bluuebunny/crossref_metadata_2025 huggingface dataset:
Overexpression of p53 predicts shorter survival in diffuse type gastric cancer
Authors: Lee W-J , Shun C-T , Hong R-L , Wu M-S , Chang K-J , Chen K-M
Published: July 2002

Background

It has been suggested that p53 plays an important part in gastric carcinogenesis but the data remain inconclusive.

Methods

Alteration of the tumour suppressor gene p53 was prospectively investigated by immunohistochemistry in 168 primary gastric cancers.

Results

Positive staining, indicative of gene mutations, was detected in 34 tumours (20·2 per cent). No correlation was observed between expression of p53 and various clinicopathological factors, including age, sex, tumour site, gross type, tumour size, depth of invasion, lymph node metastases, distant metastases, and tumour node metastasis stage. However, p53 overexpression was different between intestinal and diffuse type gastric cancer. Survival analysis revealed a significant survival disadvantage of p53 expression in diffuse type gastric cancer (P = 0·039) but not in the intestinal type. Multivariate analysis of all 168 patients revealed that independent predictors of recurrent disease included age, invasion depth and nodal involvement but not p53 expression.

Conclusion

The presence of p53 overexpression may identify a subset of more aggressive tumours with a poor prognosis in diffuse type gastric cancer.
High prevalence of abdominal aortic aneurysm in a primary care screening programme
Authors: Boll A P M , Verbeek A L M , van de Lisdonk E H , van der Vliet J A
Published: July 2002

Background

The mortality rate associated with ruptured abdominal aortic aneurysm (AAA) remains high. The objective of this study was to assess the feasibility of population screening for AAA.

Methods

In an area with a mixed rural and industrialized population of 60 000 inhabitants, all 23 general practitioners (GPs) participated. The GPs selected from their patient lists men aged 60–80 years. Men whose condition was suitable for aortic surgery were invited for screening by a single postal letter. All men responding had aortic ultrasonography in or close to the GP surgery. Diagnosis of AAA was established when the aortic diameter was 30 mm or greater. Referral for surgery was advised for an aortic diameter of 50 mm or greater.

Results

Of 2914 invitations, 2419 men had ultrasonography, resulting in an attendance rate of 83·0 per cent. A total of 2416 aortic measurements were made; 196 aortic aneurysms were diagnosed (prevalence 8·1 per cent). In 40 men the aortic diameter was over 50 mm.

Conclusion

Ultrasonographic screening for AAA is feasible in a primary care setting.
Impaired healing of extraperitoneal intestinal anastomoses
Authors: Pierie J P E N , de Graaf P W , van Vroonhoven Th J M V , Renooij W , Obertop H
Published: July 2002

Background

The extra-anatomical position of a cervical oesophagogastrostomy might be a reason for impaired anastomotic healing.

Methods

This hypothesis was tested in a rat model. Jejunal resection with an end-to-end jejunojejunostomy was placed intra-abdominally in group 1 (n = 24) and subcutaneously in group 2 (n = 30). Jejunum without anastomosis was placed subcutaneously in group 3 (n = 12). After 3, 7 or 14 days the rats were killed; the bursting pressure of the anastomosis or jejunum was measured and the hydroxyproline level was determined.

Results

Two of 24 rats in group 1 and eight of 30 in group 2 died following anastomotic leakage (P not significant) and were excluded from other measurements. Bursting pressure was decreased after 3 days in group 1 (mean(s.e.) 62(10) mmHg) and group 2 (57(10) mmHg) compared with that in group 3 (204(17) mmHg) (P < 0·001). After 7 days, it was in the normal range in group 1 (200(14) mmHg), but lower in group 2 (104(15) mmHg) compared with that in group 3 (230(8) mmHg) (P < 0·001). Differences in hydroxyproline levels were not statistically significant between the groups after 3, 7 and 14 days.

Conclusion

Healing of jejunojejunostomies is impaired in an extraperitoneal position compared with an intra-abdominal position.
Hepatitis viral status in patients undergoing liver resection for hepatocellular carcinoma
Authors: Wu C-C , Ho W-L , Chen J-T , Tang J-S , Yeh D-C , P'eng F-K
Published: July 2002

Background

Hepatitis B and C viruses are the main causative agents of hepatocellular carcinoma (HCC). The influence of hepatitis viral status on liver resection for HCC remains undetermined.

Methods

Patients who underwent curative resection for HCC were divided into four groups: group 1, seronegative for hepatitis B surface antigen (HBsAg) and antihepatitis C antibody (HCVAb); group 2, seropositive for HBsAg only; group 3, seropositive for HCVAb only; and group 4, seropositive for HBsAg and HCVAb. The clinicopathological characteristics and surgical results of the four groups were compared. Resection of HCC was determined according to liver functional reserve and tumour extent.

Results

There were 40, 131, 70 and 20 patients in groups 1, 2, 3 and 4 respectively. Due to patient selection bias, there were significant differences in some background features, resectional extent and pathological characteristics among the four groups. Postoperative morbidity and mortality, as well as the Union Internacional Contra la Cancrum tumour node metastasis stages, did not differ. Patients in group 1 had a higher disease-free survival rate than those in group 2 (P = 0·02). The actuarial survival rates of patients in groups 2 and 4 were lower than those of groups 1 and 3.

