Management of HIV and pregnancy in England's North Thames Region 1999: a survey of practice in 21 hospitals

OBJECTIVES

To ascertain current practices in the diagnosis and management of HIV and pregnancy in the North Thames Region.

METHODS

Postal survey using a self-completed questionnaire sent to the head of all of the Region's 34 units involved in the care of HIV. The survey asked questions on current policy around HIV and pregnancy in the HIV units and associated antenatal clinics and was linked to a case-note survey of pregnant, HIV-positive women in the last 2 years.

RESULTS

Over 50% of the responding antenatal units recommended the HIV test by March 1999. Most HIV units were offering a range of antiretroviral regimens in pregnancy, although a minority (33%) did not offer triple therapy. Elective Caesarean section was the recommended mode of delivery for most women (90%) irrespective of drug therapy or viral load. Most infants were being tested for HIV infection by a combination of PCR, viral culture and antibody testing to 18 months of age. All the infants (19) followed to 6 months of age in the case-note survey were PCR negative. Reporting rates to the National Survey of HIV in Pregnancy were high (87%) but poor for the Drug Exposure Register (33%).

CONCLUSIONS

Management of HIV and pregnancy in the North Thames units showed a large amount of consistency with regard to testing policies and management. However, there were a few units that did not offer therapy appropriate for advanced disease despite the recommendations of national bodies and a few units still did not recommend HIV testing to all women.

[Metformin associated lactic acidosis--case reports and literature review]

BACKGROUND

The use of metformin in the treatment of diabetes mellitus type II is increasing. The drug has several advantageous metabolic effects, and is considered safe if not used in the presence of contraindications, in particular renal failure.

MATERIAL AND METHODS

We present a patient with metformin associated lactic acidosis, to remind of a potentially lethal adverse reaction. We also review the literature about incidence and risk, prognosis and treatment of the disease.

RESULTS

Our patient was a 72 year old woman with diabetes mellitus type II treated with metformin, who presented with acute renal failure, severe metabolic acidosis and circulatory failure. Treatment with bicarbonate buffer and vasopressors did not improve her condition, only after hemodialysis was her situation stabilised.

INTERPRETATION

Metformin associated lactic acidosis must be considered in obscure metabolic acidosis in diabetic patients. The single most important therapeutic approach appears to be immediate hemodialysis.

Thanatophobia and opiophobia of hospice nurses compared with that of other caregivers

In meeting national needs for our terminally ill, health care educators need to become more aware of their students' aptitudes for hospice work. For these reasons we measured hospice nurses' attitudes toward caring for the terminally ill and their views on using opioids, and compared them to those of other health care personnel and their students. Thirty-eight hospice nurses, 64 other nurses, 93 physicians, and 676 senior medical students participated in this study. Our primary measures were scales assessing thanatophobia and opiophobia and a battery of personal and professional role trait measures. Our results indicated that in providing end-of-life care, hospice nurses expressed less discomfort, helplessness, and frustration, and indicated less reluctance to use opioids than did any of the other groups surveyed. Overall, these hospice nurses had 35 percent lower opiophobia and 55 percent lower thanatophobia scores than the other health care professionals. Despite dealing with issues of death and dying on a daily basis, hospice nurses also scored lower on depressed mood. In caring for the terminally ill, hospice nurses' other personal traits were also less maladaptive than those of the other health professionals. Psychiatrists exhibited the most opiophobia, not only scoring higher than physicians practicing oncology, but also higher than senior medical students. To assure cancer patients that they can expect to live their lives free of pain, medical educators can use these thanatophobia and opiophobia scales to develop better teaching, counseling, and monitoring strategies.

Interpreting the 13C-urea breath test among a large population of young children from a developing country

The 13C-urea breath test is a noninvasive tool for the diagnosis of gastric Helicobacter pylori infection. However, it has not been validated in young children from the developing world, where infection is very common. 13C urea breath tests were performed on 1532 occasions on 247 Gambian infants and children aged from 3 to 48 mo. The means and variances of the separate sub-populations of 13C enrichment results contained within the overall dataset were estimated by a Genstat procedure using the EM algorithm, thereby identifying a cut-off value to discriminate positive from negative results. To illustrate the appropriateness of this calculated cut-off value, 13C urea breath tests were performed upon a small group of 14 patients aged 6 to 28 mo undergoing diagnostic upper endoscopy. Fixed gastric antral biopsies were examined to identify H. pylori. Two subpopulations were identified within the large dataset. A cut-off value of 5.47 delta per thousand relative to Pee Dee Belemnite limestone above baseline at 30 min identified 95% of the normally distributed negative sub-population and 99.4% of the log normal distributed positive sub-population. Comparison with endoscopic data confirmed that this cut-off value was appropriate for this population, as 7/7 children without H. pylori on their gastric biopsies had negative urea breath tests, and 6/7 children with gastric H. pylori colonization had positive urea breath tests. These findings confirm the value of the urea breath test as a diagnostic tool in young children from developing countries. They also offer a way to calculate the most appropriate cut-off value for use in different populations and the likelihood that it will correctly assign any value into the appropriate sub-population, without the need for endoscopy.

