Defining quality assessment in vascular surgery training: an expert Delphi process

INTRODUCTION

A robust and reproducible way of assessing training should optimise and standardise vascular surgical training. This study describes the methodology supporting the Vascular Surgery Specialty Advisory Committee regional quality assurance reports for vascular surgery training programmes in the UK.

METHODS

A Delphi consensus exercise was performed to establish the domains of training that most appropriately assess the quality of a vascular surgery training programme. A total of 54 stakeholders were invited to participate, including trainees, training programme directors and members of the vascular speciality advisory committee (SAC), vascular society executive and education committees.

RESULTS

A total of 39 stakeholders successfully completed the three-stage Delphi process over 15 weeks. The domains identified as most appropriate to assess the quality of a vascular training programme were: Joint Committee on Surgical Training (JCST) survey results, clinical experience, regional education programmes, radiology support, timetable, regional support for trainees, trainer support for trainees, opportunities for professional development, trainee-rated quality of consultant teaching and training, and trainee recommendation of the post.

CONCLUSIONS

This study describes a method to identify and prioritise domains that are appropriate to assess the quality of a vascular training programme. The domains that were identified as appropriate to assess quality are transferable internationally and the Delphi methodology could be used by other training schemes to 'fine-tune' their own domains to review and optimise the quality of their own training programmes.

Survival outcomes for cancer types with the highest death rates for adolescents and young adults, 1975-2016

BACKGROUND

Five-year relative survival for adolescent and young adult (AYA) patients with cancer diagnosed at the ages of 15 to 39 years is 85%. Survival rates vary considerably according to the cancer type. The purpose of this study was to analyze long-term survival trends for cancer types with the highest mortality among AYAs to determine where the greatest burden is and to identify areas for future research.

METHODS

Using data from the Surveillance, Epidemiology, and End Results cancer registry and the National Center for Health Statistics, the authors examined the incidence, mortality, and survival for the 9 cancer types with the highest mortality rates in this age group from 1975 to 2016. JPSurv, new survival trend software, was used in the analysis.

RESULTS

Results suggested significant improvements in 5-year relative survival for brain and other nervous system tumors, colon and rectum cancer, lung and bronchus cancer, acute myeloid leukemia, and non-Hodgkin lymphoma (all P values < .05). Limited or no improvement in survival was found for female breast cancer, cervical cancer, ovarian cancer, and bone and joint sarcomas.

CONCLUSIONS

Five-year relative survival for multiple cancer types in AYAs has improved, but some common cancer types in this group still show limited survival improvements (eg, ovarian cancer). Survival improvements in colorectal cancer have been overshadowed by its rising incidence, which suggests a substantial disease burden. Future research should focus on female breast, bone, ovarian, and cervical cancers, which have seen minimal or no improvements in survival.

LAY SUMMARY

Survival trends for adolescents and young adults with cancer are presented from a 40-year period. Although survival progress is noted for brain cancer, lung cancer, acute myeloid leukemia, and colon and rectum cancer, the incidence of colon and rectum cancer remains high. Minimal progress is evident for female breast, bone, ovarian, and cervical cancers, which are in need of renewed focus.

Annual report to the nation on the status of cancer, part I: National cancer statistics

BACKGROUND

The American Cancer Society, the Centers for Disease Control and Prevention, the National Cancer Institute, and the North American Association of Central Cancer Registries collaborate to provide annual updates on cancer occurrence and trends in the United States.

METHODS

Data on new cancer diagnoses during 2001 through 2016 were obtained from the Centers for Disease Control and Prevention-funded and National Cancer Institute-funded population-based cancer registry programs and compiled by the North American Association of Central Cancer Registries. Data on cancer deaths during 2001 through 2017 were obtained from the National Center for Health Statistics' National Vital Statistics System. Trends in incidence and death rates for all cancers combined and for the leading cancer types by sex, racial/ethnic group, and age were estimated by joinpoint analysis and characterized by the average annual percent change during the most recent 5 years (2012-2016 for incidence and 2013-2017 for mortality).

RESULTS

Overall, cancer incidence rates decreased 0.6% on average per year during 2012 through 2016, but trends differed by sex, racial/ethnic group, and cancer type. Among males, cancer incidence rates were stable overall and among non-Hispanic white males but decreased in other racial/ethnic groups; rates increased for 5 of the 17 most common cancers, were stable for 7 cancers (including prostate), and decreased for 5 cancers (including lung and bronchus [lung] and colorectal). Among females, cancer incidence rates increased during 2012 to 2016 in all racial/ethnic groups, increasing on average 0.2% per year; rates increased for 8 of the 18 most common cancers (including breast), were stable for 6 cancers (including colorectal), and decreased for 4 cancers (including lung). Overall, cancer death rates decreased 1.5% on average per year during 2013 to 2017, decreasing 1.8% per year among males and 1.4% per year among females. During 2013 to 2017, cancer death rates decreased for all cancers combined among both males and females in each racial/ethnic group, for 11 of the 19 most common cancers among males (including lung and colorectal), and for 14 of the 20 most common cancers among females (including lung, colorectal, and breast). The largest declines in death rates were observed for melanoma of the skin (decreasing 6.1% per year among males and 6.3% among females) and lung (decreasing 4.8% per year among males and 3.7% among females). Among children younger than 15 years, cancer incidence rates increased an average of 0.8% per year during 2012 to 2016, and cancer death rates decreased an average of 1.4% per year during 2013 to 2017. Among adolescents and young adults aged 15 to 39 years, cancer incidence rates increased an average of 0.9% per year during 2012 to 2016, and cancer death rates decreased an average of 1.0% per year during 2013 to 2017.

CONCLUSIONS

Although overall cancer death rates continue to decline, incidence rates are leveling off among males and are increasing slightly among females. These trends reflect population changes in cancer risk factors, screening test use, diagnostic practices, and treatment advances. Many cancers can be prevented or treated effectively if they are found early. Population-based cancer incidence and mortality data can be used to inform efforts to decrease the cancer burden in the United States and regularly monitor progress toward goals.

Annual report to the nation on the status of cancer, part II: Progress toward Healthy People 2020 objectives for 4 common cancers

BACKGROUND

The Centers for Disease Control and Prevention, the American Cancer Society, the National Cancer Institute, and the North American Association of Central Cancer Registries collaborate to provide annual updates on cancer occurrence and trends in the United States and to address a special topic of interest. Part I of this report focuses on national cancer statistics, and part 2 characterizes progress in achieving select Healthy People 2020 cancer objectives.

METHODS

For this report, the authors selected objectives-including death rates, cancer screening, and major risk factors-related to 4 common cancers (lung, colorectal, female breast, and prostate). Baseline values, recent values, and the percentage change from baseline to recent values were examined overall and by select sociodemographic characteristics. Data from national surveillance systems were obtained from the Healthy People 2020 website.