Conclusion

With careful patient selection, the hepatitis viral status does not influence the surgical risks of hepatectomy for HCC. After liver resection for HCC, the long-term survival rate of patients seronegative for HBsAg is greater than that of patients seropositive for HBsAg.
Venous ulcer healing by four-layer compression bandaging is not influenced by the pattern of venous incompetence
Authors: Guest M , Smith J J , Sira M S , Madden P , Greenhalgh R M , Davies A H
Published: July 2002

Background

Previous studies have related deep venous incompetence to reduced venous ulcer healing rates. The aim of this study was to determine the relationship between the pattern of venous incompetence and ulcer healing.

Methods

A total of 198 legs with venous ulceration were investigated with colour venous duplex imaging to determine the presence and site of venous incompetence. All were treated initially with the four-layer bandage technique.

Results

At 6 months, 74 per cent of the venous ulcers had healed using the four-layer bandage technique. There was no significant correlation between the pattern of incompetence and the healing rate of the ulcer. Previous deep vein thrombosis (DVT), increased size of the ulcer and previous episodes of ulceration were associated with a poor healing rate.

Conclusion

The four-layer bandage technique achieved an ulcer healing rate of 74 per cent after 6 months, irrespective of the pattern of venous incompetence. Patients with a large ulcer, previous DVT or previous episodes of ulceration had delayed healing, supporting the previous literature.
Late results of a randomized clinical trial comparing total fundoplication versus calibration of the cardia with posterior gastropexy
Authors: Csendes A , Burdiles P , Korn O , Braghetto I , Huertas C , Rojas J
Published: July 2002

Background

The aim was to perform a prospective randomized study in patients with chronic gastro-oesophageal reflux treated either by total fundoplication or calibration of the cardia with posterior gastropexy. Late follow-up considered subjective and objective parameters, and related outcome to the presence of Barrett's oesophagus.

Methods

A total of 164 patients were randomized to fundoplication (n = 76) or calibration of the cardia (n = 88). They were evaluated by clinical questionnaire, upper gastrointestinal endoscopy with biopsies, oesophageal manometry and gastro-oesophageal reflux studies, including scintigraphy and 24-h oesophageal pH monitoring.

Results

There were no operative deaths. There was 95 per cent follow-up at a mean of 85 months. The mean recurrence rate for both operations was near 40 per cent at 10 years, but patients without Barrett's oesophagus had a recurrence rate after both operations of around 23 per cent compared with 83 per cent after 10 years for those with Barrett's oesophagus (P < 0·0001). Low-grade dysplasia developed in 13 per cent of the patients with Barrett's oesophagus. There were significant differences in all objective parameters in a comparison of patients with Visick I or II and those with Visick III or IV disease at the late assessment.

Conclusion

Both total fundoplication and calibration of the cardia with posterior gastropexy had similar subjective and objective late results. However, results were significantly worse in patients with Barrett's oesophagus.
Epidemiology of lower extremity amputation in centres in Europe, North America and East Asia
Authors:   The Global Lower Extremity Amputation Study Group, Unwin N
Published: July 2002

Background

This study was established to enable a comparison of lower extremity amputation incidence rates between different centres around the world.

Methods

Ten centres, all with populations greater than 200 000, in Japan, Taiwan, Spain, Italy, North America and England collected data on all amputations done between July 1995 and June 1997. Patients were identified from at least two data sources (to allow checks on ascertainment); denominator populations were based on census figures.

Results

The highest amputation rates were in the Navajo population (43·9 per 100 000 population per year for first major amputation in men) and the lowest in Madrid, Spain (2·8 per 100 000 per year). The incidence of amputation rose steeply with age; most amputations occurred in patients over 60 years. In most centres the incidence was higher in men than women and the incidence of major amputations was greater than that of minor amputations. Diabetes was associated with between 25 and 90 per cent of amputations.

Conclusion

Apart from the Navajo centre, differences in the known prevalence of diabetes could not account for the differences in overall incidence of amputation. Differences in the prevalence of peripheral vascular disease are likely to be important, but this and the role of other factors, including availability of health care, are worthy of further investigation.
Diagnostic accuracy of needle-localized open breast biopsy for impalpable breast disease
Authors: Verkooijen H M , Peeters P H M , Pijnappel R M , Koot V C M , Schipper M E I , Rinkes I H M Borel
Published: July 2002

Background

Needle-localized open breast biopsy (NLBB) is considered the gold standard procedure for the diagnosis of impalpable breast disease. In an observational follow-up study the sensitivity and negative predictive value of this procedure was determined in a clinical population with long-term follow-up.

Methods

Some 199 consecutive patients with a benign histological diagnosis on NLBB were followed for the occurrence of breast cancer, using information from the Dutch National Morbid-Anatomical Record Department. Based on a review of mammograms and histological slides, an expert panel decided whether the carcinomas detected during follow-up were newly developed, or were present already at the time of the NLBB.

Results

After a median follow-up of 60·5 months, seven carcinomas were detected. At panel review, six appeared to have been missed by NLBB. The sensitivity of NLBB was 99 per cent after 2 years of follow-up, but dropped to 96 per cent after 5 years. Similarly, the negative predictive value dropped from 99 per cent after 2 years to 94 per cent after 5 years of follow-up.

