bluuebunny/crossref_metadata_2025 huggingface dataset:
Prospective study of primary anastomosis following sigmoid resection for suspected acute complicated diverticular disease
Authors: Gooszen A W , Tollenaar R A E M , Geelkerken R H , Smeets H J , Bemelman W A , Van Schaardenburgh P , Gooszen H G
Published: March 2003

Background

A primary anastomosis after resection of the sigmoid colon for suspected acute complicated diverticular disease has the advantage of saving the patient a secondary operation for restoring bowel continuity. Fear of anastomotic leakage often deters surgeons from making a primary anastomosis.

Methods

A series of 45 patients who underwent primary anastomosis was studied prospectively to evaluate the feasibility of a primary anastomosis following acute sigmoid resection. Acute Physiology and Chronic Health Evaluation (APACHE) II score, Mannheim Peritonitis Index (MPI) and Hughes' peritonitis classification were used to classify patients and to detect factors predictive of postoperative outcome. Death, anastomotic leakage and septic complications were main outcome measures.

Results

Neither anastomotic leakage (four of 45 patients) nor death (three of 45) was related to a higher MPI, APACHE II or Hughes' score. More postoperative septic complications were seen in patients with a MPI over 16. Death, anastomotic leakage, reintervention and wound infection were observed more frequently in patients who presented with colonic obstruction than in those with abscess or perforation.

Conclusion

Primary anastomosis is safe and effective in non-obstructed cases of complicated diverticular disease. Colonic obstruction seems to be a risk factor for the development of postoperative complications.
Endoscopic axillary surgery in breast cancer
Authors: Kuehn T , Santjohanser C , Grab D , Klauss W , Koretz K , Kreienberg R
Published: March 2003

Background

The aim was to provide an assessment of the current status of endoscopic axillary surgery in patients with breast cancer.

Methods

Fifty-three patients underwent endoscopic lymphadenectomy. The surgical efficiency (operating time, number of resected nodes, intraoperative and postoperative complications), short-term morbidity (duration of drainage, total lymph flow, seroma rate) and long-term outcome (pain, numbness, mobility, strength, oedema) were assessed. The incidence and severity of different arm symptoms were compared with the results of 396 patients treated with a conventional axillary procedure. Finally, all available data relating to endoscopic axillary surgery were reviewed.

Results

The operating time ranged from 60 to 150 min. A mean 17 (range 10–28) lymph nodes was resected. The extent of postoperative lymphorrhoea (mean 372 ml) and the seroma rate (eight of 34 patients) were not significantly reduced in comparison with conventional surgery. The assessment of long-term morbidity revealed fewer disturbances of sensitivity and a decreased rate of severe symptom intensity for pain, oedema and complaints related to mobility.

Conclusion

Despite excellent visualization of anatomical landmarks and improved long-term morbidity, endoscopic lymph node dissection cannot be regarded as a suitable technique for routine axillary management in breast cancer because of long operating times.
Quality of life as an outcome measure in surgical oncology
Authors: Langenhoff B S , Krabbe P F M , Wobbes T , Ruers T J M
Published: March 2003

Background

There is a growing interest in assessing the impact of a disease and the effect of a treatment on a patient's life, expressed as health-related quality of life (HRQoL). HRQoL assessment can provide essential outcome information for cancer surgery.

Methods

The core of this review is derived from a literature search of the Medline database.

Results

Three types of HRQoL instrument can be distinguished: generic, disease specific and symptom specific. There are criteria against which HRQoL instruments may be evaluated. The instrument chosen must be reliable, valid and sensitive to change.

Conclusion

HRQoL measurement may be useful in identifying the optimal surgical procedure. It may also be of help in deciding whether surgery in patients with limited life expectancy should still be considered. No HRQoL instrument fits all the recommended conditions or is suitable in all clinical situations. Using the appropriate instrument is essential to arrive at valid and clinically meaningful outcome measures.
An endothelin type A receptor antagonist inhibits neointimal hyperplasia and increases luminal area in porcine vein grafts
Authors: Bulbulia R A , Smith F C T , Lamont P M , Baird R N , Angelini G D , Jeremy J Y , Yim A , Wan S
Published: March 2003

Background

Neointimal hyperplasia is responsible for the majority of cases of vein graft failure. To date, no pharmacological intervention has proved successful in preventing this process in humans. Endothelin (ET) 1 is a potent vasoconstrictor and promotes the proliferation of vascular smooth muscle cells in vitro. The authors have shown previously that porcine vein grafts contain high levels of ET-1 and ET type A (ETA) receptor subtypes. The aim was to investigate the effect of an ETA receptor antagonist, BSF 302146, on luminal area and graft wall dimensions in a porcine model of arteriovenous bypass grafting.

Methods

Bilateral saphenous vein–carotid artery interposition grafting was performed in two groups of Large White pigs (26–32 kg; n = 5 per group). BSF 302146 (10 mg kg−1 day−1) was administered orally to animals in group 1; group 2 animals acted as controls. After 4 weeks the grafts were explanted and pressure-fixed ex vivo. Histological sections were obtained and graft dimensions assessed by means of computer-aided planimetry.

Results

BSF 302146 significantly reduced both neointimal hyperplasia and medial thickening, and increased luminal area by 77 per cent.