RESULTS

Targets for death rates were met overall and in most sociodemographic groups, but not among males, blacks, or individuals in rural areas, although these groups did experience larger decreases in rates compared with other groups. During 2007 through 2017, cancer death rates decreased 15% overall, ranging from -4% (rural) to -22% (metropolitan). Targets for breast and colorectal cancer screening were not yet met overall or in any sociodemographic groups except those with the highest educational attainment, whereas lung cancer screening was generally low (<10%). Targets were not yet met overall for cigarette smoking, recent smoking cessation, excessive alcohol use, or obesity but were met for secondhand smoke exposure and physical activity. Some sociodemographic groups did not meet targets or had less improvement than others toward reaching objectives.

CONCLUSIONS

Monitoring trends in cancer risk factors, screening test use, and mortality can help assess the progress made toward decreasing the cancer burden in the United States. Although many interventions to reduce cancer risk factors and promote healthy behaviors are proven to work, they may not be equitably applied or work well in every community. Implementing cancer prevention and control interventions that are sustainable, focused, and culturally appropriate may boost success in communities with the greatest need, ensuring that all Americans can access a path to long, healthy, cancer-free lives.

Implementation of a supervised exercise therapy programme

INTRODUCTION

Guidelines for peripheral vascular disease state that supervised exercise therapy (SET) programmes improve walking distance and quality of life in patients with intermittent claudication. This paper outlines the steps needed to implement a successful SET programme and discusses some of the challenges.

METHODS

Edinburgh Leisure was approached to coordinate an exercise programme aimed at rehabilitation, run by level 4 members of the Register of Exercise Professionals. It is estimated to be cost effective at 500 referrals compared with physiotherapy referral. Success is measured by walking distance, reduction of symptoms and weight loss. Edinburgh Leisure also measures success with feedback and membership numbers at its health centres.

RESULTS

Between 4 March 2014 and 25 January 2016, 155 patients were referred to the SET programme with a median age of 68 years (range: 39-95 years) and a male-to-female ratio of 1.2:1. Of these, 117 patients attended and 29 have completed the programme. The mean walking distance increased from 298.5m (range: 150-385m) to 360m (range: 195-482m), an improvement of 20%. Increasing class numbers and venues, and introducing evening classes to make the programme accessible to more patients has addressed initial patient engagement issues.

CONCLUSIONS

Collaboration with motivated local authorities can help implement a successful healthcare intervention. Early analysis is necessary to improve the system and engage as many patients as possible. The SET programme discussed has shown similar results to those of previous studies but is available at no personal cost to regional patients with intermittent claudication.

Early estimates of cancer incidence for 2015: Expanding to include estimates for white and black races

BACKGROUND

The National Cancer Institute's cancer incidence estimates through 2015 from the Surveillance, Epidemiology, and End Results (SEER) registries' November 2017 submission are released in April 2018.

METHODS

Early estimates (February 2017) of cancer incidence rates and trends from the SEER 18 registries for diagnoses in 2000 through 2015 were evaluated with a revised delay-adjustment model, which was used to adjust for the undercount of cases in the early release. For the first time, early estimates were produced for race (whites and blacks) along with estimates for new sites: the oral cavity and pharynx, leukemia, and myeloma.

RESULTS

Model validation comparing delay-adjusted rates and trends through 2014 and using 2016 submissions showed good agreement. Differences in trends through 2015 in comparison with those through 2014 were evident. The rate of female breast cancer rose significantly from 2004 to 2015 by 0.3% per year (annual percent change [APC] = 0.3%); the prior trend through 2014 (the same magnitude) was not yet significant. The female colon and rectum cancer trend for whites became flat after previously declining. Lung and bronchus cancer for whites showed a significant decline (APC for males = -2.3%, 2012-2015; APC for females = -0.7%, 2011-2015). Thyroid cancer for black females changed from a continuous rise to a flat final segment (APC = 1.6%, not significant, 2011-2015). Both kidney and renal pelvis cancer (APC = 1.5%, 2011-2015) and childhood cancers (APC = 0.5%, 2000-2015) for white males showed a significant rise in the final segments from previously flat trends. Kidney and renal pelvis cancer for black males showed a change from a significant rise to a flat trend.

CONCLUSIONS

The early release of SEER data continues to be useful as a preliminary estimate of the most current cancer incidence trends. Cancer 2018;124:2192-204. © 2018 American Cancer Society.

Recent Spatiotemporal Patterns of US Lung Cancer by Histologic Type

BACKGROUND

After a period of increasing rates, lung cancer incidence is declining in the US for men and women. We investigated lung cancer rate patterns by gender, geographic location, and histologic subtype, and for total lung cancer (TLC), for the entire study period, and for 2000-2011 from 17 surveillance, epidemiology, and end results areas.

METHODS

For each gender-histologic type combination, time trend plots and maps of age-adjusted rates are presented. Time trend significance was tested by joinpoint regression analysis. Spatial random effects models were applied to examine effects of sociodemographic factors, health insurance coverage, smoking, and physician density at the county level. Linked micromap plots illustrate patterns for important model predictors.

RESULTS

Declining incidence trends occurred for TLC (p < 0.05, entire period). Squamous cell carcinoma trends increased for females only (p < 0.05). Small cell carcinoma trends declined overall, p < 0.05, but recently increased faster for females than males. Adenocarcinoma rates initially declined, but were significantly increasing by 2004, p < 0.05. Counties with higher current smoking and family poverty were strongly associated with higher risk for all gender-histologic types (p < 0.0001, for both variables). County socioeconomic status was associated with higher risk for all lung cancer subtypes for females, p < 0.02. Counties with more diagnostic radiologists were associated with higher TLC rates (p < 0.03); counties with greater primary care physician access were associated with lower TLC rates (p < 0.03). TLC incidence rates were higher in eastern and southern states than western areas. Male rates were higher than female rates along the West Coast. Males and females had similar small cell rate patterns, with higher rates in the Midwest and southeast. Squamous cell carcinoma and adenocarcinoma rate patterns were similar to TLC patterns, except for relatively higher female adenocarcinoma rates in the northeast and northwest.

CONCLUSION

Geographic patterns and declining time trends for incident lung cancer are consistent with previous mortality patterns. Male-female time trend and geographic pattern differences occur by histologic type. Time trends remain significant, even after adjustment for significant covariates. Knowledge of the variation of lung cancer incidence by region and histologic type is useful for surveillance and for implementing lung cancer control efforts.

Early estimates of SEER cancer incidence, 2014

BACKGROUND

Cancer incidence rates and trends for cases diagnosed through 2014 using data reported to the Surveillance, Epidemiology, and End Results (SEER) program in February 2016 and a validation of rates and trends for cases diagnosed through 2013 and submitted in February 2015 using the November 2015 submission are reported. New cancer sites include the pancreas, kidney and renal pelvis, corpus and uterus, and childhood cancer sites for ages birth to 19 years inclusive.

METHODS

A new reporting delay model is presented for these estimates for more consistent results with the model used for the usual November SEER submissions, adjusting for the large case undercount in the February submission. Joinpoint regression methodology was used to assess trends. Delay-adjusted rates and trends were checked for validity between the February 2016 and November 2016 submissions.

