Vascular access: experience with the brachiocephalic fistula

Eight years' experience with the brachiocephalic fistula for vascular access are reported. Eighty one fistulae were created in 77 patients. Forty one fistulae were created by an end to side anastomosis and 40 using a side to side technique. Overall patency was 70% at 1 year; 57% at 2 years; 50% at 3 years, which compares well with other secondary access procedures. Anastomotic configuration did not significantly affect fistula survival. Cardiac failure and arterial steal syndrome were significant problems with the side to side fistula. Two patients died from fistula complications; one exsanguinated at home from a cannulation site and another succumbed to high output cardiac failure. Infection was rare. The end to side brachiocephalic fistula is recommended as the secondary vascular access procedure of choice. It is a simple, reliable procedure which does not require graft implantation and preserves the saphenous vein, should tertiary access be required.

Intravenous drug abuse and the accident and emergency department

A 4-month prospective study of intravenous drug abusers attending an accident and emergency department was performed. A total of 92 patients presented with 104 new complaints. Seventy-eight per cent of patients were under 30 years of age and 28% were female. The primary reason for attendance was related to trauma in 30% of attendances, accidental or deliberate overdose in 26% and as a result of infection in 26%. A total of 37% of all attendances resulted in admission and two patients died in the department. Fifty-four patients (58%) had radioimmunoassay performed for hepatitis B markers and there was evidence of past or ongoing infection in 87% of these patients. Only three patients (5.6%) were HBsAg positive at the time of presentation. Accident and emergency staff should be made aware of the pattern of attendance of intravenous drug abusers and the particular problems they present.

Experiments directed towards the synthesis of anthracyclinones. VI. Claisen rearrangements of 1,4-Bis(prop-2'-enyloxy)anthraquinone

The Claisen rearrangement of 1,4-bis(prop-2'-enyloxy)anthraquinone (1) in N,N-diethylaniline and acetic anhydride has been examined. New products include compounds (3), and (6) and (14) in which a double bond has also migrated. Rearrangement of the compound (3) in o-dichlorobenzene affords the ketone (2), which supports an earlier mechanistic proposal.