Conclusion

The ETA receptor antagonist BSF 302146 inhibits neointimal hyperplasia and increases luminal area in a porcine model of saphenous vein bypass grafting.
Angiogenesis in carotid atherosclerosis: the association with morphological features of plaque instability
Authors: Mofidi R , McCarthy P , Sheehan S J , Mehigan D , Crotty T , Keaveny T V
Published: March 2003

Background

Intimal angiogenesis is a recognized feature of the atherosclerotic process. It has been described in the context of unstable coronary atherosclerotic lesions. The aims of this study were to assess the association between angiogenesis in atherosclerotic plaques and microscopic features of plaque instability, in particular intraplaque haemorrhage.

Methods

Consecutive patients undergoing carotid endarterectomy for carotid stenosis were included in the study. Endarterectomy specimens were examined and divided into their constituent atherosclerotic lesions. Histological sections were prepared and stained with haematoxylin and eosin, and immunohistochemically with an endothelial cell marker (CD34). Each lesion was classified according to the American Heart Association classification of atherosclerotic lesions. The size of plaque haemorrhage was measured in transverse histological sections using computerized image analysis. Haemorrhagic lesions were classified according to the size of haemorrhagic area (under 50 per cent of section area; over 50 per cent of section area). Microvessel counts were performed in CD34-stained sections at × 400 magnification and were verified with computerized image analysis. The Kruskal–Wallis test was used to study the differences in microvessel count in different atherosclerotic plaque types.

Results

A total of 239 atherosclerotic lesions from 73 patients was available for analysis, of which 73 were early lesions, 74 were raised fibroatheromas and 92 were unstable atherosclerotic plaques. One hundred and fifty lesions were not haemorrhagic; 89 exhibited intraplaque haemorrhage, of which 28 involved less than 50 per cent of the plaque section area. In 61 lesions the haemorrhage area was over 50 per cent of the section area. There were higher microvessel counts in plaques containing more than 50 per cent haemorrhage (median 277 (range 43–467)) compared with those containing less than 50 per cent (172 (57–372)) and non-haemorrhagic plaques (81 (7–389)) (P < 0·0001). Higher microvessel counts were observed in unstable atherosclerotic lesions (median 252 (range 43–467)), compared with stable fibroatheromas (106 (14–302)) and early atherosclerotic lesions (55 (7–237)) (P < 0·0001).

Conclusion

There are strong associations between plaque vascularity and presence and size of haemorrhage within atherosclerotic lesions, as well as features of plaque instability. This finding highlights the likely significance of these new blood vessels in the development of plaque instability and subsequent risk of stroke.
Randomized controlled trial of acute normovolaemic haemodilution in aortic aneurysm repair
Authors: Wolowczyk L , Bulbulia R A , Stewart A , Nevin M , Day A , Smith F C T , Baird R N , Lamont P M
Published: March 2003

Background

Previous studies have suggested that acute normovolaemic haemodilution (ANH) reduces the need for heterologous blood transfusion in abdominal aortic aneurysm (AAA) surgery and may thus improve postoperative outcome by reducing the systemic inflammatory response. Controlled studies are lacking. The aim of this randomized controlled trial was to evaluate the effects of ANH on the systemic inflammatory response, clinical outcome and use of bank blood after AAA repair.

Methods

Patients undergoing elective AAA repair were randomized to ANH (n = 16) or control (n = 18) groups. Intraoperative cell salvage and heterologous blood were used in both groups according to predetermined transfusion triggers. Inflammatory markers in serum and urine were measured to assess the acute-phase response. Clinical outcome was determined using mortality, morbidity and the incidence of the systemic inflammatory response syndrome (SIRS).

Results

There was no difference between the ANH and control group in serial measurements of median (range) white cell count (maximum at 2 days after operation: 11·9 (7·7–21·4) versus 10·3 (7·8–20·6) × 109 l−1; P = 0·25), serum C-reactive protein level (maximum at 3 days: 150 (1–274) versus 169 (7–238) mg ml−1; P = 0·76), interleukin 6 level (maximum at 6 h: 142 (32–793) versus 105 (29–509) pg ml−1; P = 0·89), total antioxidant capacity (lowest at 1 h: 0·83 (0·67–1·22) versus 0·83 (0·68–1·23) mmol l−1; P = 0·45) or urinary albumin/creatinine ratio (maximum at 30 min after clamp release: 41 (2–923) versus 124 (4–376) mg ml−1; P = 0·10). SIRS was observed in ten of 16 patients having ANH and in 11 of 18 control patients (P = 0·99). There was no significant difference in mortality and morbidity between the groups. Similarly, there was no difference in median (range) blood loss (ANH 1800 (400–12 000) ml versus control 1600 (500–7500) ml; P = 0·55), use of cell salvage (600 (0–4740) versus 520 (0–2420) ml; P = 0·60) or heterologous blood transfusion (2 (0–32) versus 2 (0–9) units; P = 0·68).

Conclusion

In the setting of a randomized controlled trial ANH added no additional benefit, when used in combination with cell salvage, in reducing the requirements for heterologous blood transfusion, and made no impact on systemic inflammatory response and clinical outcome after AAA repair.
Randomized controlled trial of four-layer bandaging and simple venous surgery for venous ulceration
Authors: Guest M G , Smith J J , Greenhalgh R M , Davies A H
Published: March 2003

Background

No randomized controlled trials exist to show whether simple venous surgery benefits healing or maintenance of healing of venous ulcers.