RESULTS

Validation revealed that the delay model provides similar estimates of eventual counts using either February or November submission data. Trends declined through 2014 for prostate and colon and rectum cancer for males and females, male and female lung cancer, and cervical cancer. Thyroid cancer and liver and intrahepatic bile duct cancer increased. Pancreas (male and female) and corpus and uterus cancer demonstrated a modest increase. Slight increases occurred for male kidney and renal pelvis, and for all childhood cancer sites for ages birth to 19 years.

CONCLUSIONS

Evaluating early cancer data submissions, adjusted for reporting delay, produces timely and valid incidence rates and trends. The results of the current study support using delay-adjusted February submission data for valid incidence rate and trend estimates over several data cycles. Cancer 2017;123:2524-34. © 2017 American Cancer Society.

Assessing disparities in colorectal cancer mortality by socioeconomic status using new tools: health disparities calculator and socioeconomic quintiles

Purpose

Colorectal cancer mortality rates dropped by half in the past three decades, but these gains were accompanied by striking differences in colorectal cancer mortality by socioeconomic status (SES). Our research objective is to examine disparities in colorectal cancer mortality by SES, using a scientifically rigorous and reproducible approach with publicly available online tools, HD*Calc and NCI SES Quintiles.

Methods

All reported colorectal cancer deaths in the United States from 1980 to 2010 were categorized into NCI SES quintiles and assessed at the county level. Joinpoint was used to test for significant changes in trends. Absolute and relative concentration indices (CI) were computed with HD*Calc to graph change in disparity over time.

Results

Disparities by SES significantly declined until 1993–1995, and then increased until 2010, due to a mortality drop in populations living in high SES areas that exceeded the mortality drop in lower SES areas. HD*Calc results were consistent for both absolute and relative concentration indices. Inequality aversion parameter weights of 2, 4, 6 and 8 were compared to explore how much colorectal cancer mortality was concentrated in the poorest quintile compared to the richest quintile. Weights larger than 4 did not increase the slope of the disparities trend.

Conclusions

There is consistent evidence for a significant crossover in colorectal cancer disparity from 1980 to 2010. Trends in disparity can be accurately and readily summarized using the HD*Calc tool. The disparity trend, combined with published information on the timing of screening and treatment uptake, is concordant with the idea that introduction of medical screening and treatment leads to lower uptake in lower compared to higher SES populations and that differential uptake yields disparity in population mortality.

Using Gini coefficient to determining optimal cluster reporting sizes for spatial scan statistics

BACKGROUND

Spatial and space-time scan statistics are widely used in disease surveillance to identify geographical areas of elevated disease risk and for the early detection of disease outbreaks. With a scan statistic, a scanning window of variable location and size moves across the map to evaluate thousands of overlapping windows as potential clusters, adjusting for the multiple testing. Almost always, the method will find many very similar overlapping clusters, and it is not useful to report all of them. This paper proposes to use the Gini coefficient to help select which of the many overlapping clusters to report.

METHODS

The Gini coefficient provides a quick and intuitive way to evaluate the degree of the heterogeneity of the collection of clusters, which is useful to explain how well the cluster collection reveal the underlying true cluster patterns. Using simulation studies and real cancer mortality data, it is compared with the traditional approach for reporting non-overlapping clusters.

RESULTS

The Gini coefficient can identify a more refined collection of non-overlapping clusters to report. For example, it is able to determine when it makes more sense to report a collection of smaller non-overlapping clusters versus a single large cluster containing all of them. It also fulfils a set of desirable theoretical properties, such as being invariant under a uniform multiplication of the population numbers by the same constant.

CONCLUSIONS

The Gini coefficient can be used to determine which set of non-overlapping clusters to report. It has been implemented in the free SaTScan™ software version 9.3 ( www.satscan.org ).

Preliminary estimates of SEER cancer incidence for 2013

BACKGROUND

This article presents a first look at rates and trends for cases in the Surveillance, Epidemiology, and End Results (SEER) program diagnosed through 2013 using the February 2015 submission, and a validation of rates and trends from the February 2014 submission using the subsequent November 2014 submission. To the authors' knowledge, this is the second time SEER has published trends based on the early February submission. Three new cancer sites were added: cervix, thyroid, and liver/ intrahepatic bile duct.

METHODS

A reporting delay model adjusted for the undercount of cases, which is substantially larger for the February than the subsequent November submission, was used. Joinpoint regression methodology was used to assess trends. Delay-adjusted rates and trends were checked to assess validity between the February and November 2014 submissions.

RESULTS

The validation of rates and trends from the February and November 2014 submissions demonstrated even better agreement than the previously reported comparison between the February and November 2013 submissions, thereby affording additional confidence that the delay-adjusted February submission data can be used to produce valid estimates of incidence trends. Trends for cases diagnosed through 2013 revealed more rapid declines in female colon and rectal cancer and prostate cancer. A plateau in female melanoma trends and a slowing of the increases in thyroid cancer and male liver/intrahepatic bile duct cancer trends were observed.

CONCLUSIONS

Analysis of early cancer data submissions can provide a preliminary indication of differences in incidence trends with an additional year of data. Although the delay adjustment correction adjusts for underreporting of cases, caution should be exercised when interpreting the results in this early submission. Cancer 2016;122:1579-87. © 2016 American Cancer Society.

Adolescent and young adult cancer survival

Adolescent and young adults (AYAs) face challenges in having their cancers recognized, diagnosed, treated, and monitored. Monitoring AYA cancer survival is of interest because of the lack of improvement in outcome previously documented for these patients as compared with younger and older patient outcomes. AYA patients 15-39 years old, diagnosed during 2000-2008 with malignant cancers were selected from the SEER 17 registries data. Selected cancers were analyzed for incidence and five-year relative survival by histology, stage, and receptor subtypes. Hazard ratios were estimated for cancer death risk among younger and older ages relative to the AYA group. AYA survival was worse for female breast cancer (regardless of estrogen receptor status), acute lymphoid leukemia (ALL), and acute myeloid leukemia (AML). AYA survival for AML was lowest for a subtype associated with a mutation of the nucleophosmin 1 gene (NPM1). AYA survival for breast cancer and leukemia remain poor as compared with younger and older survivors. Research is needed to address disparities and improve survival in this age group.

Early estimates of SEER cancer incidence for 2012: Approaches, opportunities, and cautions for obtaining preliminary estimates of cancer incidence

BACKGROUND

The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program collects and publishes population-based cancer incidence data from registries covering approximately 28% (seer.cancer.gov/registries/data.html) of the US population. SEER incidence rates are released annually in April from data submitted the prior November. The time needed to identify, consolidate, clean, and submit data requires the latest diagnosis year included to be 3 years before release. Approaches, opportunities, and cautions for an earlier release of data based on a February submission are described.

METHODS

First, cases submitted in February for the latest diagnosis year represented 92% to 98% of those in the following November submission. A reporting delay model was used to statistically adjust counts in recent diagnosis years for cases projected in the future. February submissions required larger adjustment factors than November submissions. Second, trends were checked to assess the validity.

RESULTS

Most cancer sites had similar annual percent change (APC) trends for February and November 2013. Male colon and rectum cancer and female lung and bronchus cancer showed an acceleration in declining APC trends only in February. Average annual percent change (AAPC) trends for the 2 submissions were similar for all sites.

