Differences in consumption of food items between obese and normal-weight people in India

BACKGROUND

There is a rising prevalence of obesity in India, and diet may be a major determinant of this. We aimed to assess differences in types and quantities of food items consumed by obese and normal-weight people in India.

METHODS

Cross-sectional data of 7067 factory workers and their families were used from the Indian Migration Study, conducted in four cities across northern, central and southern India. Food frequency questionnaire data were used to compare the quantities of consumption of 184 food items between 287 obese (body mass index>30 kg/m2) and 1871 normalweight (body mass index 18.50-22.99 kg/m2) individuals, using t tests and ANCOVAs. Individuals with diabetes,hypertension and cardio-vascular disease were excluded. SPSS 16.0 was used for analysis.

RESULTS

After adjusting for age, sex, location and socioeconomic status, obese individuals were found to eat significantly larger quantities of 11 food items compared with normalweight individuals. These included phulkas, chapatis/parathas/naan, plain dosa, mutton/chicken pulao/biryani, chicken fried/grilled, rasam, mixed vegetable sagu, vegetable raitha, honey,beetroot and bottlegourd (p< 0.01). Consumption of plain milk was higher among normal-weight than among obese individuals (p< 0.05). Consumption of some of these food items was also found to increase by socioeconomic status, decrease by age, and be higher among men relative to women.

CONCLUSION

Obese individuals were found to consume larger quantities of certain food items compared with normal weight individuals. Interventions should aim at limiting overall food consumption among obese individuals.

Prevalence and level of Listeria monocytogenes and other Listeria species in retail pre-packaged mixed vegetable salads in the UK

As part of the European Commission (EC) co-ordinated programme for 2005, a study of pre-packaged ready-to-eat (RTE) mixed salads containing meat or seafood ingredients from retail premises was undertaken in the UK to determine the frequency and level of Listeria monocytogenes in these products. Almost all (99.8%; 2682/2686) samples were of satisfactory/acceptable microbiological quality. Two (0.1%) samples exceeded EC legal food safety criteria due to the presence of L. monocytogenes in excess of 100 cfu g(-1) (1.7 x 10(2), 9.9 x 10(2)cfu g(-1)) while another two (0.1%) were unsatisfactory due to L. welshimeri levels over 100 cfu g(-1) (1.2 x 10(3), 6.0 x 10(3) cfu g(-1)). Overall contamination of Listeria spp. and L. monocytogenes found in samples of mixed salads in the UK was 10.8% and 4.8%, respectively. Almost twice as many salad samples with meat ingredients were contaminated with Listeria spp. and L. monocytogenes (14.7% and 6.0%, respectively) compared to samples with seafood ingredients (7.4% and 3.8%, respectively). Pre-packaged mixed salads were contaminated with Listeria spp. and L. monocytogenes more frequently when: collected from sandwich shops; not packaged on the premises; stored or displayed above 8 degrees C. This study demonstrates that the control of L. monocytogenes in food manufacturing and at retail sale is essential in order to minimize the potential for this bacterium to be present in mixed salads at the point of consumption at levels hazardous to health.

Provision, uptake and cost of cardiac rehabilitation programmes: improving services to under-represented groups

OBJECTIVES

To estimate UK need for outpatient cardiac rehabilitation, current provision and identification of patient groups not receiving services. To conduct a systematic review of literature on methods to improve uptake and adherence to cardiac rehabilitation. To estimate cost implications of increasing uptake of cardiac rehabilitation.

DATA SOURCES

Hospital Episode Statistics (England). Hospital Inpatient Systems (Northern Ireland). Patients Episode Database for Wales. British Association for Cardiac Rehabilitation/British Heart Foundation surveys. Cardiac rehabilitation centres. Patients from general hospitals. Electronic databases.

REVIEW METHODS

The study analysed hospital discharge statistics to ascertain the population need for outpatient cardiac rehabilitation in the UK. Surveys of cardiac rehabilitation programmes were conducted to determine UK provision, uptake and audit activity, and to identify local interventions to improve uptake. Data were also examined from a trial estimating eligibility for cardiac rehabilitation and non-attendance. A systematic review of interventions to improve patient uptake, adherence and professional compliance in cardiac rehabilitation was conducted. Estimated costs of improving uptake were identified from national survey, systematic review and sampled cardiac rehabilitation programmes.