Helicobacter pylori colonization in early life

Helicobacter pylori infection is a major cause of upper gastrointestinal disease throughout the world. Colonization begins in childhood, although little is known about its age of onset, rate, or mode of colonization. Our aim was to identify the age of acquisition of H. pylori colonization in Gambian children. A cohort of 248 Gambian children aged 3 to 45 months was studied at intervals of 3 months for 2 years, using the 13C-urea breath test, specific IgM and specific IgG serology. The prevalence of positive breath tests rose from 19% at 3 months of age to 84% by age 30 months. Elevated specific IgG and IgM antibody levels were associated with positive breath tests, although there was discrepancy between breath test results and serology, particularly IgG serology, during the 1st year of life. Neither IgG nor IgM serology could be validated as reliable diagnostic tools for infant H. pylori colonization compared with the 13C-urea breath test. Reversion to negative breath test, in association with declining specific antibody levels, occurred in 48/248 (20%) of children. On the assumption that the 13C-urea breath test is a reliable index of H. pylori colonization, we conclude that the infection is extremely common from an early age in Gambian children. Transient colonization may occur. Previous studies relying on serodiagnosis may have significantly underestimated the true early prevalence of colonization in the developing world, where the target age for intervention studies is probably early infancy.

Strawberry Cultivars Vary in their Resistance to Northern Lesion Nematode

The genetic diversity of commercial cultivars of strawberry Fragaria x ananassa from various parentages, as expressed by their resistance to the northem lesion nematode Pratylenchus penetrans, was evaluated in nematode-infested field plots for two growing seasons. Data taken for each plant in each season included soil nematode Pi and Pf, end-of-season nematode numbers in each entire root system, and end-of-season fresh and dry top weight and whole root system weight. Resistance was estimated using an index of the nematode load on the plant: Nematode load = {n(root) + (200 x n[soil])}/{root dry weight} where n (root) = number of nematodes in the root, n [soil] = number of nematodes in 50 g of nonfumigated soil, and 200 is a multiplier to convert the soil nematode count to a 10-kg basis. Nineteen strawberry cultivars varied in their resistance to the northern lesion nematode, from a mean load of 382 nematodes/plant for Pajaro to 1,818 nematodes/plant for Veestar. This variability could be related to the original family groupings, with the most resistant cultivars related to Lassen and the least resistant to Sparkle x Valentine.

The value of the SARs in spatial and area-level research

"The papers in this issue exemplify in various ways the value of the Samples of Anonymised Records (SARs) for Britain and Northern Ireland to spatial and area-level research. Before highlighting some of the strengths of the SARs for this type of analysis we give a brief overview of the structure and content of the SARs."

Helicobacter pylori infection, gastric acid secretion, and infant growth

BACKGROUND

Helicobacter pylori infection is very common in Gambian infants and children, who are also at risk of chronic diarrhoea and undernutrition. Acute H. pylori infection is associated with depressed gastric acid secretion, and loss of the gastric acid barrier may predispose to enteric infections.

METHODS

In a prospective study a noninvasive test of gastric acid output (measurement of change in urine acid output before and after a feed) was performed on a population of Gambian infants at high risk of H. pylori infection. The 13C urea breath tests was used to measure the prevalence of H. pylori infection and growth was measured by serial anthropometry.

RESULTS

In 101 infants aged 3 to 12 months, there was a significant relation between H. pylori infection and depressed urine acid output in those aged 6 months, during weaning when growth failure and malnutrition begin. Those infants with sustained H. pylori infection grew less well than those without.

CONCLUSIONS

We speculate that H. pylori, acquired in infancy, could be a "key that opens the door" to enteric infection in childhood, leading to recurrent diarrhoea, malnutrition, and growth failure.