Methods

Some 121 consecutive patients with new episodes of venous ulceration were identified; 45 patients were unfit or unwilling for randomization. The remaining 76 (39 women) were assigned randomly to received a four-layer bandage (n = 39) or simple venous surgery (n = 37). All patients were followed for a minimum of 6 months. Outcome was assessed at a minimum of 6 months as healing and health-related quality of life (HRQL).

Results

The two groups had similar co-morbidity and pattern of venous incompetence. There were no major complications in either group. The healing rate was 64 per cent (25 of 39) in the conservatively treated group and 68 per cent (25 of 37) in the operated group (P = 0·75, Pearson χ2 test). There was no significant difference between time to ulcer healing in the two treatment groups (log rank statistic = 0·69, P = 0·41). Patterns of venous incompetence did not affect the healing rate. There were no major differences in HRQL between the two groups.

Conclusion

This pilot study suggests that simple venous surgery gives no adjuvant benefit to four-layer bandaging in venous ulceration from the point of view of healing rate and quality of life.
Medicolegal claims for vascular problems
Authors: Campbell W B
Published: March 2003

Background

The continuing increase in medicolegal activity demands good risk management, and this requires knowledge of the most likely causes of litigation. This study examined ‘vascular’ cases notified to the Medical Defence Union (MDU) during 1990–1999, and claims initiated against the National Health Service Litigation Authority (NHSLA) since its inception in 1995.

Methods

The MDU was notified of 254 claims by 74 vascular (29 per cent) and 180 general (71 per cent) surgeons; only 35 have so far been settled. Varicose vein operations were the reason for 70 per cent of cases notified. A further 299 vascular cases were notified from primary care, of which 197 (66 per cent) involved critical limb ischaemia (80 per cent of patients had amputations and 16 per cent died), and 102 (34 per cent) involved diagnosis and treatment of aneurysms.

Results

Of 102 ‘vascular’ claims notified to the NHSLA, 70 (69 per cent) related to arterial disease and 32 (31 per cent) to venous problems (26 varicose veins and six thromboembolism). In addition there were ten arterial and 58 varicose vein claims involving ‘general’ surgeons. Varicose vein claims (n = 244) were most often for damage to nerves (n = 76), incorrect or ‘unsatisfactory’ surgery (n = 36) or damage to the femoral vessels (n = 29). The commonest arterial claims concerned aortic surgery (n = 45), failure to diagnose or treat ischaemia (n = 36) and complications of bypass grafts (n = 28).

Conclusion

Varicose vein surgery is a major cause of litigation: very explicit counselling (particularly about the risk of nerve damage) and good record-keeping are required to defend these claims.
Distal anastomotic environment: the influence of intrinsic and extrinsic factors on flow structure
Authors: Fisher R K , How T V , Brennan J A , Gilling-Smith G L , Bakran A , Harris P L
Published: March 2003

Background

Improved patency of the Miller cuff may be attributable to the modification of haemodynamics at the anastomosis inhibiting the accretion of myointimal hyperplasia. The influence of the distal anastomotic environment on flow patterns may therefore have important clinical significance.

Methods

Anastomotic models of Miller cuff, end-to-side (ETS) and precuffed grafts (Distaflo™, Impra, Tempe, AZ, USA) were perfused under physiological conditions. Visualization studies and Doppler colour flow mapping (P700, Philips Medical Systems, Reigate, UK) enabled qualitative flow analysis of the influence of anastomotic geometry, configuration and outflow distribution. Intraoperative flow distribution was measured with a Doppler transit time probe. Flow within in vivo precuffed grafts was analysed by means of colour flow mapping and velocity profiles.

Results

ETS anastomosis demonstrated a large area of flow separation at the graft toe, except when distal outflow approached 100 per cent, when laminar flow prevailed. The Miller cuff created a cohesive vortex within the proximal anastomosis, with reduced areas of flow separation. Outflow distribution had little effect upon the integrity of this vortex, although helical flow occurred in the distal vessel when proximal run-off was occluded. Cuff geometry, expressed as aspect ratio (cuff length: height) was important, with long and low cuffs demonstrating detrimental flow structures, including complex short-lived vortices and large areas of separation. The precuffed model produced a robust vortex, resistant to flow distribution. In vitro Doppler images of the vortex were reproduced accurately in 77 per cent of patients with precuffed grafts in situ (n = 32). Mean intraoperative flow distributions of 76 per cent distal: 24 per cent proximal in infragenicular grafts were significantly different from anticipated ratios of 50: 50 and 100: 0 (P < 0·001, single-sample t test). In above-knee grafts, however, distribution approached purely distal flow (mean 85: 15 versus 100: 0; P = 0·046).

Conclusion

Anastomotic flow structures are determined by the geometry of the anastomosis and the relative flow distribution proximally and distally in the recipient artery. A cuffed configuration of anastomosis is likely to be of most benefit when there is substantial flow proximally as well as distally in the run-off vessel, a situation that applies most often in infragenicular reconstruction. In addition, variable cuff geometry may detract from the full potential of the Miller cuff. A precuffed graft of optimum geometry may negate this concern, with the majority of patients demonstrating accurate replication of potentially beneficial flow patterns.
A single ultrasonographic scan at age 65 years excludes 95 per cent of men from future aneurysm risk
Authors: Crow P , Shaw E , Earnshaw J , Poskitt K , Whyman M , Heather B
Published: March 2003

Background

In 1988, 236 men, then aged 65 or 66 years, underwent an abdominal ultrasonographic scan as part of a pilot study for an aneurysm screening programme; 223 (95 per cent) had an aortic diameter of 25 mm or less, and form the main study group.