RESULTS

In England, Wales and Northern Ireland nearly 146,000 patients discharged from hospital with primary diagnosis of acute myocardial infarction, unstable angina or following revascularisation were potentially eligible for cardiac rehabilitation. In England in 2000, 45-67% of these patients were referred, with 27-41% attending outpatient cardiac rehabilitation. If all discharge diagnoses of ischaemic heart disease were considered, nearly 299,000 patients would be potentially eligible and in England rates of attendance and referral would be 22-33% and 13-20% respectively. Rates of referral and attendance were similar in Wales, but somewhat lower in Northern Ireland. It was found that referral and attendance of older people and women at cardiac rehabilitation tended to be low. It was also suggested that patients from ethnic minorities and those with angina or heart failure were less likely to be referred to or join programmes. A wide range of local interventions suggested awareness of the problem of uptake. In an NHS-funded randomised controlled trial, possibly representing more optimal protocol-led care, medical and nursing staff identified 73-81% of patients with acute myocardial infarction as eligible for cardiac rehabilitation. Excluded patients tended to be older with more severe presentation of cardiac disease. Experiences of patients suggested that uptake may be improved by addressing issues of motivation and relevance of rehabilitation to future well-being, co-morbidities, site and time of programme, transport and care for dependents. Systematic review of studies supported the use of letters, pamphlets or home visits to motivate patients and the use of trained lay visitors. Self-management techniques showed some value in promoting adherence to lifestyle changes. Studies examining professional compliance found that professional support for practice nurses may have value in the coordination of postdischarge care. Average costs in 2001 of cardiac rehabilitation to the health service per patient completing a cardiac rehabilitation programme were about GBP350 (staff only) and GBP490 (total). If services were modelled on an intermediate multidisciplinary configuration with three to five key staff, approximately 13% more patients could be treated with the same budget. Depending on staffing configuration an approximate 200-790% budget increase would be required to provide cardiac rehabilitation to all potentially eligible patients.

CONCLUSIONS

Provision of outpatient cardiac rehabilitation in the UK is low and little is known about the capacity of cardiac rehabilitation centres to increase this provision. There is an uncoordinated approach to audit data collection and few interventions aimed at improving the situation have been formally evaluated. Motivational communications and trained lay volunteers may improve uptake of cardiac rehabilitation, as may self-management techniques. Experience of low-cost interventions and good practice exists within rehabilitation centres, although cost information frequently is not reported. Increased provision of outpatient cardiac rehabilitation will require extra resources. Further trials are required to compare the cost-effectiveness of comprehensive multidisciplinary rehabilitation with simpler outpatient programmes, also research is needed into economic and patient preference studies of the effects of different methods of using increased funding for cardiac rehabilitation. An evaluation of a range of interventions to promote attendance in all patients and under-represented groups would also be useful. The development of standards is suggested for audit methods and for eligibility criteria, as well as regular and comprehensive data collection to estimate the need for and provision of cardiac rehabilitation. Further areas for intervention could be identified through qualitative studies, and the extension of low-cost interventions and good practice within rehabilitation centres. Regularly updated systematic reviews of relevant literature would also be useful.

A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of the left anterior descending coronary artery

OBJECTIVES

To compare the clinical- and cost-effectiveness of minimally invasive direct coronary artery bypass grafting (MIDCAB) and percutaneous transluminal coronary angioplasty (PTCA) with or without stenting in patients with single-vessel disease of the left anterior descending coronary artery (LAD).

DESIGN

Multi-centre randomised trial without blinding. The computer-generated sequence of randomised assignments was stratified by centre, allocated participants in blocks and was concealed using a centralised telephone facility.

SETTING

Four tertiary cardiothoracic surgery centres in England.

PARTICIPANTS

Patients with ischaemic heart disease with at least 50% proximal stenosis of the LAD, suitable for either PTCA or MIDCAB, and with no significant disease in another vessel.

INTERVENTIONS

Patients randomised to PTCA had local anaesthetic and underwent PTCA according to the method preferred by the operator carrying out the procedure. Patients randomised to MIDCAB had general anaesthetic. The chest was opened through an 8-10-cm left anterior thoracotomy. The ribs were retracted and the left internal thoracic artery (LITA) harvested. The pericardium was opened in the line of the LAD to confirm the feasibility of operation. The distal LITA was anastomosed end-to-side to an arteriotomy in the LAD. All operators were experienced in carrying out MIDCAB.

MAIN OUTCOME MEASURES

The primary outcome measure was survival free from cardiac-related events. Relevant events were death, myocardial infarction, repeat coronary revascularisation and recurrence of symptomatic angina or clinical signs of ischaemia during an exercise tolerance test at annual follow-up. Secondary outcome measures were complications, functional outcome, disease-specific and generic quality of life, health and social services resource use and their costs.