CONCLUSIONS

For the first time, preliminary 2012 incidence rates, based on February submissions, are provided. An accelerated decline starting in 2008 for male colon and rectum cancer rates and male lung cancer rates did not persist when 2012 data were added. An earlier release of SEER data is possible. Caution must be exercised when one is interpreting changing trends. Use of the more conservative AAPC is advised.

US lung cancer trends by histologic type

BACKGROUND

Lung cancer incidence rates overall are declining in the United States. This study investigated the trends by histologic type and demographic characteristics.

METHODS

Surveillance, Epidemiology, and End Results (SEER) program rates of microscopically confirmed lung cancer overall and squamous cell, small cell, adenocarcinoma, large cell, other, and unspecified carcinomas among US whites and blacks diagnosed from 1977 to 2010 and white non-Hispanics, Asian/Pacific Islanders, and white Hispanics diagnosed from 1992 to 2010 were analyzed by sex and age.

RESULTS

Squamous and small cell carcinoma rates declined since the 1990s, although less rapidly among females than males. Adenocarcinoma rates decreased among males and only through 2005, after which they then rose during 2006 to 2010 among every racial/ethnic/sex group; rates for unspecified type declined. Male/female rate ratios declined among whites and blacks more than among other groups. Recent rates among young females were higher than among males for adenocarcinoma among all racial/ethnic groups and for other specified carcinomas among whites.

CONCLUSIONS

US lung cancer trends vary by sex, histologic type, racial/ethnic group, and age, reflecting historical cigarette smoking rates, duration, cessation, cigarette composition, and exposure to other carcinogens. Substantial excesses among males have diminished and higher rates of adenocarcinoma among young females have emerged as rates among males declined more rapidly. The recognition of EGFR mutation and ALK rearrangements that occur primarily in adenocarcinomas are the primary basis for the molecular revolution that has transformed lung cancer diagnosis and treatment over the past decade, and these changes have affected recent type-specific trends.

A nurse-run clinic for patients with incidentally discovered small abdominal aortic aneurysms is feasible and cost-effective

INTRODUCTION

Patients with incidentally discovered small abdominal aortic aneurysms (AAA) require assessment by a vascular surgery department for possible enrollment in a surveillance programme. Our unit implemented a vascular nurse-run AAA clinic in October 2010. The aim of this study was to assess the feasibility of a specialist nurse-run small AAA clinic.

METHODS

Demographic and clinical data were collected prospectively for all patients seen in the new vascular nurse clinic between October 2010 and November 2012. A validated AAA operative mortality score was used to aid decision making by the vascular nurse.

RESULTS

Some 250 patients were seen in the clinic. 198 (79.2%) patients were enrolled in surveillance, 40 (16%) declined enrollment and 12 (4.8%) were referred to a consultant clinic for further assessment. The majority of patients were male and the mean age was 73.7 years. Co-morbidities included hypertension, a history of cardiovascular disease, and hyperlipidaemia. The majority of referrals were considered to be low operative risk. No aneurysms ruptured whilst under surveillance.

CONCLUSIONS

A nurse-run clinic that assesses patients with incidentally discovered small AAAs for inclusion in AAA surveillance is a feasible alternative to assessment of these patients in a consultant-run clinic.

Negative pressure wound therapy as an adjunct to compression for healing chronic venous ulcers

OBJECTIVE

To determine the efficacy of negative pressure wound therapy (NPWT), when used in combination with compression bandaging, for healing chronic resistant venous ulcers.

METHOD

In this pilot study, seven patients (with a total of 12 chronic resistant venous ulcers) received adjunctive NPWT and compression bandaging for 4 weeks. Their wounds were monitored for a total of 12 weeks.

RESULTS

Dormant ulcers were seen to rapidly develop into healthy wounds, with a granulating base.

CONCLUSION

This regimen may have a role in stimulating chronic venous ulcers into healing wounds, or in preparing them for skin grafting.

Lung disease mortality in the United States: the National Longitudinal Mortality Study

SETTING

The National Longitudinal Mortality Study (NLMS) offers the advantage of assessing mortality in a representative population of the United States.

OBJECTIVE

To evaluate health disparities associated with lung cancer and chronic obstructive pulmonary disease (COPD) mortality in the United States and whether these associations are similar between these outcomes.

DESIGN

The NLMS is a prospective study. Data from NLMS cohort years 1985, 1992, 1993, 1995 and 1996 were included, representing nearly 1.5 million person-years. Lung cancer and COPD mortality relative risks (RRs) from Cox regression analysis, including residential characteristics, marital status, education, health insurance and family income, were evaluated.

RESULTS

By 1998, 1273 lung cancer deaths and 772 COPD deaths occurred. Lung cancer mortality rates were approximately two times higher than COPD mortality rates among race and ethnic groups. Cox regression analysis revealed that low education (RR = 1.77, significant, P = 0.01) and low family income (RR = 1.50, significant, P = 0.01) are associated with lung cancer and COPD mortality, controlling for age, race/ethnicity, sex and smoking status.

CONCLUSIONS

COPD and lung cancer mortality have similar associations with health disparity indicators in the NLMS data, with some differences in the magnitude of the effect.

The crossroads of GIS and health information: a workshop on developing a research agenda to improve cancer control

Cancer control researchers seek to reduce the burden of cancer by studying interventions, their impact in defined populations, and the means by which they can be better used. The first step in cancer control is identifying where the cancer burden is elevated, which suggests locations where interventions are needed. Geographic information systems (GIS) and other spatial analytic methods provide such a solution and thus can play a major role in cancer control. This report presents findings from a workshop held June 16-17, 2005, to bring together experts and stakeholders to address current issues in GIScience and cancer control. A broad range of areas of expertise and interest was represented, including epidemiology, geography, statistics, environmental health, social science, cancer control, cancer registry operations, and cancer advocacy. The goals of this workshop were to build consensus on important policy and research questions, identify roadblocks to future progress in this field, and provide recommendations to overcome these roadblocks.

Modelling through-soil transport of phosphorus to surface waters from livestock agriculture at the field and catchment scale

A model of phosphorus (P) losses in a small dairy farm catchment has been set up based on a linkage of weather-driven field-scale simulations using an adaptation of the MACRO model. Phosphorus deposition, both in faeces from grazing livestock in summer and in slurry spread in winter, has been represented. MACRO simulations with both forms of P deposition had been calibrated and tested at the individual field scale in previous studies. The main contaminant transport mechanism considered at both field and catchment scales is P sorbed onto mobile colloidal faeces particles, which move through the soil by macropore flow. Phosphorus moves readily through soil to field drains under wet conditions when macropores are water-filled, but in dry soil the P carrying colloids become trapped so losses remain at a low level. In the catchment study, a dairy farm is assumed to be composed of fields linked by a linear system of ditches which discharge into a single river channel. Results from linked simulations showed reasonable fits to values of catchment outflow P concentrations measured at infrequent intervals. High simulated outflow P concentrations occurred at similar times of year to high measured values, with some high loss periods during the summer grazing season and some during the winter when slurry would have been spread. However, there was a lack of information about a number parameters that would be required to carry out a more exact calibration and provide a rigorous test of the modelling procedure. It was nevertheless concluded that through soil flow of colloid sorbed P by macropore flow represents a highly plausible mechanism by which P is transported to river systems in livestock farming catchments. This represents an alternative to surface runoff transport, a mechanism to which high P losses from livestock farming areas have often been attributed. The occurrence of high simulated levels of loss under wet conditions indicates environmental benefits from avoiding slurry spreading on wet soil or during rain, and from some forms of grazing management.