Conclusion

NLBB is an accurate diagnostic procedure for the evaluation of impalpable breast disease. However, with longer follow-up the accuracy becomes lower than generally reported.
Extending the indications for curative liver resection by portal vein embolization
Authors: Seymour K , Charnley R M , Rose J , Baudouin C J , Manas D M
Published: July 2002

Aims

The aim of ipsilateral portal vein embolization is to induce hypertrophy of normal tissue when resection of a cancerous portion of the liver is contraindicated only by the volume of liver that would remain following surgery. This study reports its use in primary and metastatic liver tumours.

Methods

Eight patients with inoperable liver tumours (three women and five men of median age 68·5 years; three colorectal hepatic metastases, two cholangiocarcinomas and three hepatocellular cancers) were selected for portal vein embolization. Selected portal branches were occluded distally with microbeads and proximally with coils. Liver volumes were determined by magnetic resonance imaging before embolization and again before surgery, 6–8 weeks later.

Results

Embolization was performed successfully in seven patients by the percutaneous–transhepatic route; one further patient required an open cannulation of the inferior mesenteric vein. Management was altered in six patients, who proceeded to ‘curative’ surgery. The projected remaining (predominantly left lobe) liver volumes increased significantly from a median of 350 to 550 ml (P < 0·05, Wilcoxon matched pairs test). Two patients had disease progression such that surgery was no longer indicated. One patient, whose disease progressed, had the left portal branch occluded unintentionally by a misplaced coil that was successfully retrieved, although the left portal branch remained occluded.

Conclusions

Portal vein embolization produced significant hypertrophy of the normal liver and extended the option of ‘curative’ surgery to six of the eight patients in whom it was attempted. It appears to be equally effective for primary and metastatic liver tumours in selected patients.
Laparoscopic splenectomy: a suitable technique for children and adults
Authors: Wheatley T J , Johnstone J M S , Robertson G S M , Hutchinson M , Wood J K , Lloyd D M
Published: July 2002

Aims

Splenectomy retains an important role in the management of certain haematological conditions that fail to respond to conventional medical therapy, and has traditionally been performed through a midline or left subcostal incision with patients requiring 5–7 days in hospital. The well recognized benefits of laparoscopic surgery should also apply to splenectomy. This study aimed to develop a safe and effective technique suitable for all age ranges and without the requirement for expensive stapling devices.

Methods

An operative technique evolved over the 5-year period from 1994, from an initial six-port approach with the patient supine, to a four-port approach in a modified right lateral position, with locking surgical clips applied down a 5-mm port to vessels in the hilum, and removal of the spleen within a retrieval bag through a 4–6-cm Pfannanstiel incision. Data were collected prospectively for all patients undergoing laparoscopic splenectomy at Leicester Royal Infirmary, including demographic details, indication for surgery, duration of surgery, length of inpatient stay, transfusion requirement, postoperative complications and the response of the original condition to surgical intervention.

Results

A total of 40 patients underwent laparoscopic splenectomy (14 children, 26 adults) for a variety of conditions (idiopathic thrombocytopenia (ITP) (n = 24), haemolytic anaemia (n = 9) or malignancy (n = 7)) with a median operating time of 180 min for the first 20 patients and 100 min for the second 20 (P < 0·0001), and median inpatient stay of 3 days for the first 20 patients and 2 days for the second 20 (P < 0·0003). None of the operations was converted to open surgery, five patients required blood and/or platelet transfusion perioperatively, none of the patients had major postoperative complications, 23 of the 24 patients with ITP developed normal platelet counts after operation, and all nine patients with haemolytic anaemia maintained a normal haemoglobin concentration after operation.

Conclusions

Laparoscopic splenectomy can be performed safely and effectively in adults and children without the need for stapling devices.
Morbidity and mortality of inadvertent enterotomy during adhesiotomy
Authors: van der Krabben A A , Dijkstra F R , Nieuwenhuijzen M , Reijnen M M P J , Schaapveld M , van Goor H
Published: July 2002

Background

Inadvertent enterotomy is a feared complication of adhesiotomy during abdominal reoperation. The nature and extent of this adhesion-associated problem are unknown.

Methods

The records of all patients who underwent reoperation between July 1995 and September 1997 were reviewed retrospectively for inadvertent enterotomy, risk factors were analysed using univariate and multivariate parameters, and postoperative morbidity and mortality rates were assessed.

Results

Inadvertent enterotomy occurred in 52 (19 per cent) of 270 reoperations. Dividing adhesions in the lower abdomen and pelvis, in particular, caused bowel injury. In univariate analysis body mass index was significantly higher in patients with inadvertent enterotomy (mean(s.d.) 25·5(4·6) kg/m2) than in those without enterotomy (21·9(4·3) kg/m2) (P < 0·03). Patient age and three or more previous laparotomies appeared to be independent parameters predicting inadvertent enterotomy (odds ratio (95 per cent confidence interval) 1·9 (1·3–2·7) and 10·4 (5·0–21·6) respectively; P < 0·001). Patients with inadvertent enterotomy had significantly more postoperative complications (P < 0·01) and urgent relaparotomies (P < 0·001), a higher rate of admission to the intensive care unit (P < 0·001) and parenteral nutrition usage (P < 0·001), and a longer postoperative hospital stay (P < 0·001).