RESULTS

A total of 12,828 consecutive patients undergoing an angiogram were logged at participating centres from November 1999 to December 2001. Of the 1091 patients with proximal stenosis of the LAD, 127 were eligible and consented to take part; 100 were randomised and the remaining 27 consented to follow-up. All randomised participants were included in an intention-to-treat analysis of survival free from cardiac-related events, which found a non-significant benefit from MIDCAB. Cumulative hazard rates at 12 months were estimated to be 7.1 and 9.2% for MIDCAB and PTCA, respectively. There were no important differences between MIDCAB and PTCA with respect to angina symptoms or disease-specific or generic quality of life. The total NHS procedure costs were 1648 British pounds and 946 British pounds for MIDCAB and PTCA, respectively. The costs of resources used during 1 year of follow-up were 1033 British pounds and 843 British pounds, respectively.

CONCLUSIONS

The study found no evidence that MIDCAB was more effective than PTCA. The procedure costs of MIDCAB were observed to be considerably higher than those of PTCA. Given these findings, it is unlikely that MIDCAB represents a cost-effective use of resources in the reference population. Recent advances in cardiac surgery mean that surgeons now tend to carry out off-pump bypass grafting via a sternotomy instead of MIDCAB. At the same time, cardiologists are treating more patients with multi-vessel disease by PTCA. Future primary research should focus on this comparison. Other small trials of PTCA versus MIDCAB have now finished and a more conclusive answer to the original objective could be provided by a systematic review.

Socioeconomic deprivation is a predictor of poor postoperative cardiovascular outcomes in patients undergoing coronary artery bypass grafting

OBJECTIVE

To investigate the effects of socioeconomic deprivation on cardiovascular risk factors and postoperative clinical outcomes of patients undergoing coronary artery bypass grafting (CABG).

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Surgical population of the southwest of England, April 1996 and August 2000.

STUDY GROUP

Data on 3578 consecutive patients undergoing CABG at the Bristol Royal Infirmary NHS Trust were abstracted. Data were retrieved from the Patient Analysis & Tracking System. Carstairs index was used to measure socioeconomic deprivation of area of residence and was divided into five quintiles, where quintile 1 denotes least deprived and 5 most deprived.

OUTCOME MEASURES

End points were postoperative complications and 30 day mortality.

RESULTS

Higher deprivation scores were associated with younger age (p < 0.004), greater body mass index, diabetes, smoking at time of surgery, and higher EuroSCOREs (all p < or = 0.001). After adjustment for EuroSCORE, socioeconomic deprivation was independently associated with postoperative myocardial infarction (p = 0.05) and combined postoperative myocardial infarction, stroke, and death (p = 0.016). Hospital length of stay for the patients in the highest quintiles was also significantly longer than for those in the lower quintiles (p = 0.04).

CONCLUSION

Patients undergoing CABG living in areas with high deprivation scores are younger, have more clinical risk factors, and experience more postoperative cardiovascular complications than patients living in low deprivation score areas.

Controlled clinical trial of two weight reducing diets in a NHS hospital dietetic outpatient clinic - a pilot study

BACKGROUND

Outpatient dietary weight reduction for obesity is unsatisfactory. The objective of this study was to compare the efficacy of an energy prescription diet with usual care (a healthy eating diet) in adult overweight patients referred to a NHS hospital dietetic outpatient clinic, in terms of weight change over 12 weeks.

METHODS

Controlled clinical trial (systematic allocation).

RESULTS

Of the 53 patients who attended their first appointment, 27 completed the trial. Mean weight loss (kg) after 12 weeks was 4.2 (sd 3.8) on the energy prescription diet (n = 16) and 6.0 (sd 2.8) on the healthy eating diet (n = 11).

CONCLUSIONS

Patients on a weight reducing diet based on energy prescription or healthy eating lost, on average, clinically significant amounts of body weight by 12 weeks. Mean weight loss was greater by about 50% in the healthy eating group and supports the development of a larger trial to estimate true effect [corrected].

Angioplasty or stent placement in the proximal common iliac artery: is protection of the contralateral side necessary?

PURPOSE

To determine if protection of the contralateral common iliac artery is necessary when performing angioplasty or stent placement in a proximal common iliac artery.

MATERIALS AND METHODS

A retrospective review of all patients undergoing endovascular treatment for unilateral common iliac artery stenosis or occlusion from 1979 to 2000 was performed. All angiograms were reviewed independently by three experienced vascular interventional radiologists who evaluated both common iliac arteries before and after angioplasty or stent placement.

RESULTS

The medical records or angiograms of 514 patients were located. Of these, complete records and angiograms were found for 175 patients who underwent proximal (within 2 cm of its origin) common iliac artery angioplasty or stent placement without treatment or protection of the contralateral common iliac artery. Treatment of proximal common iliac stenosis in 160 patients resulted in luminal compromise of the contralateral common iliac in two patients (17% and 24% reduction in luminal diameter). No contralateral compromise was noted in 15 patients treated for iliac occlusion.

CONCLUSION

The data reported herein suggest that protection of the contralateral common iliac artery during angioplasty or stent placement in a proximal common iliac artery is not mandatory.