Predicting the effect of livestock inputs of E. coli on microbiological compliance of bathing waters

Three alternative approaches to predicting delivery of faecal indicators from livestock sources to surface water in the catchment of the River Irvine, Ayrshire, Scotland, are described. These are a soil transport model which assumes all E. coli are transported through the soil, a regression model using observed E. coli concentrations in surface waters, and a distributed catchment model (PAMIMO). Each of these is linked to a simple group of equations describing inputs of E. coli from livestock to land, transport and inactivation in the river Irvine and mixing and inactivation in the sea. The models predict E. coli content of bathing water for Irvine beach. The regression model gives the best predictions of bathing water quality. The low values predicted by the soil transport model suggests that preventing surface runoff of faecal indicators from livestock would provide an adequate solution to the problem of bathing water contamination.

Aspirin Resistance in Cardiovascular Disease: A Review

BACKGROUND

Aspirin is effective at reducing the cardiovascular event rate in defined patient groups. The introduction of antiplatelet therapies other than aspirin and the concept of aspirin resistance have led to critical reappraisal of current treatment. This review aims to clarify the evidence for aspirin resistance in patients with atherosclerosis.

METHODS

Medline search was performed to identify publications concerned with antiplatelet effects of aspirin and failure of aspirin therapy. Manual cross referencing was also performed.

RESULTS AND CONCLUSION

Wide variations in the rate of aspirin resistance (5.5-75%) have been reported. The lack of consensus on an appropriate definition and the number of different tests used to investigate aspirin resistance needs to be addressed. There are few studies where the primary aim was to document aspirin resistance or aspirin non-response. Further work should aim to investigate if aspirin resistance is clinically important and, if it is, what treatments may be beneficial to the at risk patient.

Cancer survival and incidence from the Surveillance, Epidemiology, and End Results (SEER) program

An overview of data on cancer at all sites combined and on selected, frequently occurring cancers is presented. Descriptive cancer statistics include average annual Surveillance, Epidemiology, and End Results (SEER) Program incidence, U.S. mortality and median age at diagnosis, and death for the period 1996-2000. Changes during the time period 1992-2000 are summarized by the annual percent change in SEER incidence and U.S. mortality data for this period. Five-year relative survival for selected cancers is examined by stage at diagnosis, based on data from 1990-1999. In addition, 5-year conditional survival for patients already surviving for 1-3 years after diagnosis is discussed as well as relative survival for other time periods. These measures may be more meaningful for clinical management and prognosis than 5-year relative survival from time of diagnosis. The likelihood of developing cancer during one's lifetime is 1 in 2 for males and 1 in 3 for females, based on 1998-2000 data. It is estimated that approximately 9.6 million people in the U.S. who have had a diagnosis of cancer are alive. Five-year relative survival varies greatly by cancer site and stage at diagnosis, and tends to increase with time since diagnosis. The median age at cancer diagnosis is 68 for men and 65 for women. The 5-year relative survival rate for persons diagnosed with cancer is 62.7%, with variation by cancer site and stage at diagnosis. For patients diagnosed with cancers of the prostate, female breast, corpus uteri, and urinary bladder, the relative survival rate at 8 years is over 75%.

Randomized clinical trial of suction versus standard clearance of the diathermy plume

BACKGROUND

Diathermy smoke contains complex hydrocarbons and organic material, and may contain viable tumour cells or viral particles. These particles measure from 0.05 to more than 25 microm, and long-term exposure to such particles may have adverse effects on health. This study investigated whether a suction clearance device reduces the amount of smoke reaching the surgeon's mask.

METHODS

This was a randomized clinical trial in which subjects were randomized to standard diathermy equipment (group 1) or a diathermy smoke extraction system (group 2). All patients underwent thyroid or parathyroid surgery with standard anterior cervical collar incision and division of the strap muscles. The difference in the amount of smoke reaching the level of the operator's mask was measured by means of an aerosol monitor.

RESULTS

Fifteen patients were randomized to each group. The mean amount of smoke detected at the level of the operator's mask was 0.137 mg/m(3) in group 1 and 0.012 mg/m(3) in group 2 (P < 0.001). The maximum amount detected was 2.411 and 0.255 mg/m(3) respectively (P < 0.001). There were no significant differences between the groups in terms of incision time or background particles measured before and after surgery. There was no correlation between gland weight and incision time or amount of smoke detected.

CONCLUSION

Suction clearance of the diathermy plume resulted in a significant reduction in the amount of smoke reaching the level of the operator's mask. Although the risk of diathermy smoke inhalation is currently unknown, use of such a system appears advisable.

Risk factor documentation in elective and emergency vascular surgical admissions

OBJECTIVES

this study investigates current practice of risk factor documentation in a vascular unit and compares variations in risk factor assessment between elective and emergency admissions.

METHODS

one hundred and forty-four patients who underwent vascular surgical intervention for atherosclerotic disease during the year 2000 were retrospectively identified from computerised database. Case note review collated demographic details, data on risk factor assessment and the nature of surgery. Data were analysed using SPSS statistical software.

RESULTS

the male to female ratio was 2.3:1 with a median (range) age of 73 (31-95) years. For 55 (38%) emergency admissions the following risk factors were not documented; ischaemic heart disease (8), diabetes mellitus (10), hypertension (10), smoking habit (13) and antiplatelet therapy (18). For 89 (62%) elective admissions the following risk factors were not documented; ischaemic heart disease (11), diabetes mellitus (9), hypertension (4), smoking habit (5) and antiplatelet therapy (19). Sixty-six (72.5%) routine admissions and 11 (20.8%) emergency admissions had estimations of serum cholesterol documented (chi(2) p < 0.001). There were no statistically significant differences in the documentation of other risk factors between the 2 groups.

CONCLUSION

risk factors are not documented consistently for emergency vascular surgical admissions. Staff education should aim to improve risk factor assessment for elective and emergency admissions to reduce cardiovascular events and possibly improve surgical outcome in patients with atherosclerotic disease.

The systemic effects of intermittent claudication are reversed by angioplasty

INTRODUCTION

exercise in patients with intermittent claudication causes systemic effects, the consequences of which are unknown. This study investigates whether successful PTA reverses the systemic effects.

PATIENTS AND METHODS

ten patients with IC were recruited prior to PTA. Having emptied their bladders and rested for 1 h, pre-exercise blood and urine samples were collected. Patients underwent treadmill exercise to maximum walking time and blood samples were collected at 10, 20 and 30 min. A second urine sample was collected at 60 min. Total antioxidant capacity (TAC) and von Willebrands Factor (vWF) were measured in blood and albumin/creatinine ratio (ACR) and retinol binding protein/creatinine ratio (RBP/Cr) in urine. Patients were recalled 2 weeks after successful angioplasty and the protocol repeated. Following PTA patients walked for a maximum of 5 min.