Conclusion

The incidence of inadvertent enterotomy during reoperation is high. This adhesion-related complication has an impact on postoperative morbidity.
Prognostic significance of oestrogen receptor β in breast cancer
Authors: Speirs V , Kerin M J
Published: July 2002

Background

Endocrine therapy for breast cancer is now well established and with the identification of a second oestrogen receptor, ERβ, 3 years ago it is timely to review the possible significance of this receptor in breast cancer management.

Methods

An up-to-date review of the current literature concerning the role and possible implications of ERβ in human breast cancer was undertaken.

Results

Wild-type and variant ERβ are expressed in human breast tumours. Expression of ERβ correlates with accepted prognostic indicators including lymph node status and tumour grade. Furthermore, levels of ERβ messenger RNA alter during carcinogenesis and are upregulated in breast tumours that develop antioestrogen resistance.

Conclusion

ERβ has potential as a novel clinical prognostic marker in breast cancer, particularly in determining tumours that are resistant to tamoxifen.
Non-operative treatment of abdominal gunshot injuries
Authors: Saadia R , Degiannis E
Published: July 2002

Background

Non-operative treatment is a management option that challenges the traditional mandatory laparotomy for abdominal gunshot injuries.

Methods

All published relevant clinical reports were retrieved by searching through the Medline database and manually. The theoretical arguments in favour of non-operative management as well as the results of the reviewed reports are analysed and evaluated.

Results and conclusion

Patients with proven non-penetration of the abdominal cavity can be offered conservative treatment with a satisfactory outcome. Greater caution should be exercised in the presence of a documented visceral injury until the safety of this option has been established by further clinical trials.
Role of the neutrophil in the development of sepsis following abdominal aortic aneurysm surgery
Authors: Spark J I , Chetter I C , Kester R C , Scott D J A
Published: July 2002

Background

There is evidence to suggest that the neutrophil (PMN) plays a critical early step in development of the ischaemia–reperfusion syndrome and sepsis. Not all patients undergoing aortic aneurysm repair develop these postoperative complications. The PMN receptor CD16 plays an important role in phagocytosis, cell-mediated cytotoxicity and the release of free radicals and proteolytic enzymes. This study determined if there is any relationship between PMN CD16 expression, phagocytosis and the development of sepsis.

Methods

Some 50 patients (39 men and 11 women, median age 70 years) who underwent elective infrarenal abdominal aortic aneurysm repair were studied. Venous blood was taken before operation, throughout surgery and for 7 days afterwards. CD16 was measured, unstimulated and following further stimulation with phorbol myrisate, lipopolysaccharide and N-formyl-methionyl-leucyl-phenylalanine using flow cytometry. Phagocytosis was measured using flow cytometry and the production of elastase using an enzyme-linked immunosorbent assay. Sepsis was defined according to the ACCP/SCCM definition.

Results

There were 36 uncomplicated operations and 14 patients with sepsis. There was no difference between the two groups in respect of nutritional, co-morbid or technical factors. In the group that developed septic complications, the level of PMN CD16 expression was significantly higher before operation (30·2 versus 10·4 mcf; P < 0·05, Mann–Whitney U test) and throughout the postoperative period. Surgery produced no change in CD16 expression in either the septic or uncomplicated group. Stimulation of the PMNs before operation caused an increase in CD16 expression in both groups. After operation, stimulation of PMNs in the septic group resulted in a fall in CD16 expression (40·8 versus 20·4 mcf; P < 0·05, Mann–Whitney U test); surgery produced no change in the level of expression in the uncomplicated group. Phagocytic ability was comparable before operation (91·2 versus 94·2 mcf), but showed a greater reduction in the septic group after operation (73·4 versus 86·2 mcf; P < 0·05, Mann–Whitney U test). Elastase concentration was also similar before operation (48 versus 49 μg l−1); after operation, there was a greater increase in the septic group (166 versus 104 μg l−1; P < 0·05, Mann–Whitney U test).

Conclusion

This study provides evidence of functional differences in PMN behaviour in patients who subsequently develop sepsis following aneurysm surgery. This difference occurs early in the postoperative course and it may be possible to identify these patients before operation.
Prospective comparison of recurrent venous ulceration after superficial surgery or compression bandaging
Authors: Bello A M , Wheatley C , Scriven M , London N J M
Published: July 2002

Background

The purpose of this prospective study was to investigate and compare the recurrence rate of venous ulcers treated by superficial surgery or compression bandaging.

Methods

Patients received treatment for ulcers between May 1994 and July 1997. All legs in the study had an ankle: brachial pressure index above 0·8. The superficial surgery group consisted of 91 legs with superficial venous incompetence and normal deep veins which healed after superficial surgery. This group did not receive postoperative compression bandaging or hosiery. The community compression bandaging group consisted of 152 legs that healed during the recruitment period. A recurrent ulcer was defined as a further episode of venous ulceration in a previously healed leg. Patient follow-up was by surgeons, district nurses' telephone call and/or letter. Recurrence rates were calculated by life-table analysis (Kaplan–Meier). Patients who died or were lost to follow-up were censored to their last visit.

Results

The recurrence rate in the superficial surgery group at 1 and 2 years was 3 and 6 per cent respectively, compared with 26 and 33 per cent respectively in the compression bandaging group. The differences between the superficial surgery and compression bandaging groups were statistically significant (P = 0·00001, log rank test).