Methods

This group was followed with repeat ultrasonography in 1993 and 2000. Eight men (4 per cent) were lost to follow-up or refused further scanning, but all are known to be still alive. Eighty-six men (39 per cent) died during the 12-year follow-up. Causes of death were investigated. None was related to abdominal aortic aneurysm (AAA). Some 129 men (58 per cent) had all three ultrasonographic scans, including some arranged in other hospitals or performed with a portable scanner at a home visit. Mean(s.e.m.) aortic diameter for this group was 18·9(2·3) mm in 1988, 19·0(2·6) mm in 1993 and 20·2(3·8) mm in 2000.

Results

At the scan in 2000, four men had an aortic diameter greater than 30 mm (32, 34, 34 and 36 mm respectively). In contrast, of the 13 men with an aortic diameter greater than 25 mm in 1988, three have undergone elective aneurysm repair, eight have died from causes unrelated to AAA and two remain under ultrasonographic surveillance.

Conclusion

Using an aortic diameter threshold of 25 mm, a single ultrasonographic scan at the age of 65 years is able to exclude 95 per cent of men who appear extremely unlikely ever to develop a clinically significant aortic aneurysm and to identify the 5 per cent who require further follow-up.
Registry of endovascular treatment of abdominal aortic aneurysms (RETA): the fate of patients with primary endoleaks
Authors: Thomas S M , Gaines P A , Beard J D
Published: March 2003

Background

The aim was to present the follow-up data of patients with a primary endoleak identified in the periprocedural period to establish the consequences of these endoleaks.

Methods

There were 123 primary endoleaks in the 1000 operations logged in the Registry of Endovascular Treatment of Abdominal Aortic Aneurysms (RETA) database, visualized either immediately after the procedure or at 30-day computed tomography. The sites of these were: collateral, 42 (34 per cent); proximal anastomotic (PA), 41 (33 per cent); distal anastomotic (DA), 19 (15 per cent); midgraft, 12 (10 per cent); occluder, three (2 per cent); and site not stated in six (5 per cent). The fate of these endoleaks was examined from available follow-up data.

Results

Nine patients (22 per cent) with PA endoleaks died from rupture (n = 3) or following surgery for the endoleak (n = 6). Eleven patients had persistent primary PA endoleak with or without treatment; three of these patients had rupture. Others were treated successfully with surgery, proximal cuffs or angioplasty of the proximal anastomosis. Twenty-two collateral endoleaks (52 per cent) resolved spontaneously at 30 days. There were no ruptures at follow-up. Seven of the 19 DA endoleaks resolved spontaneously by 30 days and four had further endovascular treatment before discharge. Of the eight persistent endoleaks, three resolved spontaneously and three had endovascular treatment. There were no ruptures at follow-up. Two of the three occluder endoleaks resolved spontaneously; the other patient died suddenly from an unknown cause. Nine of the 12 midgraft endoleaks resolved by 30 days, and one had resolved spontaneously at 1 year; again there were no ruptures in this group.

Conclusion

The presence of a PA endoleak justifies an aggressive approach to treatment because of their association with aneurysm rupture. However, open surgical treatments carry a significant mortality rate. Other endoleaks follow a more benign course, and many will resolve spontaneously.
Combined effects of aspirin and the novel antiplatelet agent clopidogrel on platelet function in vivo and in vitro
Authors: Payne D A , Hayes P D , Bell P R , Goodall A H , Naylor A R
Published: March 2003

Background

The platelet adenosine 5′-diphosphate (ADP) receptor antagonist clopidogrel has proved an effective antiplatelet agent in the prevention of arterial thrombosis. In the vast majority of studies clopidogrel has been used as an alternative to aspirin, but the widespread use of aspirin, and the different modes of actions of the two drugs, makes it important to determine the safety and efficacy of using both drugs in combination. This study reports the effect of this drug combination on bleeding times and platelet function in humans.

Methods

The study was conducted in normal, healthy subjects to evaluate the effects of different doses of clopidogrel on bleeding time, platelet aggregation and activation, above a baseline of standard aspirin therapy. Seven normal men (mean age 30 years) were given aspirin (150 mg) for 3 days. Subjects received clopidogrel (75 mg) at 24 and 48 h, followed by a third dose of clopidogrel (300 mg) on day 3.

Results

The combination of aspirin plus clopidogrel leads to a significant reduction in platelet function relative to aspirin alone (P < 0·05), and is associated with a significant increase in the bleeding time (P < 0·05). The response to collagen was similarly affected. Platelet fibrinogen binding in response to both ADP and thrombospondin-related adhesive protein was reduced only partially by aspirin, but significantly reduced by both doses of clopidogrel (P < 0·05 for all). P-selectin expression in response to both agonists was also reduced, but not significantly. Basal levels of fibrinogen binding, P-selectin, glycoprotein (GP) IIb–IIIa and GPIb expression were not affected by treatment.