RESULTS

there was no significant change in vWF. Exercise in claudicants induced a significant increase in median ACR (pre/post exercise=0.85 p =0.03) and in median RBP/Cr (pre/post exercise=1.8 p =0.04). These changes were no longer evident after successful PTA. TAC was significantly different before and after angioplasty at all time intervals.

CONCLUSION

successful PTA reverses glomerular effects of exercise in claudicants. Future work should investigate the use of PTA in conjunction with exercise in the treatment of peripheral vascular disease.

The effect of acute normovolaemic haemodilution on blood transfusion requirements in abdominal aortic aneurysm repair

OBJECTIVE

to evaluate the impact of acute normovolaemic haemodilution (ANH) on the blood transfusion requirements in elective abdominal aortic aneurysm (AAA) repair in a single vascular unit.

METHODS

thirty-two patients underwent ANH during elective AAA repair between 1992 and 1997. The operation was performed by the same surgeon/anaesthetist team in 75% of cases. Their demographic details, type of aneurysm (infra-renal or supra-renal), preoperative blood cross match, use of intra-operative red cell salvage, blood loss, peri-operative bank blood requirements, pre-op and on-discharge haemoglobin levels and post-operative outcome were recorded. The results were compared to a group of 40 randomly selected patients (to represent the unit average) who underwent elective AAA repair by variable surgeon/anaesthetist teams without ANH in the same time period.

RESULTS

there were more supra-renal AAA repairs in the ANH group (8/32) than in the non-ANH group (0/40, p<0.01). ANH patients required significantly less blood transfusion peri-operatively (median 2 units) than the non-ANH patients (median 3 units, p=0.02). There were no other significant differences between the variables measured.

CONCLUSION

these results suggest that a dedicated team can achieve significant reductions in the use of heterologous blood transfusion compared to the vascular unit average experience by the effective use of ANH.

Improving cytological diagnosis and surgical management of parotid adenolymphoma

BACKGROUND

The role of fine-needle aspiration cytology (FNAC) in the diagnosis and management of discrete parotid swellings remains controversial. Controlled enucleation can be appropriate with accurate preoperative diagnosis. This study (1985-1995) reviewed the role of FNAC in the diagnosis and surgical management of adenolymphoma.

METHODS

Review of cytological smears by two observers concentrated on the features of infarction and squamoid metaplasia. Sensitivity, interobserver and intraobserver variation were evaluated statistically in a two-run 'blinded' analysis of 80 cytological slides from a variety of lesions.

RESULTS

Of 222 epithelial neoplasms of the parotid, 33 were adenolymphomas. FNAC was performed before operation in 32, producing 34 slides, and a correct cytological diagnosis was made in 21 patients. Retrospective review of the 34 slides, to examine specific features of squamoid metaplasia and infarction, improved diagnostic accuracy. The reliability and reproducibility of cytodiagnosis was confirmed by analysis of interobserver and intraobserver agreement. The sensitivity was high (0.76-0.88). Controlled enucleation was performed in 12 patients and superficial parotidectomy in 11. There were no tumour recurrences.

CONCLUSION

Attention to the features of squamoid metaplasia and infarction improves cytological diagnosis and directs appropriate surgical management.

Potassium uptake supporting plant growth in the absence of AKT1 channel activity: Inhibition by ammonium and stimulation by sodium

A transferred-DNA insertion mutant of Arabidopsis that lacks AKT1 inward-rectifying K+ channel activity in root cells was obtained previously by a reverse-genetic strategy, enabling a dissection of the K+-uptake apparatus of the root into AKT1 and non-AKT1 components. Membrane potential measurements in root cells demonstrated that the AKT1 component of the wild-type K+ permeability was between 55 and 63% when external [K+] was between 10 and 1,000 microM, and NH4+ was absent. NH4+ specifically inhibited the non-AKT1 component, apparently by competing for K+ binding sites on the transporter(s). This inhibition by NH4+ had significant consequences for akt1 plants: K+ permeability, 86Rb+ fluxes into roots, seed germination, and seedling growth rate of the mutant were each similarly inhibited by NH4+. Wild-type plants were much more resistant to NH4+. Thus, AKT1 channels conduct the K+ influx necessary for the growth of Arabidopsis embryos and seedlings in conditions that block the non-AKT1 mechanism. In contrast to the effects of NH4+, Na+ and H+ significantly stimulated the non-AKT1 portion of the K+ permeability. Stimulation of akt1 growth rate by Na+, a predicted consequence of the previous result, was observed when external [K+] was 10 microM. Collectively, these results indicate that the AKT1 channel is an important component of the K+ uptake apparatus supporting growth, even in the "high-affinity" range of K+ concentrations. In the absence of AKT1 channel activity, an NH4+-sensitive, Na+/H+-stimulated mechanism can suffice.

The pharmacokinetics of a single dose of gentamicin (4 mg/kg) as prophylaxis in cardiac surgery requiring cardiopulmonary bypass

BACKGROUND

Cardiopulmonary bypass has complex effects on drug pharmacokinetics, which is important when considering the use of once-daily aminoglycoside regimens during cardiac surgery.

AIM

To study the effects of cardiopulmonary bypass on the pharmacokinetics of a single dose of gentamicin (4 mg/kg).

PATIENTS AND METHODS

Nine patients undergoing valve replacement surgery were given a single dose of gentamicin (4 mg/kg) at induction of anaesthesia and blood was taken for assay at 0, O.5, 1, 1.5, 2, 2.5, 3, 4, 6, 10, 16, 22 and 24 h following administration. The mean (range) gentamicin Cmax was 18.7 (12.4-26.3) mg/litre. Three patients had concentrations of gentamicin after 24 h of > 1 mg/litre. During cardiopulmonary bypass, the mean (range) gentamicin half-life (t1/2) was 5.1 (2.0-15.1) h and post-bypass the t1/2 was 7.1 (3.0-13.9) h.

CONCLUSION

There is significant correlation between the elimination t1/2 and length of cardiopulmonary bypass (r = 0.89, P < 0.01). These results suggest that gentamicin excretion is delayed following cardiopulmonary bypass so that with dose regimens of > 4 mg/kg there is a risk of toxicity.