A new nausea model in humans produces mild nausea without electrogastrogram and vasopressin changes

The standard human vection model utilized for nausea has been an optokinetic drum. This model may be difficult to extrapolate to the usual clinical setting. Our goals were to develop an experimental model which could induce low grade nausea in humans and to determine the relationship between mild nausea and changes in the electrogastrogram and plasma vasopressin concentrations.

METHODS

Twenty-one volunteers (11 males, mean age: 37 years) participated. At baseline and throughout the study the electrogastrogram was monitored, blood was drawn for vasopressin assay and symptoms of nausea, dizziness and headache were rated on a 0-10-point scale. Subjects were semireclined in a darkened room while viewing moving bars of light rotating at a rate of 85 degrees s-1. Subjects were asked to rate their proneness to motion sickness and their current level of anxiety at baseline.

RESULTS

Eight subjects developed mild to moderate (mean: 3.6) nausea during vection. Symptoms of nausea were correlated with a reported history of motion sickness (r = 0.49, P < 0.05) but not with anxiety (r = 0.14, P = 0.54). Degrees of nausea correlated with degrees of dizziness (r = 0.47, P < 0.05) but not with headache (r = 0.29, P = 0.14). Subjects who developed mild nausea were not significantly more likely to exhibit altered electrogastrogram or vasopressin than subjects who did not report nausea. Vasopressin levels during baseline and experimental conditions were highly correlated (r = 0.66, P < 0.005 and r = 0.55 P < 0.005, respectively) with reported baseline anxiety.

CONCLUSIONS

(1) This new model in humans induced mild nausea that was unrelated to electrogastrogram and vasopressin abnormalities, (2) high correlation between anxiety and vasopressin suggests that vasopressin may not be directly related to nausea, and (3) these data indicate that onset of nausea mediated centrally can occur without associated electrogastrogram changes.

Bleomycin and cyclophosphamide toxicity simulating metastatic nodules to the lungs in childhood cancer

Two pediatric oncology patients with Ewing's sarcoma and one with mixed germ cell tumor were treated with drug regimens that included bleomycin or cyclophosphamide. Despite progress to apparently complete remission, all manifested pulmonary nodules on computed tomography during or at the end of treatment. Thoracoscopic biopsy to confirm metastasis revealed instead fibrotic lesions apparently attributable to bleomycin or cyclophosphamide. After cessation of chemotherapy, the pulmonary lesions resolved and all three patients sustained their remissions. The case histories and comments on the diagnosis and management of pulmonary nodules are reviewed.

Potential for anatomic localization in colorectal cancer using the SCM test

We analysed a series of 81 colorectal cancer cases in which the SCM (structuredness of the cytoplasmic matrix) test had already been performed with a diagnostic sensitivity of 92% and a specificity of 92.6%, yielding positive and negative predictive values of 96.3% and 84.7% respectively. We subdivided this group of 81 patients by anatomic location of the malignancy. Although the resultant subgroups were admittedly small, we noted a tendency for the most prominent changes in observed and calculated polarization parameters to be associated with cecal cancers. This finding was of special interest because the cecum is the most inaccessible site for colonoscopy. Ongoing site-specific surveillance in SCM-tested cases of colorectal cancer is necessary to validate this result.

Locating the stranger rapist

As part of a larger project evaluating aspects of offender profiling, an initial study was undertaken of the geographic aspects of approximately 300 sexual offences carried out by 79 stranger rapists. The objective was to focus further research on the topic into potentially useful channels, but information thought to be of immediate use to investigating officers was also produced. It was ascertained that at least one-fifth of the sample of stranger rapists were itinerant to a greater or lesser extent. Analysis of the cases where both the offender's address and the location where he approached the victim were known, indicated that the majority of attacks (75 per cent) were initiated within five miles of the offenders' homes. The apparent reasons for victims being approached unusually far away included targeting of locations where numbers of suitable victims were available; raping during relatively sophisticated property offences; 'prowling' or 'hunting' over large areas by subjects who spent considerable amounts of time so doing; access to transport; and familiarity with widely dispersed neighbourhoods, often due to the offender having lived in two or more locations. As a result of this work, future research on the geography of rape will be directed towards those aspects of the offences which have been identified as relevant to the distance between an offender's base and the site where he approached his victim.