Systematic review of long term anticoagulation or antiplatelet treatment in patients with non-rheumatic atrial fibrillation

OBJECTIVE

To examine the benefits and risks of long term anticoagulation (warfarin) compared with antiplatelet treatment (aspirin/indobufen) [corrected] in patients with non-rheumatic atrial fibrillation.

METHODS

Meta-analysis of randomised controlled trials from Cochrane library, Medline, Embase, Cinhal, and Sigle from 1966 to December 1999. Odds ratios (95% confidence intervals) calculated to estimate treatment effects.

OUTCOME MEASURES

Fatal and non-fatal cardiovascular events, reductions of which were classified as benefits. Fatal and major non-fatal bleeding events classified as risks.

RESULTS

No trials were found from before 1989. There were five randomised controlled trials published between 1989-99. There were no significant differences in mortality between the two treatment options (fixed effects model: odd ratio 0.74 (95% confidence interval 0.39 to 1.40) for stroke deaths; 0.86 (0.63 to 1.17) for vascular deaths). There was a borderline significant difference in non-fatal stroke in favour of anticoagulation (0.68 (0.46 to 0.99)); and 0.75 (0.50 to 1.13) after exclusion of one trial with weak methodological design. A random effects model showed no significant difference in combined fatal and non-fatal events (odds ratio 0.79 (0.61 to 1.02)). There were more major bleeding events among patients on anticoagulation than on antiplatelet treatment (odds ratio 1.45 (0.93 to 2.27)). One trial was stopped prematurely after a significant difference in favour of anticoagulation was observed. The only trial to show a significant difference in effect (favouring anticoagulation) was methodologically weaker in design than the others.

CONCLUSIONS

The heterogeneity between the trials and the limited data result in considerable uncertainty about the value of long term anticoagulation compared with antiplatelet treatment. The risks of bleeding and the higher cost of anticoagulation make it an even less convincing treatment option.

Endoscopic ureteroureterostomy: long-term followup using a new technique

PURPOSE

We describe a new technique using a single ureteroscope and fluoroscopy for reestablishing ureteral continuity.

MATERIALS AND METHODS

Nine patients with obliterated ureteral segments (1 bilateral) were referred for treatment, of whom 3 had concurrent ureterovaginal fistulas. Mechanism of injury included open pelvic surgery in 9 ureteral segments and ureteroscopy in 1. Ureteral continuity was reestablished using a technique combining ureteroscopy and a fluoroscopically guided antegrade snare. The affected ureteral segment was then dilated and stented using a 14/7 reversed endopyelotomy stent.

RESULTS

Ureteral continuity was reestablished in all 10 consecutive attempts with this technique. At a mean followup of 16 months (range 6 to 33) all patients were stent-free without radiological evidence of obstruction. All 3 patients with fistulas were dry. In 3 patients ureteral strictures developed and required balloon dilation. Balloon dilation failed in 1 case and ultimately ureteral reimplantation was required.

CONCLUSIONS

Ureteral continuity can be safely and effectively reestablished using a single ureteroscope. As a minimally invasive technique, endoscopic ureteroureterostomy should be considered before open surgical reconstruction.

Balloon occlusion versus wedged hepatic venography using carbon dioxide for portal vein opacification during TIPS

Balloon occlusion hepatic venography using carbon dioxide (CO2) is proposed as a safer yet simpler alternative to wedged catheter techniques that have caused hepatic lacerations during the transjugular intrahepatic portosystemic shunt (TIPS) procedure. The image quality of CO2 wedged catheter and balloon occlusion venograms was comparable in our small series, with no venographic-related complications occurring in the balloon occlusion group.

Setting up a nurse-led anticoagulant clinic

People on anticoagulation therapy need regular monitoring. With appropriate training, nurse specialists can improve patient care in anticoagulant clinics.

Evaluation of a nurse specialist anticoagulant service

Safe levels of anticoagulation are normally considered to be achieved if patients are maintained within their therapeutic international normalized ratio (INR) range for 70% or more time, but evidence in the United Kingdom suggests that this is often not attained. Recently, alternative models in the management of out-patient anticoagulation have been investigated with favourable results. We report on a study which compared a consultant anticoagulant service (CAS) with a nurse specialist service (NSAS). A sequential design was used with data collected on the consultant run service (CAS), followed by similar data on a NSAS over two 6 month periods. Two patient groups were recruited: those newly referred (group A) and those on long-term treatment (group B). Outcomes were the proportion of time patients spent within INR range, documentation of relevant clinical details, number of drugs taken which may adversely interact with and/or inhibit haemostatic function and patient knowledge. The results indicate that the NSAS was as good as the CAS in maintaining therapeutic control and better at documenting relevant clinical details in reducing the number of drugs taken which may adversely interact with and/or inhibit haemostatic function and in improving some aspects of patient knowledge.