Conclusion

Ulcer healing after superficial surgery is sustained in the absence of postoperative compression. Conversely, the ulcer recurrence rate after compression bandaging is very high, probably because the underlying venous abnormality has not been corrected. The follow-up of this study needs to be continued to 5 years, but the data so far suggest that a prospective randomized study comparing superficial surgery with compression bandaging is required.
In major limb vessel trauma, reperfusion injury is increased by delayed venous reflow and prevented by antioxidant pretreatment
Authors: Harkin D W , Barros D'sa A A B , Mirakhur M , Halliday M I , Parks T G
Published: July 2002

Background

Clinical experience of the early use of intraluminal shunts in major limb trauma at this centre aimed at restoring arterial inflow and venous outflow has been shown to reduce amputation rates and morbidity. In a model of combined arterial and venous limb vessel trauma, ischaemia–reperfusion injury caused by delayed restoration of venous drainage locally on skeletal muscle and remotely on lung was studied. Furthermore, using antioxidant pretreatment the possibility of reversing these detrimental effects was investigated.

Methods

New Zealand white rabbits (n = 36) were randomized into six groups: (1) sham operation; unilateral hind limb arterial and venous occlusion for 1 h followed by (2) no reflow for 2 h; (3) arterial and venous reflow for 2 h; (4) arterial reflow alone for 2 h; (5) arterial reflow for 1 h followed by arterial and venous (delayed) reflow for a further 1 h; (6) pretreatment with an enteral combination antioxidant before combined arterial and venous occlusion with delayed venous reflow. Plasma hydroperoxide (HPO) concentration in the femoral vein was a measure of lipid peroxidation. Hindlimb skeletal muscle and lung wet-to-dry weight ratio reflected tissue oedema, and myeloperoxidase (MPO) tissue levels estimated neutrophil sequestration. Plasma glutathione peroxidase (GPx) levels in systemic vein (SV) and femoral vein effluent (FV) reflected antioxidant status. Hindlimb skeletal muscle injury was graded histologically.

Results

Conclusion

In combined major arterial and venous vessel injury of the limb, delayed venous repair leads to significantly greater local skeletal muscle injury and remote neutrophil-mediated lung damage. Reversal of these detrimental effects with antioxidant pretreatment suggests that failure of antioxidant scavenging systems may be central to the injury accentuated by delayed venous drainage. These results support the clinical rationale for early restoration of not only arterial inflow but also venous drainage by intraluminal shunts.
Smoking, cadmium accumulation and aortic aneurysm
Authors: Jones K G , Abu-Hayyeh S , Sian M , Powell J T
Published: July 2002

Background

Smoking is an important risk factor for abdominal aortic aneurysm (AAA), a disorder associated with loss of medial smooth muscle cells. Cadmium, one of the toxic components inhaled in cigarette smoke, is known to alter the metabolism of aortic smooth muscle cells. This was an investigation of the hypothesis that excess cadmium accumulation in the abdominal aorta is associated with the development of aneurysms.

Methods

Samples of abdominal aorta were obtained at the time of surgery from 12 patients with AAA (seven men and five women, mean age 72 years) and at autopsy from 17 patients (ten men and seven women, mean age 76 years) with an undilated aorta (diameter 1·6–2·2 cm). The smoking history of all patients was noted. The aorta was dissected into three layers, intima, media and adventitia; each was dried to a constant weight, hydrolysed and cadmium was measured by atomic absorption spectrometry. In separate experiments 5-bromo-2′-deoxyuridine uptake and picogreen assay of DNA were used to investigate the effect of cadmium on the proliferation of cultured aortic smooth muscle cells.

Results

The mean(s.e.) cadmium content of the intima, media and adventitia was 1·14(0·24), 3·25(0·53) and 1·87(0·38) ng per mg dry weight respectively; the medial concentration was significantly higher than the concentration in the other two layers (P < 0·005). The medial cadmium content was similar in AAA and normal diameter aortas: 3·65(1·00) and 2·97(0·59) ng per mg dry weight respectively. Only trace amounts of cadmium were present in the aorta of those who had never smoked and there was a strong positive association between medial cadmium content and pack-year history of smoking (rs = 0·87, P < 0·001). Cadmium inhibited the proliferation of smooth muscle cells cultured on polymeric collagen, 5-bromo-2′-deoxyuridine uptake (IC50 1·4 nmol l−1) and DNA content (IC50 6·3 nmol l−1). Cadmium was less toxic, by more than tenfold, to smooth muscle cells cultured on fibronectin, monomeric collagen or plastic.

Conclusion

Cadmium accumulates selectively in the medial layer of the abdominal aorta of smokers, where it may inhibit DNA synthesis and proliferation of smooth muscle cells. The toxic effects of cadmium on cultured smooth muscle cells depend on their underlying matrix and this may explain why the accumulation of cadmium in aortic media was not associated with the development of aneurysms.
‘Kissing stent’ insertion is not safe or durable
Authors: Brittenden J , Ingram S , Beattie G , Bradbury A W
Published: July 2002

Background

The morbidity, and clinical and haemodynamic outcome of kissing stent insertion was assessed.

Methods

A prospectively gathered database of endovascular procedures performed between 1 January 1993 and 31 December 1998 was analysed.