Lavender oil and perineal repair

The study examined the practice of adding six drops of pure lavender oil to bath water daily for 10 days following childbirth to reduce perineal discomfort. Mothers using the oil found it pleasant to use, and there were no side effects. The pattern of discomfort scores shows no statistical differences between groups. Those using lavender oil showed lower mean discomfort scores, particularly between days 3 and 5. Further studies might explore the effect of varying the amount of oil used or changing the mode of application.

The role of lavender oil in relieving perineal discomfort following childbirth: a blind randomized clinical trial

Aromatherapy is a movement growth in popularity, but lacking scientific justification in the field of practice, although laboratory experiments are in evidence. Lavender oil is frequently selected for aromatherapy as having antiseptic and healing properties. More specifically, it has been used as a bath additive postnatally to reduce perineal discomfort. A blind randomized clinical trial is described, involving three groups of mothers, one using pure lavender oil, one a synthetic lavender oil and one an inert substance as a bath additive for 10 days following normal childbirth. Analysis of daily discomfort scores revealed no statistically significant difference between groups. It cannot be concluded that current practice results in a reduction of postnatal perineal discomfort at the dilution levels used. However, there is some consistency in results between the 3rd and 5th days, with those women using lavender oil as a bath additive recording lower mean discomfort scores. This is a time when the mother usually finds herself discharged home and perineal discomfort is high. A total of 635 women participated and no side-effects were found.

Isolation of Helicobacter pylori from human faeces

Helicobacter pylori is arguably the commonest chronic infection in man. However, its route of transmission is unknown. We have isolated viable H pylori from the faeces of an infected individual from The Gambia. The organism was cultured on selective media after concentration of faecal bacteria by centrifugation in a buffer equilibrated with a microaerophilic gas mixture. Growth characteristics, microscopic appearances, and enzyme activities were the same as those of a typical gastric isolate of H pylori. Protein preparations derived from the new isolate and the typical strain were antigenically similar, and had very similar electrophoretic profiles (including two major protein bands of 62 and 26 kDa, corresponding to the urease enzyme subunits). With the same technique, organisms with the colony morphology, growth requirements, enzyme activities, and microscopic appearances of H pylori were isolated from the faeces of 9 of 23 randomly selected children aged 3-27 months from a Gambian village with a high prevalence of H pylori infection in early life. Faecal-oral transmission is probably important in the spread of infection in such communities.

Lipoprotein lipase in heart and myocytes: characteristics with intralipid as substrate

1. Intralipid is a suitable substrate for measuring lipoprotein lipase activity in the presence of other triacylglycerol lipases in heart and myocytes. 2. Triacylglycerol lipase activity in heart and myocytes was increased 10-fold in the presence of serum at pH 7.4 and 8.1. The serum-stimulated activity in myocytes was 95% inhibited by saturating concentrations of antiserum to lipoprotein lipase. 3. Both heparin-releasable and non-releasable lipoprotein lipase fractions had similar Km values for Intralipid and a similar pattern of inhibition by high density lipoprotein but different responses to heparin. 4. Isoproterenol did not alter lipoprotein lipase activity in cardiac myocytes.

Towards a process evaluation model for community-based initiatives aimed at preventing the spread of HIV amongst injecting drug users

An action research model is presented for the evaluation of community-based interventions. The short- and long-term application of this model is illustrated by means of a study of a community drug team which was initiated to prevent the spread of HIV infection amongst substance misusers in south-west London. A client caseload of 155 was monitored over a year-long period and the results used to evaluate the extent to which the CDT had achieved its stated aims and objectives. Other tools used in the evaluation and monitoring were surveys of generic, specialist and general practitioner services, and needs assessment of samples of drug users. The potential of the model is explored, both in terms of its research role and in facilitating service development. The value of action research methodology in assessing HIV/AIDS prevention is stressed.

Haemophilus influenzae infections in siblings: the need for prophylaxis

An 8 month old child developed Haemophilus influenzae meningitis 12 days after his elder brother had developed epiglottitis. There is not at present in the United Kingdom a recognised policy for prophylactic treatment of contacts of patients with H influenzae infection. Variations in clinical practice were confirmed by the result of a survey of paediatricians in the Northern region.