Costs and effectiveness of a nurse specialist anticoagulant service

AIMS

To determine the costs and effectiveness of an anticoagulant nurse specialist service compared with a conventional consultant service based on two hospital sites in northwest Hertfordshire.

METHODS

Sequential design comparing retrospectively the conduct and outcomes of a consultant service with a nurse specialist service over two six month periods. In each of the six month study periods, all new patients consecutively referred for anticoagulation over a three month period (group A) at the start of each study period and a random selection of patients who had already been attending the anticoagulant service for one year or more (group B) were included in the study. Group A patients wre followed for up to three months and group B patients for six months. The main outcome measures were costs of service provision and effectiveness. Costs included those for the use of the anticoagulant service, those related to general practitioner (GP) visits and hospitalisations, and running costs (staff time, laboratory tests, patient transport). Measures of effectiveness were the mean proportion of time patients spend in the therapeutic range, the number of drugs being taken that could interact adversely and/or inhibit haemostatic function, and patient and GP satisfaction with service provision.

RESULTS

In the consultant service, for group A there were more patients aged 66-75 years (p = 0.004) and fewer patients aged more than 76 years (p = 0.001); and for group B, there were fewer patients on anticoagulation for cardiac conditions (p = 0.001), but more on anticoagulation for thromboembolic conditions (p = 0.02) than in the nurse specialist service. The clinic running costs of the nurse specialist service were 4.99 Pounds per attendance, compared with 4.75 Pounds in the consultant service. Including all other costs related to treatment, there was no statistically significant difference in cost per patient. There was no significant difference in the proportion of time patients spent in the therapeutic range between the consultant service and the nurse specialist service. In the nurse specialist service, fewer patients in group A were taking drugs that could interact adversely and/or inhibit haemostatic function (p = 0.01) and more patients were satisfied with service provision (p = 0.04) compared with the consultant service. There was no significant variation in GP satisfaction between the two services.

CONCLUSION

In the provision of outpatient anticoagulation, the nurse specialist service was no more expensive than the consultant service and, using our primary outcome, at least as effective. The nurse specialist service has some clear advantages compared to the consultant service: provision of domicilliary care for housebound patients, fewer new patients taking drugs that could interact adversely and/or inhibit haemostatic function patients, it is preferred by newly referred patients to the consultant service, and it is as acceptable to their GPs.

Infection of a chronically implanted iliac artery stent

Pseudoaneurysm formation and infection at the site of iliac artery stenting are uncommon complications that occur soon after stent placement. We describe a case in which an infected pseudoaneurysm developed 22 months following stent implantation. Stent infection, although rare, has potentially disastrous implications, as made evident by a review of the literature. Prophylactic antibiotic therapy at the time of stent placement is recommended.

Renal angiomyolipomas: long-term follow-up of embolization for acute hemorrhage

OBJECTIVE

To determine if elective, angiographically directed embolization of enlarged renal angiomyolipomas can be used to prevent future hemorrhagic episodes in patients with tuberous sclerosis and thus avoid nephrectomy.

PATIENTS AND METHODS

Records were reviewed for all 5 patients who underwent elective, subtotal embolization of large, symptomatic angiomyolipomas at the authors' institution between 1975 and 1996.

RESULTS

All 5 patients had tuberous sclerosis and bilateral renal angiomyolipomas. Initial embolization in these patients was performed in 1975, 1981, 1993 (2 patients) and 1994. In 1 patient only a single embolization session was required. In another, initial embolization on the left side was followed by embolization on the right 13 months later. Two patients underwent 2 sessions, and 1 patient had 4 sessions over a 13-year period. Subtotal embolization with particulate material led to a decrease in size of the most severely affected portion of the kidney. One large angiomyolipoma underwent sterile liquefaction after embolization; percutaneous catheter drainage was required. The embolization allowed subsequent partial nephrectomy in this patient.

CONCLUSION

Embolization is effective for the long-term management of renal angiomyolipomas in patients with tuberous sclerosis; in this way nephrectomy and loss of renal function can usually be avoided.

A combined antegrade and retrograde technique for reestablishing ureteral continuity

Ureteral injuries are not uncommon and may lead to ureteral stricture, complete obliteration, or urinary fistula. Traditionally, open surgical repair was required to reestablish ureteral continuity. With the development of improved instrumentation and technique, it is now possible to treat these injuries endoscopically. Endoscopic ureteroureterostomy has been demonstrated to be an effective means of treating ureteral strictures and obliterated segments of the ureter. We describe a combined ureteroscopic and fluoroscopic technique to reestablish ureteral integrity. Using this technique we have successfully treated two patients with ureteral injuries. The first patient had a ureterovaginal fistula that occurred after a hysterectomy. The second patient had a completely obstructed distal ureter. These cases and the techniques used to successfully manage them are described.