Results

Bilateral kissing stents were deployed in 12 patients (median age 62 (range 43–67) years; five men and seven women). Indications were bilateral intermittent claudication (IC) in nine patients, unilateral IC with contralateral rest pain in two and bilateral rest pain/tissue loss in one. Major morbidity occurred in three patients and comprised bilateral distal iliac dissection (treated medically), distal embolization (thrombolysis and suction aspiration) and false aneurysm (surgical repair). All patients reported an immediate improvement in symptoms. However, at a median (range) follow-up of 27 (3–70) months, symptoms have deteriorated in 13 legs, the ankle: brachial pressure index has fallen by more than 0·15 (with respect to values immediately after the procedure) in 15 legs, six stents have occluded (bilaterally in two patients, unilaterally in two) and four stents have stenosed significantly (greater than 50 per cent). Four patients have undergone aortobifemoral grafting and one further patient has undergone bilateral amputation following failed revascularization necessitated by stent thrombosis.

Conclusion

In contrast to the single previously published series of 20 patients which found the technique to be ‘effective’ with ‘few serious adverse events’, present data suggest that kissing stents are associated with significant morbidity and a poor outcome.
Combined surgical and radiological procedures
Authors: Dunlop P , Owen R , Gett S K , Akomolafe A B , Wilson L , Rose J D G , Jones N A G , Lambert D , Wyatt M G , Lees T A
Published: July 2002

Background

The aim was to audit the effect of provision of an interventional theatre on the management of vascular disease in a tertiary centre.

Methods

All patients undergoing joint vascular surgical and radiological procedures during 20 months were reviewed. Data are presented with respect to type of procedure, initial success and length of hospital stay.

Results

Between October 1997 and July 1999, 100 combined procedures were performed in an endovascular operating theatre. Sixty of these were for stent-graft repair of abdominal aortic aneurysm and are excluded from further analysis. Forty patients (23 men and 17 women, of median age 65 (range 37–80) years) underwent combined procedures for claudication (nine), rest pain (13), tissue necrosis (five), acute ischaemia (seven), iliac aneurysm (three), amaurosis fugax (one), arteriovenous malformation (one) and subclavian vein occlusion (one).

Combined intervention was successful initially in 35 patients. Of the five failures, three were technical (not possible to cross an occluded vessel) and two were due to absence of run-off vessels. There was no perioperative death. Median hospital stay was 9 (range 1–116) days.

Conclusion

These data confirm that patients requiring both radiological and surgical intervention can be treated successfully within the confines of an interventional operating suite. Cooperation and coordination between surgeon and radiologist allows the tailoring of procedures to the individual patient's needs.
Upper limb arterial injuries: experience of 713 patients and analysis of risk factors associated with limb loss
Authors: Hafez H M , Woolgar J , Robbs J
Published: July 2002

Background

Experience of upper limb arterial injury management was analysed and risk factors associated with limb loss were identified.

Methods

Between 1987 and 1997, data on 713 patients with 760 upper limb arterial injuries were analysed retrospectively.

Results

The mechanism of injury was stabbing in 52 per cent, gunshot in 23 per cent, blunt trauma in 14 per cent and shotgun in 5 per cent. The most frequently injured vessel was the brachial artery (53 per cent) followed by the axillary (20 per cent), subclavian (14 per cent), radial (7 per cent) and ulnar (6 per cent) arteries. Associated injuries included bony injury in 12 per cent, nerve injury in 39 per cent and remote injury affecting the head, chest or abdomen in 3 per cent. Surgical revascularization was carried out in 95 per cent of patients and arm fasciotomy was necessary in 9 per cent. The limb salvage rate for this series was 96 per cent (27 amputations) and the survival rate was 98 per cent (11 deaths). On stepwise logistic regression analysis, significant (P < 0·01) independent risk factors for amputation were blocked graft (odds ratio (OR) 7·6), tense compartment at presentation (OR 6·5), neurological deficit at presentation (OR 5·4) and associated compound fracture (OR 5·4).

Conclusion

Despite good collateral circulation, upper limb arterial injuries carry a considerable risk of limb loss, particularly when associated with soft tissue damage.
Staged in situ bypass
Authors: Ojimba T A , Garnham A W , Samman Y , Simms M H
Published: July 2002

Background

After femoral revascularization, following embolectomy or proximal reconstruction, the need for additional distal revascularization may be unpredictable. This dilemma may be addressed by anastomosing the detached upper end of the long saphenous vein to the femoral arteriotomy, as for in situ bypass, permitting some outflow into proximal vein tributaries. Later, if ischaemia persists, distal arterial flow can be established by closed retrograde saphenous valvulotomy.

Methods

Over 12 years this technique was employed in 26 legs in 22 patients, following inflow reconstruction in 15 and femoral embolectomy in seven. Postoperative observation showed persisting distal ischaemia in 14 legs and distal bypass was completed after 1–9 days, using local anaesthesia without femoral re-exposure. One patient died at 15 days and 13 grafts were patent on discharge from hospital.

Results

In 12 legs in 11 patients, limb perfusion was deemed adequate after operation. Four patients (five legs) died in hospital and seven were discharged. No further procedure was required in five and the proximal long saphenous vein presumably thrombosed. In two legs the whole long saphenous system had become pulsatile at 7 and 8 months, and a distal bypass was completed. No amputations were required in this series.