Conclusion

Blocking both the cyclo-oxygenase and ADP pathways of platelet activation has a profound effect on platelet response to agonists, which may offer significant potential benefit in preventing thrombotic events relative to aspirin alone. Achieving the correct balance between haemostasis and thrombosis with these useful agents will require further study.
Autologous thrombin-induced thrombosis of pseudoaneurysms
Authors: Quarmby J W , Engelke C , Chitolie A , Morgan R A , Belli A-M
Published: March 2003

Background

This study was designed to evaluate the use of autologous thrombin (as opposed to commercial bovine thrombin) in the percutaneous obliteration of postcatheterization femoral pseudoaneurysms.

Methods

Ten consecutive patients with a symptomatic femoral pseudoaneurysm following cardiac catheterization underwent duplex assessment. All ten pseudoaneurysms were at least 2 cm in the longest axis. Autologous thrombin was isolated from 60 ml blood, under sterile conditions. The autologous thrombin was injected into the cavity of the pseudoaneurysm under ultrasonographic guidance. The progression of thrombosis was monitored throughout with ultrasonography. After the procedure, the femoral arteries were examined for thrombosis propagation or embolization. The foot pulses and ankle pressures were checked. Samples of the thrombin isolates were analysed to quantify thrombin activity. Duplex assessment was repeated at 6 weeks.

Results

All ten patients had successful thrombosis of the pseudoaneurysm, although three required repeat thrombin injections within 24 h. No long-term symptoms were identified relating to the thrombosis and no patient required surgery. There was no evidence of recanalization at 6 weeks on duplex imaging, and no signs of infection.

Conclusion

Autologous thrombin-induced thrombosis of pseudoaneurysms is a simple, safe, painless and inexpensive procedure. This novel approach, which uses the patient's own thrombin, is cheaper than bovine thrombin; it also avoids the risk of viral contamination or anaphylaxis from commercial thrombin.
Comparison of primary closure with dacron patch angioplasty in early and late restenosis after carotid endarterectomy
Authors: Gerrard D J , Hatrick A H , Dourado R A , Patel H , Irvine A T , Burnand K G
Published: March 2003

Background

The primary closure of carotid arteriotomy has a high incidence of intraoperative residual stenosis following carotid endarterectomy.

Methods

Completion angiograms in a consecutive series of 197 patients undergoing carotid endarterectomy were reviewed. All operations were performed under general anaesthesia with routine shunt insertion and middle cerebral artery transcranial Doppler monitoring. The first 117 patients had primary closure of the arteriotomy and the last 80 all had patch closure. An independent radiologist, who was unaware of the procedure performed, randomly assessed the intraoperative angiograms. All patients have been followed by 3-monthly duplex screening for 1 year. Results were assessed with the χ2 test.

Results

The stroke and death rate of 7 per cent in the primary closure group was significantly higher than the 1 per cent stroke and death rate in the patched group (P < 0·05). Perioperative angiograms scored 0–20 per cent residual stenosis in 75 per cent of the primary closures, compared with 89 per cent in the patched group (P < 0·05). Some 25 per cent of the primary closures were considered unsatisfactory, compared with 11 per cent of the patched closures. Restenosis greater than 50 per cent at 1 year was significantly higher in the primary closure group (33 versus 19 per cent; P < 0·05).

Conclusion

Patch closure results in a better technical result than primary closure, as judged by radiological appearance, and reduces the overall stroke and death rate. Restenosis is significantly lower at 1 year.
Midterm results of a single endovascular device for repair of an abdominal aortic aneurysm: one centre's experience of the Vanguard device
Authors: Holtham S J , Dugdill S , Rose J D G , Lees T A , Wyatt M G
Published: March 2003

Background

The aim of the study was to evaluate the midterm results of the Vanguard device.

Methods

All deployments performed in a single centre with follow-up according to EUROSTAR criteria were reviewed.

Results

Fifty-five patients underwent deployment of a Vanguard device between December 1995 and July 1999. All stents were implanted successfully, with a perioperative mortality rate of 5 per cent (three of 55 patients). Twelve systemic complications (23 per cent) and three access site complications (6 per cent) were observed. Predischarge computed tomograms revealed one type I and five type II endoleaks. Eleven patients died during follow-up (median 23·4 (range 6–48) months) (ten unrelated, one ruptured abdominal aortic aneurysm). The 2-year survival rate was 70 per cent. Eleven occluded graft limbs (22 per cent; median onset 18 months (range from 24 h to 36 months)), one graft migration and eight late endoleaks (16 per cent; median onset 24 (range 3–42) months) were observed. The 2-year intervention-free survival rate was 68 per cent, with an endoleak-free survival rate of 84 per cent. Median (range) neck diameter increased from 20 (15–23) to 23 (17–27) mm at 24 months (P < 0·01).

Conclusion

The onset of late endoleak and limb occlusion suggests that follow-up is essential, even after 36 months. The increasing neck diameter may prove significant with regard to long-term fixation of the proximal device.
Outcome analysis of over 1000 episodes of limb ischaemia treated by peripheral thrombolysis
Authors: Braithwaite B D , Whitman B , Foy C
Published: March 2003

Background

In the past 10 years, 13 hospitals with an interest in peripheral arterial thrombolysis have collected information on 1064 episodes of thrombolysis used to treat some 933 patients. The aim of the database was to identify clinical factors at the time of admission to hospital and relate them to the patients' outcome.