Complications of iliac artery stent deployment

PURPOSE

This study was performed to determine the primary patency, foot salvage, and complication rates associated with iliac artery stent deployment.

METHODS

From March 1992 to May 1995, 147 iliac artery stents were deployed in 98 limbs of 72 patients for disabling claudication or limb-threatening ischemia. Procedure-related and late (> 30 days) complications, as well as adjunctive maneuvers required to correct a complication, were tabulated. Stented iliac artery cumulative primary patency and foot salvage rates were calculated with life-table analysis. Factors that impacted early complications, late complications, foot salvage rates, and stented iliac artery primary patency rates were identified with stepwise logistic regression analysis.

RESULTS

A procedure-related complication occurred in 19 (19.4%) limbs. Initial technical success, however, was achieved in all but three of 98 limbs (96.9%). Stented iliac artery cumulative primary patency rates were 87.6%, 61.9%, 55.3%, and foot salvage rates were 97.7%, 85.1%, 76.1%, at 12, 18, and 24 months, respectively. External iliac artery stent deployment, superficial femoral artery occlusion before treatment, and single-vessel tibial runoff before treatment negatively affected stented iliac artery cumulative primary patency rates. Stented iliac artery primary patency rates were not significantly affected by age, smoking, coronary artery disease, diabetes, hypercholesterolemia, hypertension, presenting symptom, early complication, number of stents deployed, type of stent deployed, or stent deployment for stenosis versus occlusion.

CONCLUSIONS

Limb-threatening and life-threatening complications can be associated with iliac artery stent deployment. Stented iliac artery primary patency rates are affected by distal atherosclerotic occlusive disease and the position of the deployed stent within the iliac system. Stent reconstruction of severe iliac artery occlusive disease is feasible but should be thoughtfully selected.

Endovascular stent infection

We report a case of iliac stent infection. Nine days after a 24-hour infusion of urokinase and right iliac artery stent deployment, the patient had fever, in addition to severe groin pain and petechiae isolated to the stented limb. The hospital course was complicated by sepsis, adult respiratory distress syndrome, liver dysfunction, and renal insufficiency. Stent removal and iliac/femoral artery resection, as well as an above-knee amputation, were life-saving. Arterial and stent cultures grew Staphylococcus aureus. Stent infection with arterial necrosis is a devastating, rare endovascular complication. Given its potential seriousness, we would recommend the use of prophylactic antibiotics before stent deployment.

Dimenhydrinate pretreatment in patients receiving intra-arterial ioxaglate: effect on nausea and vomiting

OBJECTIVE

To determine the effectiveness of the antihistamine dimenhydrinate (Dramamine) as a prophylactic agent against the nausea and vomiting that occasionally accompany the use of ioxaglate.

PATIENTS AND METHODS

Three hundred patients (165 men and 135 women, ranging in age from 18 to 89 [mean 62] years) undergoing noncoronary arteriography received dimenhydrinate or placebo before the injection of the low-osmolality contrast material ioxaglate (Hexabrix). The patients were observed and questioned about nausea and vomiting, as well as many other possible reactions to the contrast material.

RESULTS

There were no statistical differences in the occurrence of adverse reactions between the groups receiving dimenhydrinate and placebo (chi 2 or Fisher's exact test, p > 0.05).

CONCLUSION

Dimenhydrinate, as administered in this study, was ineffective as a prophylactic agent against adverse reactions accompanying administration of ioxaglate.

Stenting without thrombolysis for aortoiliac occlusive disease: experience in 14 high-risk patients

Stenting without thrombolysis of 16 occluded iliac artery segments and one occluded infrarenal abdominal aorta was attempted in 14 patients. All patients were either considered to be prohibitive operative risks or had contraindications to thrombolytic therapy. Indications for limb reperfusion included rest pain, disabling claudication, or dry gangrene. Successful recanalization was achieved primarily in 13 patients with self-expandable Wallstents, balloon-expandable Palmaz stents, or a combination of the two stents. Follow-up was carried out in all patients in whom recanalization was successful. All stented patients showed symptomatic improvement, and the mean preprocedure ankle/brachial index, which was 0.31, improved to 0.78 after the procedure (p = 0). Complications included a vertebrobasilar stroke during the procedure in one patient, perforation during angioplasty of a stenotic but nonoccluded external iliac artery in one, and dissection of the distal external iliac artery in one. Distal embolization did not occur. Percutaneous recanalization of aortoiliac occlusions without initial thrombolysis is possible and has a high potential for technical success. Additional data and longer follow-up are still needed, but this procedure may provide a reasonable, less invasive option in some patients at high surgical risk or in patients who have contraindications to thrombolytic therapy.