Conclusion

Staged in situ bypass can avoid prolonged and complex reconstructions in frail patients and facilitates the use of local anaesthesia, where necessary.
Randomized prospective study comparing pre-emptive epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation
Authors: Lambert A W , Dashfield A , Cosgrove C , Wilkins D C , Walker A J , Ashley S
Published: July 2002

Background

The reported incidence of phantom limb pain (PLP) following amputation is up to 85 per cent. This study was designed to compare the efficacy of two perioperative analgesic techniques with respect to postoperative stump pain (POSP) and PLP.

Methods

Patients were randomized prospectively. Group 1 received a pre-emptive epidural for a minimum of 24 h before surgery which was continued after operation. Group 2 had intraoperative placement of a perineural catheter for the administration of local anaesthetic by infusion after operation. All amputations were performed under general anaesthesia. POSP was assessed by visual analogue score (VAS), ranging from 0 to 10. The presence of PLP was assessed 6 and 12 months after operation.

Results

A total of 30 patients were recruited, 12 men and 18 women, of median age 74 (range 47–93) years. Each group was well matched for concurrent cardiovascular disease and the level of amputation. VAS at 6 h, 1, 2 and 3 days after operation was significantly less in group 1 than group 2 (P < 0·05, two-sample t test). Six patients died in each group and one was lost to follow-up. The overall incidence of PLP was 75 per cent at 6 months and 44 per cent at 12 months, with no significant difference between the two groups.

Conclusion

In this series, pre-emptive epidural analgesia significantly reduced the severity of POSP. The incidence of PLP remains disappointingly high regardless of the analgesic technique used.
Impact of a lifestyle clinic on vascular workload: analysis of factors predicting a successful outcome
Authors: Olojugba D H , Vallabhaneni R , McCormick S , Reilly D T , Blair S D , Greaney M G
Published: July 2002

Background

Regular exercise and risk factor control has been shown to treat patients with intermittent claudication effectively; however, patients are often non-compliant and never achieve the full benefits of a conservative approach. In this vascular unit, a nurse-led lifestyle intervention clinic has been established with the aim of optimizing the conservative management of such patients. The aim of this study was to assess the short-term impact of this strategy on radiological and operative vascular workload since its introduction in 1997, and to identify factors predictive of a successful conservative outcome.

Methods

The number of operative and radiological lower limb interventional procedures performed between January 1996 and January 1999 was obtained from departmental databases. The details of 145 consecutive referrals to the claudication clinic were also retrieved. These details were entered into a separate database for analysis. The factors analysed included age, sex, duration of symptoms, ankle: brachial pressure index and maximal walking distance at the start of the programme, co-morbid problems, smoking history and attendance. The outcome was change in claudication distance after 3 months of therapy. Analysis was performed using logistic and multiple linear regression models.

Results

Open revascularization procedures reduced from 104 in 1996 to 52 in 1998, femoral-to-popliteal bypass procedures reduced from 66 to 18. Iliac and lower limb angioplasties reduced from 133 to 101, and there were 53 major lower limb amputations in 1996 compared with 58 in 1998. The lifestyle clinic achieved a 36 per cent smoking cessation rate. Change in claudication distance ranged from −51 to 3100 (median 126) per cent. None of the factors analysed could significantly predict a successful outcome.

Conclusion

Lifestyle management is an effective strategy in management of claudicants. It can also reduce interventional vascular workload. The prediction of a successful outcome in individual patients may not be possible.
Modelling the effects of the reorganization of vascular services
Authors: Michaels J , Palfreyman S , Shackley P , Slack R , Brazier J
Published: July 2002

Background

Vascular services are currently in a state of evolution in many areas. A study has been carried out to model the economic and outcome implications of possible reconfiguration of vascular services.

Methods

Computer modelling was carried out based on an urban area with a teaching hospital (TH) and four surrounding district hospitals (DGHs) serving a population of 1·8 million. Data for the model were derived from a number of sources including local activity analysis, record linkage for cross-boundary flows, local audit, prospective surveys and systematic literature reviews.

Results

Analysis demonstrated a number of key differences in service provision between the TH and DGHs which were consistent with findings from literature reviews. These included differences in the use of endovascular treatments and femorodistal bypass, differences in case-mix and rates of particular procedures, and differences in outcome as measured by mortality and amputation rates. Computer modelling examined a number of options for the reconfiguration of services, including variations on fully centralized and hub and spoke arrangements. Cost estimates suggested that centralization and hub and spoke would result in an increased cost of £1 240 000–1 430 000 per year for the entire service, with over 80 per cent of these costs being related to expected increases in activity. Consideration of a number of key areas suggested that the resultant changes would save approximately 20 lives, 65 amputations and seven strokes per year for the population under consideration.

Conclusion

Reconfiguration of vascular services is likely to be highly cost effective. There is little difference in expected cost and outcomes between fully centralized and hub and spoke arrangements but the latter is preferred on the basis of decreased shift of resources and strong patient preference for local services.
Comparison of cognitive function and quality of life after endovascular or conventional aortic aneurysm repair
Authors: Lloyd A J , Boyle J , Bell P R F , Thompson M M
Published: July 2002

Introduction

The long-term effects of endovascular aortic aneurysm repair on cognitive function and quality of life are not known.

Methods

The cognitive function and quality of life of 82 patients undergoing aortic aneurysm repair (34 endovascular and 48 conventional procedures) were assessed before and 6 months after operation. Cognitive function was quantified using a battery of psychometric tests. Quality of life was assessed with the Medical Outcomes Short Form 36 (SF-36) questionnaire.