Methods

After verification of the database, a regression analysis was done in three stages: univariate analysis, logistic regression including the initial success of thrombolysis, and logistic regression analysis excluding initial success. The endpoints were amputation-free survival (AFS), survival but with amputation, and death. Statistical analysis was performed with SPSS software (SPSS, Chicago, Illinois, USA).

Results

The overall AFS was 72·9 per cent; 12·6 per cent of events resulted in amputation and 12·9 per cent of patients died. Univariate analysis showed that patients receiving warfarin had a survival advantage, whereas those with diabetes and ischaemia that caused sensory loss were significantly more likely to require amputation. Logistic regression analysis confirmed the above effects of diabetes and ischaemia. Major haemorrhage occurred in 8 per cent of events, but there was a significantly increased risk if the patient had a history of peripheral vascular disease (P = 0·007) or presented with graft thrombosis (P = 0·001). Stroke occurred in 2·4 per cent of events; a greater incidence occurred in patients with a duration of ischaemia of less than 8 h.

Conclusion

Further detailed analysis of this large and unique database should help clinicians to refine the indications for peripheral thrombolysis in the management of acute leg ischaemia.
Impact of angioplasty on infrainguinal bypass for critical ischaemia of the leg
Authors: Evoy D , Sultan S , Colgan M P , Moore D , Shanik G
Published: March 2003

Background

Both angioplasty and infrainguinal bypass procedures may be used to achieve limb salvage in patients with critical ischaemia. The authors investigated the effect of the introduction of angioplasty on the frequency with which infrainguinal bypass was performed and, second, the changes in outcome of infrainguinal bypass following the introduction of angioplasty.

Methods

All patients had critical ischaemia of the leg. Three patient groups were studied: 215 patients undergoing infrainguinal bypass before the introduction of angioplasty (1986–1991), 216 patients who had infrainguinal bypass after the introduction of angioplasty (1993–1998) and 193 patients undergoing angioplasty in the same 5-year interval (1993–1998).

Results

The age and risk profile of the three groups was identical. The overall caseload increased by 19 per cent following the introduction of angioplasty. Primary and secondary patency rates were superior for bypass compared with angioplasty, but were similar for the two bypass groups (5-year primary patency rate 60 per cent versus 18-month primary patency rate 45 per cent; 5-year secondary patency rate 80 per cent versus 18-month secondary patency rate 60 per cent). By 18 months 26 per cent of patients having angioplasty had gone on to have bypass. The limb salvage rate of 90 per cent at 1 year was similar for all groups. Survival was significantly higher in the group of patients undergoing bypass from 1993 to 1998 compared with the other two groups (80 versus 60 per cent; P < 0·0002).

Conclusion

The introduction of angioplasty has increased overall workload. Angioplasty has a lower patency rate than bypass but a comparable limb salvage rate, making it a suitable alternative to bypass in the management of patients with critical ischaemia.
P-POSSUM models for abdominal aortic aneurysm surgery
Authors: Boyle J R , Prytherch D R , Payne S P , Pemberton R M , Sutton G L
Published: March 2003

Background and methods

POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) data on 444 (213 emergency, 231 elective) admissions for abdominal aortic aneurysm (AAA) surgery between August 1993 and July 2000 were analysed using the P-POSSUM equation for general surgery and the P-POSSUM equations developed for the Vascular Surgical Society of Great Britain and Ireland (physiological and operative and physiology only).

Results

All three equations successfully modelled the elective admissions but failed to fit the emergency admissions and the elective and emergency admissions combined. This suggests that admission method (not a POSSUM data item) is an important factor for patients with AAA. However, with these data it was not possible to generate a model, including admission method, that successfully modelled the combined elective and emergency data. Emergency AAAs had to be treated separately. The 213 emergency admissions were divided into two groups by operation date. The first 106 (training set) were used to form logistic regression models following the P-POSSUM methodology. These models were found successfully to fit the remaining 107 records (test set) on prospective application, as shown in the Table.

Conclusion

Emergency AAAs appear to be fundamentally different from elective AAAs and other vascular cases, and require their own distinct risk model. The ability to model risk for elective AAAs using a physiology-only risk model could perhaps be used to optimize the timing of operation as well as informing all concerned of the risks involved.
Risk modelling for carotid endarterectomy
Authors: Kuhan G , Gardiner E , Abidia A , Chetter I , Renwick P , Johnson B F , Wilkinson A R , McCollum P T
Published: March 2003

Background

A 30-day stroke or death rate of 3–10 per cent has been reported in patients undergoing carotid endarterectomy (CEA). The aim of this study was to identify the risk factors that influenced the outcome and to develop a logistic regression model that can aid in the comparative audit of CEA.

Methods

Some 836 CEAs performed by four vascular surgeons from 1992 to 1999 were analysed. The median age of the population was 69 (range 38–86) years, and the male: female ratio was 1·6. Multiple logistic regression was used to model the effect of 15 risk factors on the 30-day stroke and death rate. The outcome after risk adjustment was compared for four surgeons and two vascular units.

