully.

Blunt abdominal trauma with intraperitoneal injury usually presents acutely. On rare occasions, such patients can present later on with features of small bowel obstruction due to stricture formation. It is thought that such a delayed stricture is due to subclinical bowel perforation, localised gut ischaemia, or injury to the mesenteric vasculature. This case demonstrates the mesenteric vascular injury theory to be the cause of the bowel stricture.

We report the case of a 68-year-old male who presented to our emergency department with severe acute testicular pain and syncope. A precipitous fall in his hematocrit along with the presence of a pulsatile expansile abdominal mass prompted the diagnosis of ruptured aortic aneurysm (AAA). He underwent emergency repair of the AAA and was subsequently discharged after an uneventful hospital stay. Our case demonstrates an unusual presentation of ruptured AAA, which is potentially lethal if unrecognised.

Background In less than ideal situations wounds have to be closed without extensive cleaning using sterile adhesive strips (Steristrips). This prospective analyses the efficiency of this technique and compares it to the more conventional approach. Methods Altogether 147 lacerations were closed with sterile strips with no wound cleaning. Patients were subsequently followed up for a minimum of three months. Results The sepsis rate in compliant patients was 1.4% with a total complication rate of 2.7%. Conclusion This technique, while contradicting the “sacred tenets” of wound closure, is a cheap, quick, and effective alternative to routine closure of traumatic wounds in a casualty department.

Giant fibroadenomas can produce breast deformity and should be excised. Several techniques have been discussed, including a sub-mammary incision, which often leave a disfiguring scar. We describe a new technique for removal of such large masses via a small cosmetic circumareolar incision.

Peritoneal encapsulation is an exceedingly rare developmental abnormality in which the small intestine is encased in an accessory peritoneal sac between the omentum and mesocolon. Two clinical signs associated with the dense fibrous layer encapsulating the intestine are described. The first is a fixed, asymmetrical distension of the abdomen, which does not vary with peristaltic activity due to the unvarying position of the fibrous capsule. The second is the difference in the consistency of the abdominal wall to palpation. The flat area is firm, due to the dense fibrous capsule and the distended area soft, due to the thin walled distended small intestine with no overlying fibrous layer.

Our study showed that of the 300 consecutive people interviewed at the General Hospital at Port-of- Spain, Trinidad, most persons (80%) preferred to be called 'patients' as opposed to 7% choosing the term 'client' and 6% opting for the term 'customer'. This proves our hypothesis that in the developing world people prefer to maintain the doctor-patient relationship and leave the word 'client' and 'customer' for the businessman.