Results

Data at 6 months were available for 78 per cent of patients. As a group the patients showed a significant decline on one cognitive function test (visual search) and on two domains of the SF-36 (physical function and vitality) when they were reassessed. There were no significant differences between patients undergoing endovascular or conventional aneurysm repair after 6 months in cognitive function or quality of life.

Conclusion

Endovascular aneurysm surgery had a similar impact on health-related quality of life and cognitive function compared with conventional aneurysm repair. Patients in both groups demonstrated a significant decline in cognitive function.
Venous ulcer healing by four-layer compression bandaging is not influenced by the pattern of venous incompetence
Authors: Barwell J , Whyman M R , Poskitt K R
Published: July 2002

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Clinical presentation of the pseudomyxoma peritonei syndrome
Authors: Esquivel J , Sugarbaker P H
Published: July 2002

Background

Pseudomyxoma peritonei syndrome is characterized by a gradual expansion of mucoid tumour and fluid at specific sites within abdominopelvic regions as a result of a perforated appendiceal adenoma. The aim was to analyse the presenting symptoms and signs of patients with this condition.

Methods

Of 410 patients with appendiceal tumours 217 had the diagnosis of pseudomyxoma peritonei syndrome with histological confirmation. A retrospective review of the clinical characteristics that determine presentation was performed.

Results

Overall, suspected acute appendicitis was the most common presentation (27 per cent). For women the diagnosis was most commonly made while being evaluated for an ovarian mass (39 per cent). Increasing abdominal girth was the second most common presentation overall (23 per cent). Thirty patients (14 per cent) presented with new-onset hernia, of which the majority (26) were inguinal hernias.

Conclusion

Consideration of appendicitis, increased abdominal girth, ovarian mass and new-onset hernia as caused by this syndrome may facilitate diagnosis and definitive treatment.
Localization of matrix metalloproteinase 2 within the aneurysmal and normal aortic wall
Authors: Crowther M , Goodall S , Jones J L , Bell P R F , Thompson M M
Published: July 2002

Background

Current research has shed new light on the role of matrix metalloproteinase (MMP) 2 in the development of abdominal aortic aneurysms (AAAs). MMP-2 is a major protease in the wall of small aneurysms and is produced at increased levels by smooth muscle cells derived from AAAs compared with normal controls. In vivo, MMP-2 is produced as an inactive proenzyme that is activated predominantly by the cell membrane-bound enzyme, membrane type 1 matrix metalloproteinase (MT1-MMP). This study investigated the production of the MMP-2–MT1-MMP–tissue inhibitor of metalloproteinases (TIMP) 2 system within the wall of aortic aneurysms and in age-matched control arterial tissue.

Methods

Arterial tissue from four patients with aortic aneurysms and four age-matched aortic samples was examined for the production and expression of MMP-2, TIMP-2 and MT1-MMP protein using immunohistochemistry, in situ hybridization and in situ zymography.

Results

All components of the MMP-2–TIMP-2–MT1-MMP enzyme system were detected in the arterial wall of both aneurysm and control samples, specifically in the medial tissue. The enzymes co-localized with medial smooth muscle cells. Gelatinolytic activity was localized to elastin fibres in normal and aneurysmal aorta.

Conclusion

The presence of MT1-MMP within the media of arterial tissue suggests a powerful pathway for the activation of MMP-2. The localization of the MMP-2–TIMP-2–MT1-MMP enzyme system to the medial layer of the arterial wall gives support to the concept that this system may play an aetiological role in the pathogenesis of AAAs.
Randomized controlled trial of the effect of early enteral nutrition on markers of the inflammatory response in predicted severe acute pancreatitis
Authors: Powell J J , Murchison J T , Fearon K C H , Ross J A , Siriwardena A K
Published: July 2002

Background

Recent evidence suggests that intestinal dysfunction has a role in sustaining the systemic inflammatory response in acute pancreatitis and may be ameliorated by the introduction of enteral nutrition. This study therefore assessed the effect of early enteral nutrition on the systemic inflammatory response in patients with prognostically severe acute pancreatitis.

Methods

Patients with prognostically severe acute pancreatitis within 72 h of disease onset were randomized to receive either enteral nutrition or conventional therapy consisting of a nil-by-mouth regimen. Serum interleukin (IL) 6, soluble tumour necrosis factor receptor I (sTNFRI) and C-reactive protein (CRP) were used as markers of the inflammatory response. Intestinal function was assessed using a differential sugar permeability technique.

Results

Of 27 patients, 13 received enteral nutrition. A median of 21 (range 0–100) per cent of calorific requirements was delivered over the first 4 days by enteral nutrition. There were no significant complications of enteral nutrition. The introduction of enteral nutrition did not affect the serum concentrations of IL-6 (P = 0·28), sTNFRI (P = 0·53) or CRP (P = 0·62) over the first 4 days of the study. Although there were no significant differences in intestinal permeability between the two patient groups at admission (χ2 = 2·33, d.f. = 1, P = 0·13), by day 4 abnormal intestinal permeability occurred more frequently in patients receiving enteral nutrition (χ2 = 4·94, d.f. = 1, P = 0·03)

Conclusion

Early enteral nutrition did not ameliorate the inflammatory response in patients with prognostically severe acute pancreatitis. Furthermore, it did not have a beneficial effect on intestinal permeability.