Results

The overall 30-day stroke and death rate was 3·9 per cent. Regression modelling identified heart disease, diabetes and stroke at presentation as significant risk factors. A risk score of 1 was assigned to each of these risk factors to produce a logistic regression equation (where P is the probability of 30-day stroke or death):

ln(P/1 − P) = 0·9294(risk score) − 4·2726.

The observed 30-day stroke and death rate for four vascular surgeons was 3·0, 4·0, 4·2 and 4·3, and for two vascular units was 3·9 and 3·9. Differences between the surgeons and the vascular units were not statistically significant after allowing for risk adjustment using this model.

Conclusion

Multiple logistic regression models can successfully identify patients at higher risk from CEA, and aid in the comparative audit of surgeons and vascular units.
Economic evaluation of a randomized clinical trial of haemodilution with cell salvage in aortic surgery
Authors: Haynes S L , Torella F , Wong J C L , Dalrymple K , James M , McCollum C N
Published: March 2003

Background

This study evaluated the costs of acute normovolaemic haemodilution (ANH) and intraoperative cell salvage (ICS) versus homologous blood transfusion in aortic surgery in a prospective multicentre randomized trial.

Methods

One hundred and forty-five patients were randomized either to standard transfusion practice (homologous) or to a combination of ANH and ICS (autologous). Costs for each inpatient admission were identified. Cell salvage costs were assigned on the assumption that 50 operations were done each year employing a trained cell salvage operator. The results were analysed statistically using bias-corrected bootstrap analysis.

Results

Patients who had transfusion of homologous blood received some 251 units and those having a homologous transfusion received 103 units (P = 0·008). There was no difference in morbidity, mortality and duration of hospital stay. Transfusion-related mean costs were similar at £340 for patients having a homologous transfusion and £357 for those receiving autologous blood (mean difference £17 (95 per cent confidence interval (c.i.) −£184 to £174); P not significant). There was also no significant difference in mean overall costs: £5859 for homologous and £5384 for autologous transfusion (mean difference −£475 (95 per cent c.i. −£2231 to £1342)). Sensitivity analysis showed that costs remained similar for 20 and 150 operations per annum. Exclusion of a dedicated cell salvage operator reduced autologous transfusion costs but did not have a significant impact on overall cost.

Conclusion

Autologous transfusion is cost neutral in aortic surgery even when surgical activity is low.
Therapeutic relevance of breast cancer micrometastases in sentinel lymph nodes
Authors: Noguchi M
Published: March 2003

Background and methods

This review examines the various methods of detecting occult breast cancer metastasis in the sentinel lymph node (SLN). The prognostic relevance of such micrometastases and isolated tumour cells, and their impact on stage migration and decision making with respect to axillary dissection and adjuvant systemic therapy, are discussed.

Results

Examination of SLNs by serial section with haematoxylin and eosin and/or immuno histochemical staining significantly increases the detection rate of micrometastases, even in patients with very small (T1) tumours. However, the prognostic relevance of isolated tumour cells and small micrometastases is uncertain. Moreover, deciding which patients might benefit from axillary dissection is complicated by the fact that adjuvant radiotherapy and systemic chemotherapy alone may eradicate most micrometastases.

Conclusion

Ongoing randomized trials comparing the results of SLN biopsy alone with those of axillary dissection should answer the question of whether isolated tumour cells and small micrometastases are clinically relevant. This should also indicate which patients with SLN micrometastasis are likely to benefit from axillary dissection. In this sense, SLN biopsy must be considered still to be at an investigative stage; outwith clinical trials complete axillary dissection should be performed on all patients with SLN micrometastasis.
Cell membrane changes of structure and function in protein kinase inhibitor‐induced polyploid cells
Authors: Zong Z. P. , Fujikawa‐Yamamoto K. , Li A. L. , Yamaguchi N. , Chang Y. G. , Murakami M. , Tanino M. , Odashima S.
Published: March 2003

Exogenous cyclic AMP has been thought to be a chemical without marked pharmacological effect until now, as it is not capable of penetrating the cell membrane in most eucaryotic cells. The present study obtained results consistent with those of most previous studies, showing that exogenous cyclic AMP itself did not interfere with the cell cycle even at the high dose of 100 μM. However, it was found that K252a, a potent inhibitor of protein kinases including protein kinase C, induced DNA re‐replication, i.e. DNA synthesis at a elevated DNA ploidy in cells that had not undergone cytokinesis (leading to polyploidization), and that exogenous cyclic AMP markedly potentiated the K252a‐induced polyploidization at a very low dose similar to the effective dose of membrane‐permeable cyclic AMP analogue dibutyryl cyclic AMP. These findings suggested that the cell membrane changed during the formation of polyploid cells. This supposition was confirmed by scanning electron microscopy to observe structural changes and by determination of cellular attachment to investigate functional changes.
Monocyte proliferation induced by modified serum is associated with endogenous M‐CSF production: evidence for involvement of a signalling pathway via scavenger receptors
Authors: Asakura E. , Tojo N. , Tanabe T.
Published: March 2003