Practical and psychological problems for parents of children with epidermolysis bullosa

Parents of children with epidermolysis bullosa were sent a questionnaire seeking information on problems associated with the condition; 45% replied and their responses are discussed in terms of reported needs. Epidermolysis bullosa (EB) is the name given to a group of distinct, inherited disorders which are manifest as an exceptional liability of the skin to blister and ulcerate following mechanical trauma. There are three principal groups: EB simplex, dystrophic EB and junctional EB. All forms of EB simplex are inherited as autosomal dominant traits. These diseases are generally relatively mild but some patients are sufficiently disabled to prevent their walking more than 200 yards at a time. Dystrophic EB is of variable severity; not unknown are problems such as fusion of the fingers, fixation of the tongue, shrinkage of the mouth and oesophageal stenosis. When severe this is an exceptionally disabling disorder associated with a significant reduction in life expectancy. Junctional EB is always serious and death within the first few years of life, often within the first few weeks, is usual. DEBRA, the Dystrophic Epidermolysis Bullosa Research Association, is a self-help group of sufferers and their families. A questionnaire aimed at eliciting problems associated with this condition was sent to 138 members and their replies form the basis of this paper.

Comparison of buffering capacity in patients on hemodialysis and continuous ambulatory peritoneal dialysis

A standard acid loading test was used to assess the buffering capacity in 9 hemodialysis (HD) and 25 continuous ambulatory peritoneal dialysis (CAPD) patients. There was a significant increase in H+ concentration and a decrease in plasma bicarbonate levels after the acid loading in all patients; however, PaCO2 did not change significantly. CAPD patients tolerated the acid load better, at least in the first 2 h, than HD patients. The brief duration of experiments did not allow us to observe differences, if any, in the recovery rates between HD and CAPD patients. CAPD patients tolerated the acid load equally, whether studied with or without fresh dialysate in the peritoneal cavity. Their tolerance to the acid load did not change with an increasing duration of the CAPD therapy. Baseline values and acid tolerance curves were similar in CAPD patients on regular Dianeal (lactate 35 mEq/l) and Dianeal PD2 (lactate 40 mEq/l). It is concluded that the buffering capacity is marginally higher in CAPD than in HD patients, although the baseline acid-base parameters were essentially identical.

Serial studies of pulmonary function in continuous ambulatory peritoneal dialysis. A prospective study

Continuous ambulatory peritoneal dialysis (CAPD) produces a nearly continuous state of iatrogenic ascites which may interfere with respiratory excursions of the diaphragm and compromise ventilatory function. Sitting and supine studies of pulmonary function and arterial blood gas analyses done serially in 13 patients undergoing CAPD showed a significant decline in pulmonary volumes immediately after the institution of CAPD; however, the decline was not accompanied by abnormalities in gas transfer. Pulmonary volumes returned to baseline values within two weeks in all patients, including those with preexisting mild chronic obstructive pulmonary disease (COPD). It is concluded that CAPD does not compromise pulmonary function in patients with normal pulmonary function or in those with mild COPD.

Massive hydrothorax complicating continuous ambulatory peritoneal dialysis

2 patients on continuous ambulatory peritoneal dialysis (CAPD) developed massive hydrothorax. Further studies revealed preferential transfer of fluid from peritoneal cavity to pleural space in absence of a direct pleuroperitoneal communication. Hydrothorax resolved in both following a brief interruption in CAPD but recurred in one upon restitution of CAPD. In case of recurrent hydrothorax, pleurodesis or alternate dialytic therapy should be considered.

Locus of control and expectancy in electromyographic biofeedback

From a subject pool of 226 psychology students, 16 external and 16 internal subjects, as determined by the Nowicki-Strickland Locus of Control Scale, were randomly assigned to either a positive or a negative expectancy group (n = 8). In Session I all subjects were asked to relax their frontalis muscle using auditory proportional biofeedback over 8 subsequent 3-min trials. The procedure was repeated during Session II except for the inclusion of a verbal expectation which suggested subjects' likelihood or non-likelihood of achieving further muscle relaxation. Results indicated that externals with positive expectancy had significantly higher levels of tension than internals with positive expectancy. No difference between externals and internals in the negative expectancy condition were observed. Results are interpreted to indicate that cognitive set affected the perception of performance ability with externals being disrupted by comments suggesting positive expectancies.

Voluntary heart-rate changes mediated by muscle tension and respiration

20 undergraduates completed heart-rate mediation treatments (isometric exercise, relaxation, hyperventilation, and hypoventilation) with and without feedback. Heart rate increased during tension, decreased with relaxation, and changed even more with feedback. During hyperventilation the heart rates were lower than during hypoventilation, and this difference was even greater during trials with feedback. This paradoxical finding was attributed to the shallowness of the breathing. Additional data from an experiment on voluntary heart-rate control (n = 31) without feedback and one with biofeedback of heart rate (n = 18) showed that subjects were following heart-rate increase and decrease instructions with altered respiration rates. These observations are interpreted as indicating that biofeedback changes in heart rate are mediated by skeletal muscle tension, respiration, and other mediating mechanisms.