Vascular surgical society of great britain and ireland: systemic effects of exercise in claudicants are associated with neutrophil activation

BACKGROUND: Claudication induces potentially harmful systemic effects which may be mediated through free radicals and neutrophil activation. This study examined the impact of these mechanisms on renal tubular function. METHODS: Flow cytometry was used to determine CD11b expression by neutrophils and monocytes, and expression of P selectin (CD62P) by platelets, in 16 patients with intermittent claudication and eight matched controls before and at intervals after exercise. Total antioxidant capacity (TAC) and von Willebrand factor (vWF) were measured at similar intervals. Renal tubular function was assessed before and 60 min after exercise by assay of retinol binding protein : creatinine ratio (RBP : Cr) in urine. All patients and none of the controls had a significant exercise-induced fall in ankle pressure. Fluorescein isothiocyanate-labelled monoclonal antibodies against CD11b and CD62P were added to blood and analysis was performed on the flow cytometer within 72 h. RESULTS: There were no significant differences in monocytes, platelets or vWF between patients and controls over time. There was a significant change in RBP : Cr following exercise in patients (median 4.2 (95 per cent confidence interval 2.4-85.2); P </= 0.01, Wilcoxon test) but not controls (2.7 (-1 to 7.5); P not significant). See Table above. CONCLUSION: Renal tubular function was adversely affected by acute exercise in claudicants. TAC was higher in claudicants at rest and was increased after exercise suggesting an increased free radical challenge. Neutrophil activation is significantly different between claudicants and controls before and after exercise, and may provide a link between free radical generation and renal tubular injury.

Vascular surgical society of great britain and ireland: angioplasty reverses the systemic effects of exercise in intermittent claudication

BACKGROUND: The choice between exercise training and percutaneous transluminal angioplasty (PTA) in the treatment of intermittent claudication (IC) remains controversial. Exercise is known to induce systemic effects in claudicants. This study aimed to determine whether such systemic effects are reversed by PTA. METHODS: Ten patients with IC were recruited before PTA. Having emptied the bladder and rested for 1 h, pre-exercise blood and urine samples were collected. Patients underwent treadmill exercise to their maximum walking time and further blood samples were collected at 10, 20 and 30 min. A second urine sample was collected at 60 min. Total antioxidant capacity (TAC) and von Willebrand factor (vWF) were measured in blood, and albumin : creatinine ratio (ACR) and retinol binding protein : creatinine ratio (RBP : Cr) in urine. Patients were recalled 2 weeks after successful angioplasty and the protocol was repeated. Statistical analysis was by Wilcoxon signed rank test. RESULTS: Following PTA, all patients walked for 5 min on the treadmill. All patients had a significant exercise-induced fall in ankle pressure that was reversed by PTA. Changes in TAC are shown in the Table. There was no significant change in vWF. Exercise in claudicants induced a significant increase in median ACR (pre/post exercise (pre-exercise value divided by post-exercise value) 0.8; P = 0.03) and in median RBP : Cr (pre/post exercise 1.8; P = 0.04). These changes were no longer evident after successful PTA. CONCLUSION: Exercise-induced changes in renal glomerular (ACR) and tubular function (RBP : Cr) in claudicants were reversed by successful angioplasty. PTA reduced the systemic TAC before and after exercise suggesting a reduced free radical challenge.

Drinking water arsenic in Utah: A cohort mortality study

The association of drinking water arsenic and mortality outcome was investigated in a cohort of residents from Millard County, Utah. Median drinking water arsenic concentrations for selected study towns ranged from 14 to 166 ppb and were from public and private samples collected and analyzed under the auspices of the State of Utah Department of Environmental Quality, Division of Drinking Water. Cohort members were assembled using historical documents of the Church of Jesus Christ of Latter-day Saints. Standard mortality ratios (SMRs) were calculated. Using residence history and median drinking water arsenic concentration, a matrix for cumulative arsenic exposure was created. Without regard to specific exposure levels, statistically significant findings include increased mortality from hypertensive heart disease [SMR = 2.20; 95% confidence interval (CI), 1.36-3.36], nephritis and nephrosis (SMR = 1.72; CI, 1.13-2.50), and prostate cancer (SMR = 1.45; CI, 1.07-1. 91) among cohort males. Among cohort females, statistically significant increased mortality was found for hypertensive heart disease (SMR = 1.73; CI, 1.11-2.58) and for the category of all other heart disease, which includes pulmonary heart disease, pericarditis, and other diseases of the pericardium (SMR = 1.43; CI, 1.11-1.80). SMR analysis by low, medium, and high arsenic exposure groups hinted at a dose relationship for prostate cancer. Although the SMRs by exposure category were elevated for hypertensive heart disease for both males and females, the increases were not sequential from low to high groups. Because the relationship between health effects and exposure to drinking water arsenic is not well established in U.S. populations, further evaluation of effects in low-exposure populations is warranted.

Vascular surgical society of great britain and ireland: patients with a failed infrainguinal bypass graft have abnormal lipid metabolism

BACKGROUND: Dyslipidaemias adversely affect vascular tone, endothelial function and platelet activation. Abnormal lipid metabolism has not been established as a risk factor for infrainguinal bypass graft failure. Lipid metabolism was evaluated prospectively in patients with patent and occluded grafts. METHODS: Twenty-eight patients with failed infrainguinal grafts (group 1) were identified from a prospective computerized database. Twenty matched controls with functioning grafts (group 2) were recruited from a graft surveillance programme. Fasting blood samples were analysed for triglyceride (TG), high-density lipoprotein (HDL) and cholesterol. A newly devised rapid TG tolerance test was conducted with analysis of TG at 1, 2 and 2.5 h. Endothelial lipoprotein lipase (LPL) was measured 30 min after intravenous administration of heparin 50 units kg-1. RESULTS: The cholesterol : HDL ratio was significantly higher in group 1 than group 2 (median 6.0 (range 3. 1-10.0) versus 4.7 (2.3-9.4); P = 0.0008, Mann-Whitney test) as was fasting TG (2.6 (1.0-6.3) versus 1.7 (0.6-4.7) mmol l-1; P = 0.03). The area under the curve of the TG tolerance test was not significantly different (P = 0.08); however, the 2.5-h levels of TG were significantly different between the groups (group 1, 2.0 (0.5-6. 6) mmol l-1; group 2, 1.2 (0.3-6.8) mmol l-1; P = 0.01). LPL was significantly lower in group 1 (52.4 (2.2-235.9) versus 86.8 (28. 6-281.5) mmol/l; P = 0.04). CONCLUSION: These data suggest that abnormal lipid metabolism is a significant risk factor for infrainguinal graft occlusion. This study provides a rationale for randomized trials of lipid-modifying therapies in patients undergoing arterial reconstruction for peripheral vascular disease.

Small cell osteosarcoma of the ulna: a case report and review of the literature

We report a case of small cell osteosarcoma arising in the distal ulna. The radiologic and pathologic features of this histologic variant of osteosarcoma that allow differentiation from other lytic lesions with small round cells are discussed.