Flexible ureteroscopically assisted percutaneous renal access

OBJECTIVE

To combine retrograde flexible ureteroscopic techniques with a simultaneous percutaneous puncture to gain precise antegrade renal access in selected patients.

METHODS

Patients with minimally dilated collecting systems and complex stone burdens (including caliceal diverticular calculi) underwent adjunctive flexible ureteroscopy in an attempt to expedite percutaneous renal access. This combined retrograde and antegrade approach was also used in treating obese patients and those in whom prior attempts at percutaneous renal access had failed. The prone split-leg position and flexible retrograde ureteroscopy were employed. The exact calyx for percutaneous puncture was selected under direct vision using an actively deflectable, flexible ureteroscope. Access to narrow infundibula and caliceal diverticula was facilitated by employing injectable guidewires as well as small-diameter balloon dilators passed through the working channel of the flexible endoscope. A fluroscopically guided percutaneous puncture was then performed. The tip of the intrusive needle was visualized both fluoroscopically and endoscopically. An antegrade guidewire was advanced through a ureteroscopically positioned snare and withdrawn out the urethra. With this through-and-through guidewire access, standard percutaneous tract dilation and nephroscopic lithotripsy were performed expeditiously.

RESULTS

Seven patients with renal disease or body habitus that made precise percutaneous access difficult underwent adjunctive retrograde flexible ureteroscopy. One patient had a large perinephric hematoma from previous attempts at nephrostomy placement. The other six patients presented with: tightly branched staghorn calculi (three patients) and lateral/anterior caliceal diverticular calculi (three patients). Four patients were morbidly obese (240-320 lb), which also complicated antegrade access. Percutaneous renal access was obtained in < 30 min in all cases.

CONCLUSION

A precise percutaneous puncture into a complex collecting system and establishing a through-and-through safety guidewire can be facilitated with simultaneous retrograde flexible ureteroscopic techniques.

Evaluation of patients' knowledge about anticoagulant treatment

OBJECTIVE

To develop a questionnaire to evaluate patients' knowledge of anticoagulation.

DESIGN

Anonymous self completed questionnaire study based on hospital anticoagulant guidelines.

SETTING

Anticoagulant clinic in a 580 bed district general hospital in London.

SUBJECTS

70 consecutive patients newly referred to the anticoagulant clinic over six months.

MAIN MEASURES

Information received by patients on six items of anticoagulation counselling (mode of action of warfarin, adverse effects of over or under anticoagulation, drugs to avoid, action if bleeding or bruising occurs, and alcohol consumption), the source of such information, and patients' knowledge about anticoagulation.

RESULTS

Of the recruits, 36 (51%) were male; 38(54%) were aged below 46 years, 22(31%) 46-60, and 10(14%) over 75. 50 (71%) questionnaires were returned. In all, 40 respondents spoke English at home and six another language. Most patients reported being clearly advised on five of the six items, but knowledge about anticoagulation was poor. Few patients could correctly identify adverse conditions associated with poor control of anticoagulation: bleeding was identified by only 30(60%), bruising by 23(56%), and thrombosis by 18(36%). Only 26(52%) patients could identify an excessive level of alcohol consumption, and only seven (14%) could identify three or more self prescribed agents which may interfere with warfarin.

CONCLUSION

The questionnaire provided a simple method of determining patients' knowledge of anticoagulation, and its results indicated that this requires improvement.

IMPLICATIONS

Patients' responses suggested that advice was not always given by medical staff, and use of counselling checklists is recommended. Reinforcement of advice by non-medical counsellors and with educational guides such as posters or leaflets should be considered. Such initiatives are currently being evaluated in a repeat survey.

Recurrent urinary conduit bleeding in a patient with portal hypertension: management with a transjugular intrahepatic portosystemic shunt

OBJECTIVE

To determine if a transjugular intrahepatic portosystemic shunt can control recurrent urinary conduit bleeding in a patient with portal hypertension.

METHODS

Following transjugular catheterization of the right hepatic vein, a long curve Colapinto needle was advanced through the liver parenchyma into the portal vein near its bifurcation. After a guide wire exchange, a catheter was advanced into the portal system and venogram was obtained. Following another guide wire exchange, a balloon angioplasty catheter was used to create the shunt by dilating the parenchymal tract between the hepatic and portal veins. A self-expandable stent was used to ensure patency of the shunt.

RESULTS

After shunt placement, bleeding from the ileal conduit and stroma decreased significantly. A duplex ultrasound at five-month follow-up demonstrated the shunt to be completely patent.

CONCLUSIONS

Based on this limited experience, it appears that the transjugular, intrahepatic, portosystemic shunt is an acceptable method to control massive, recurrent urinary conduit bleeding in patients with portal hypertension.