Abstract. It was found that human serum stored for 2 months at 4°C (modified serum) induced monocyte proliferation and simultaneous macrophage colony stimulating factor (M‐CSF) production by these cells in vitro. Cell number, estimated by DNA content, doubled after 10 days in culture in the presence of modified serum, while it decreased in culture with freshly thawed control serum. As the addition of more than 2.5 ng/ml of recombinant M‐CSF significantly supported monocyte survival/proliferation, cells were cultured for 10 days in medium supplemented with control serum, and endogenous M‐CSF production was investigated by enzyme‐linked immunosorbent assay. M‐CSF concentration in the supernatants was 15–30 ng/ml after 10 day in culture with modified serum, a level that might be sufficient for monocyte proliferation. The modified serum induced M‐CSF from freshly isolated monocytes, while M‐CSF was hardly detected in cultures supplemented with control serum. Assay for peroxidized lipid and agarose gel electrophoresis demonstrated that the modified serum contained more oxidized low density lipoproteins (LDL) than the control serum. Ligands of scavenger receptors, which are receptors for oxidized LDL, such as dextran sulphate, polyinosinic acid, heparin and acetylated LDL also significantly induced M‐CSF production from human monocytes, although this was at levels below 2 ng/ml. These results indicate that serum modified by oxidation stimulates monocytes to produce M‐CSF resulting in their proliferation, and that signalling via scavenger receptors is one of the mechanisms responsible for this induction of M‐CSF.
Shemin pathway and peroxidase deficiency in a fully habituated and fully heterotrophic non‐organogenic sugarbeet callus: an adaptative strategy or the consequence of modified hormonal balances and sensitivities in these cancerous cells? A review and reassessment
Authors: Gaspar T. , Kevers C. , Bisbis B. , Penel C. , Greppin H. , Garnier F. , Rideau M. , Hault C. , Billard J. P. , Foidart J. ‐M.
Published: March 2003

Abstract. There are many arguments for considering a specific fully habituated (auxin and cytokinin‐independent) and fully heterotrophic non‐organogenic (HNO) sugarbeet callus cell line as terminating a neoplastic progression, and thus to be made of cancerous cells. The similarities with animal tumour and cancer cells are recalled. All types of habituated tissues examined in the literature share at least three common biochemical characteristics: low apparent peroxidase activity, high content of polyamines (PAs) and low production of ethylene. However, results concerning their auxin and cytokinin levels are not consistent. Peroxidase synthesis in the achlorophyllous HNO callus appears to arise from aminolevulinic acid (ALA) synthesis through the Shemin pathway, commonly used by animals and fungi. This pathway is limited by disturbed nitrogen metabolism that diverts glutamate (directly used for ALA synthesis in green higher plants) from the Kreb's cycle into PA synthesis. There is no argument to suggest that the low ethylene production is caused by a competition with PAs for their common precursor, S‐adenosylmethionine. The results we report here indicate modified anabolic and catabolic pathways of auxins and cytokinins but also the possibilities of unusual compounds playing similar roles (dehydrodiconiferyl alcohol glucosides, for instance). A higher turnover of PAs is shown in the HNO callus, which could suggest a role for H2O2 and γ‐aminobutyric acid, products or intermediates in the PA catabolic pathway, as secondary messengers. The habituated cells retain some sensitivity towards exogenous auxins and cytokinins. Their increased sensitivity to PAs and ethylene suggests modified hormonal balances for the control of these actively dividing cells.
Degradation of apoptotic cells and fragments in HL‐60 suspension cultures after induction of apoptosis by camptothecin and ethanol
Authors: Baisch H. , Bollmann H. , Bornkessel S.
Published: March 2003

Abstract. Early indicators of apoptosis in mammalian cells are membrane potential breakdown (loss) in mitochondria (MPLM), chromatin condensation, DNA degradation, and phosphatidylserine exposure (PSE) on the outside plasma membrane. One aim of the present study was to determine the kinetics of these characteristics. These changes were measured by flow cytometry using the following methods: membrance potential of mitochondria was analysed using Mito Tracker Green and Red, PSE was analysed using annexin‐V‐FITC staining simultaneously with propidium iodide (PI) to detect membrane permeability; chromatin condensation was measured using the acid denaturation Acridine Orange (AO) method; DNA degradation was studied by the sub G1 method and the terminal transferase dUTP nick end‐labelling (TUNEL) assay (labelling of strand breaks). HL‐60 cells were induced to apoptosis by 3% ethanol and 1.5 μM camptothecin (CAM) and the kinetics of the apoptotic cells were measured. The same kinetics were found for chromatin condensation and DNA degradation indicating that these changes appeared at approximately the same time after induction. The MPLM and PSE kinetics showed a considerably later increase indicating that MPLM occurred downstream of DNA degradation and that plasma membrane changes occurred downstream of MPLM.

The main aim of the study was to follow the fate of apoptotic cells after the appearance of the initial characteristics. The lifetime of apoptotic cells was studied by chase experiments. The inducing drug was removed after 4 h treatment and the disappearance of apoptoses recorded. An exponential decay was measured with a half life (T½) of 17.8 h. As a corollary from these experiments, camptothecin was found to induce apoptosis also in G1 and G2 phase cells, however, it took much longer to occur than in S phase cells.

Using labelling of the plasma membrance with a fluorescent cell membrance linker, it was possible to show that the majority of apoptotic bodies as well as condensed apoptotic cells contain DNA and membrance. The degradation of these apoptotic bodies follows similar kinetics as those of the condensed apoptotic cells. The membrane remained considerably stable, there was no further loss in the next 7 days, after the first day when the apoptotic characteristics develop. It is concluded that the apoptosis programme is completed within a day and no further steps follow.