Vascular surgical intervention for complications of cardiovascular radiology: 13 years' experience in a single centre

This study investigates incidence and outcome of iatrogenic vascular complications needing surgery in a single vascular unit serving interventional vascular radiology and interventional cardiology. Evolution of diagnostic and interventional cardiovascular radiology, along with the introduction of non-surgical therapies for such complications, may have influenced the number of vascular complications requiring emergency surgery. Vascular surgical data were collected from information prospectively entered on computerised database and case note review. Radiology data were collated from prospective entries in logbooks and computerised database. In all 24,033 cardiovascular radiological procedures were performed between 1984 and 1996 (61% cardiac), numbers increasing annually. During this period, 62 patients (40 peripheral; 22 cardiac) required emergency surgical intervention after radiological procedures. Mean age was 61.9 years (range 1-92 years), male to female ratio was 1:1. The absolute number of cases requiring surgical intervention peaked in 1989, subsequently reducing annually. Sites of vascular injury included common femoral artery (40), brachial artery (6), iliac artery (6), popliteal artery (5), other (5). A total of 87 vascular surgical operations was performed (range 1-6 operations per patient). Interventions included thrombectomy/embolectomy (29), bypass grafting (16), direct repair (27). Seven major amputations were performed (two bilateral). Mortality after surgery was 9.7%. Mean inpatient hospital stay was 11.3 days (range 0-75 days). A Poisson regression model indicates a 5% reduction in risk for each successive year of observation; however, this did not reach statistical significance (P = 0.16, 95% CI 12% decreased risk to 2% increased risk). The risk of surgical intervention after diagnostic or interventional cardiovascular radiology is diminishing but still requires vigilance. Necessity for surgical intervention is associated with a high risk of morbidity and mortality.

Compression ultrasonography for false femoral artery aneurysms: hypocoagulability is a cause of failure

OBJECTIVES

False femoral artery aneurysm is an occasional complication of percutaneous cardiovascular radiological procedures. Compression ultrasonography causes thrombosis non-invasively, reducing need for operative intervention. The technique fails in a proportion of cases. Analysis was undertaken to identify causes of failure.

DESIGN

Prospective open study.

MATERIALS AND METHODS

Patients presenting with false femoral artery aneurysm since 1984 were identified from a computerised database (BIPAS). Since 1993 compression ultrasonography has been performed as first line treatment according to a standard protocol. Prospectively collected ultrasonographic data and case notes were reviewed to identify causes of failed compression.

RESULTS

False femoral artery aneurysm occurred as a complication in 32/26,687 (0.12%) cardiovascular radiological procedures. Eighteen aneurysms were treated by compression. The technique was successful in 11/18 (61%) cases but primary failure occurred in seven cases. Six out of seven had bleeding abnormalities (Chi-squared analysis with Yates correction 10.55, p = 0.0012), four were anticoagulated and compression was subsequently successful following reversal of warfarin therapy in three of these patients. In 4/18 cases surgical repair was necessary.

CONCLUSION

Compression ultrasonography is an effective treatment of false femoral aneurysms, however, hypocoagulability is a significant cause of failure. For patients in whom anticoagulation cannot be reversed, primary surgical repair should be considered.

The progression and correction of duplex detected velocity shifts in angiographically normal vein grafts

OBJECTIVES

To review the sensitivity of duplex scanning and angiography at detecting vein graft stenoses in patients on a graft surveillance programme.

DESIGN

Prospective, open, non-randomised study.

PATIENTS AND METHODS

Since February 1993, 143 patients with 148 grafts (70% in situ, 30% reversed) have attended postoperative infrainguinal vein graft surveillance for a minimum of 6 weeks. Fifty-seven graft stenoses in 57 grafts were identified by duplex scanning as a localised high velocity jet. Angiography was performed in all except 12 patients.

RESULTS

Angiography confirmed a duplex abnormality in all but 10 patients. Of these, five patients remain stable and asymptomatic with a persisting duplex abnormality. The remaining five patients, although asymptomatic, exhibited disease progression on duplex and surgical intervention confirmed significant stenoses, which were successfully treated.

CONCLUSION

The results suggest that duplex scanning is a reliable imaging modality for detecting vein graft stenoses. Selection for surgical correction can be made, in some circumstances on the basis of clinical and ultrasound criteria alone.

Sympathetic skin response and patient satisfaction on long-term follow-up after thoracoscopic sympathectomy for hyperhidrosis

OBJECTIVES

To determine effect of sympathectomy for hyperhidrosis on sympathetic skin response (SSR) during long-term follow-up. Patient satisfaction was assessed and surgical complications noted.

DESIGN

Prospective, Open, Non-randomised study.

MATERIALS AND METHODS

Patients who had undergone bilateral thoracoscopic sympathectomy for hyperhidrosis underwent postoperative assessment of SSRs. A 15 mA stimulus was applied over the median nerve contralateral to the sympathectomy and evoked electrodermal activity was recorded from the sympathectomised palm using a Dantec Counterpoint Mk 2. Patient satisfaction with surgery was assessed by questionnaire and visual analogue score (0-1.0).

RESULTS

Of 26 patients, 21 were female. Mean (range) age was 23 (9-36) years. Mean (range) follow up was 39 (4-138) months. 12% of cases had residual or recurrent symptoms. Median (range) patient satisfaction was 0.83 (0.06-1.0). In 7/52 palms recurrent SSRs were not detected. Repeated measures analysis of variance found amplitude of SSR to be of low significance with respect to time since surgery (F = 0.48; p = 0.49) and incidence of compensatory sweating (F = 2.38; p = 0.14).

CONCLUSION

Thoracoscopic sympathectomy for hyperhidrosis is an effective procedure. Following sympathectomy SSRs are not permanently abolished, but return of SSRs does not correspond with symptom recurrence. As such, SSRs are a poor tool for objective assessment of long-term outcome following sympathectomy.

Physiological characterization of Taxol-induced large-fiber sensory neuropathy in the rat

The cancer chemotherapeutic agent Taxol (paclitaxel) causes a dose-related peripheral neuropathy in humans. We produced a dose-dependent large-fiber sensory neuropathy, without detrimental effects on general health, in mature rats by using two intravenous injections 3 days apart. Tests of other dosing schedules demonstrated the dependence of the severity of the neuropathy and of animal health on both the dose and the frequency of dosing. Pathologically, severe axonal degeneration and hypomyelination were observed in sections of dorsal roots, whereas ventral roots remained intact. Electrophysiologically, H-wave amplitudes in the hindlimb and amplitudes of predominantly sensory compound nerve action potentials in the tail were reduced. These effects persisted for at least 4 months after treatment. Motor amplitudes were not affected, but both motor and sensory conduction velocities decreased. The ability of rats to remain balanced on a narrow beam was impaired, indicating proprioceptive deficits. Muscle strength, measured by hindlimb and forelimb grip strength, and heat nociception, measured by tail-flick and hindlimb withdrawal tests, were not affected by Taxol. This model of Taxol-induced neuropathy in mature rats, with minimal effects on general health, parallels closely the clinical syndrome observed after Taxol treatment in humans.

Computerised audit of carotid endarterectomy: audit loopholes closed?

The number of carotid endarterectomies being performed in the UK is increasing. The role of carotid endarterectomy (CEA) in the prevention of stroke depends on the procedure being associated with as few operative strokes as possible. Good clinical practice, with minimum morbidity, depends upon the integration of recent advances. Continuing audit has been used to examine changes in surgical practice and in case mix. There was a combined death and permanent stroke rate of 3.6% after 333 CEAs in a 6-year period (1990-1995) compared with 4.4% in 203 CEAs in an earlier 5-year audit period (1985-1989). The impact of an increase in the number of operations performed after recovered strokes, those performed by trainees and the use of prosthetic patches on the results of CEA has been assessed. Specific areas to be targeted in future audits are identified.