An epidemiological study of cerebral palsy in Western Australia, 1956-1975. II: Spastic cerebral palsy and perinatal factors

This case:control study demonstrates that although the incidence of spastic cerebral palsy is falling in Western Australia, the contribution made by low-birthweight and small-for-dates infants who have significant neonatal morbidity, and who have been treated in neonatal intensive care units, has increased significantly. This points to factors other than care being important in diminishing the incidence of spastic cerebral palsy. Further falls in incidence may only result from improvements in the management of the very small and very sick neonate, and preventive programmes aimed at preterm births. Obstetric intervention and fetal distress were more frequent in recent cerebral-palsy cases than in the controls. Thus, falling neonatal mortality among low-birthweight infants in Western Australia coincided with an increased incidence of spastic cerebral palsy in these infants, despite an over-all drop in the incidence of cerebral palsy.

Biofeedback and relaxation effects in electromyographic biofeedback training: a methodological note

The present study documented progressive reductions of electromyographic potentials in a biofeedback study involving instructions to 11 female and 5 male college students to both increase and decrease the feedback (and therefore the muscle tension). When only pre-experimental baselines were employed, electromyographic reductions were found with instructions to decrease the feedback. When repeated, nontreatment baseline conditions were employed as references for analysis, no electromyographic reductions were detected beyond the progressive reductions that occurred during those baselines.

Perceptual aura: not spirit but afterimage and border contrast effects

This study demonstrates that auras can be produced under laboratory conditions and explained by the principles of afterimages and border contrast phenomena.

Information variables in voluntary control and classical conditioning of heart rate: field dependence and heart-rate perception

Two experiments focused on two information variables relevant to changes in heart rate, field dependence and the ability to perceive one's own heart rate. In Exp. I, 14 field-independent and 17 field-dependent subjects completed a heart-rate perception and a voluntary heart-rate control task. The anticipated superiority in heart-rate control by field-independent subjects was detected although no evidence was found for a relationship between the amount of biofeedback available in the situation and voluntary control of the cardiovascular system. Exp. II involved 9 field-independent and 8 field-dependent subjects in a classical conditioning paradigm involving shock sensitivity. In contrast with Exp. I, in this phase of the study heart-rate increases were correlated with the ability of the subject to discriminate heart beats, especially for the field-independent group. It was concluded that field dependence and heart-rate perception are related to classically conditioned heart-rate increase for some subjects and further that field dependence may be a potent variable operating in those situations involving the voluntary control of heart rate without exteroceptive feedback.

Comparison of biofeedback pulse wave velocity and progressive relaxation on essential hypertensives

In a study undertaken to evaluate the clinical effectiveness of two behavioral treatments for essential hypertension (biofeedback on arterial pulse-wave velocity and progressive relaxation) 24 hypertensive subjects were randomly assigned to either a relaxation or biofeedback treatment group for 5 weekly sessions. In a second stage of the study 16 of the original subjects received both biofeedback and relaxation treatments during 5 additional weekly sessions. Results indicated that biofeedback and relaxation were equally effective in initial lowering of blood pressure in hypertensives. Although biofeedback training lead to superior reductions at the 3-mo. follow-up point, after 1 yr. the blood pressures of both groups were not only equal but well below those presented at the beginning of the study.

Arm veins for peripheral arterial reconstruction

The ipsilateral saphenous vein has become accepted as the best available material for femoropopliteal bypass and for arterial patch grafts as well as for visceral and cardiac bypasses. However, in a few patients, nonavailability or nonsuitability of the saphenous vein forces use of some other material. We report an experience with 32 operations using arm veins. Among the 11 long vein grafts, seven composite vein-Dacron or vein-vein grafts, and 14 vein patch grafts during the past six years, there were no infections or aneurysms and only nine thrombotic failures have been detected to date, to our knowledge. Our present indications are (1) ipsilateral saphenous vein is not available or is not suitable, (2) only a short graft or patch is needed and the saphenous vein may therefore be saved for the future, (3) to join to a saphenous graft or to a Dacron composite graft for additional length, and (4) to reconstruct an arm artery. Our experiences using cephalic and basilic veins confirms them as a useful source of autogenous material for arterial reconstruction.