Quantification of the effects of respiration and parallax on inferior vena caval filter position

PURPOSE

The change in inferior vena caval (IVC) filter position at follow-up relative to the filter position at implantation has been used as a criterion for evaluation and comparison of these devices. Perceived changes in filter position may be due to respiratory movement and/or changes in parallax between the initial and follow-up imaging studies. In this study the authors evaluated and attempted to quantify the effects of respiratory movement and parallax.

PATIENTS AND METHODS

After placement of an IVC filter, radiographs of the abdomen were taken at maximum inspiration and maximum expiration in 30 patients. The effect of parallax on apparent filter movement was studied by using a phantom.

RESULTS

The average filter movement on inspiration/expiration radiographs (corrected for magnification) was 3.6 mm +/- 2.2. An 8.5-mm maximal change secondary to parallax was seen in the phantom study.

CONCLUSION

When follow-up images are obtained, efforts should be made to closely reproduce patient positioning and patient respiration to reduce errors in the interpretation of filter migration.

Referral of patients to an anticoagulant clinic: implications for better management

The quality of anticoagulant treatment of ambulatory patients is affected by the content of referral letters and administrative processes. To assess these influences a method was developed to audit against the hospital standard the referral of patients to one hospital anticoagulant clinic in a prospective study of all (80) new patients referred to the clinic over eight months. Administrative information was provided by the clinic coordinator, and the referral letters were audited by the researchers. Referral letters were not received by the clinic for 10% (8/80) of patients. Among the 72 referral letters received, indication for anticoagulation and anticipated duration of treatment were specified in most (99%, 71 and 81%, 58 respectively), but only 3% (two) to 46% (33) reported other important clinical information (objective investigations, date of starting anticoagulation, current anticoagulant dose, date and result of latest international normalised ratio, whether it should be the anticoagulant clinic that was eventually to stop anticoagulation, patients' other medical problems and concurrent treatment. Twenty two per cent (16/80) of new attenders were unexpected at the anticoagulant clinic. Most patients' case notes were obtained for the appointment (61%, 47/77 beforehand and 30% 23/77 on the day), but case notes were not obtained for 9% (7/77). The authors conclude that health professionals should better appreciate the administrative and organisational influences that affect team work and quality of care. Compliance with a well documented protocol remained below the acceptable standard. The quality of the referral process may be improved by using a more comprehensive and helpful referral form, which has been drawn up, and by educating referring doctors. Measures to increase the efficiency of the administrative process include telephoning the clinic coordinator directly, direct referrals through a computerised referral system, and telephone reminders by haematology office staff to ward staff to ensure availability of the hospital notes. The effect of these changes will be assessed in a repeat audit.

In vitro flow phantom analysis and clot-capturing ability of incompletely opened Vena Tech-LGM vena caval filters

It has been shown recently that Vena Tech-LGM (B. Braun Vena Tech, Evanston, IL) filters inserted into the inferior vena cava via the jugular route may be deployed sometimes in an incompletely opened (IO) position. The flow characteristics and clot capturing ability of IO Vena Tech-LGM filters are not clearly understood. Using a vena cava flow phantom, the clot-capturing abilities of the IO and opened Vena Tech-LGM filters were assessed. For 5 x 5-mm clots, the IO Vena Tech-LGM filter captured only 40% of thrombi compared with a 90% capture rate for the opened filter. The capture rates were 90 and 100% for the IO and opened filter, respectively, for larger 5 x 15-mm clots. It was found that the IO filter could capture 2-7 x 25 mm thrombi prior to the development of a turbulent bypass channel which prevented subsequent clot capture. Using 5 x 15 mm clots, this same phenomenon occurred with the capture of 6 and 11 thrombi by the IO and opened Vena Tech-LGM filters, respectively. Our results suggest a significantly reduced filtering efficiency for the IO Vena Tech-LGM device. However, there is a high rate of clot capture with the opened Vena Tech-LGM filter.

Steel coil embolization supplementing filter placement in a patient with a duplicated inferior vena cava

Anatomic anomalies involving the inferior vena cava (IVC) can present both diagnostic and therapeutic challenges when percutaneous placement of a filter is considered. A patient with a duplicated IVC was treated with placement of a filter in the right-sided IVC and steel coil embolization of a smaller left-sided IVC.

Comparison of filters in an oversized vena caval phantom: intracaval placement of a bird's nest filter versus biiliac placement of Greenfield, Vena Tech-LGM, and Simon nitinol filters

For patients with an oversized inferior vena cava (IVC) (diameter greater than 28 mm, corrected for magnification) who require vena caval filtration for prophylaxis against pulmonary emboli, the accepted treatment has been the biiliac venous placement of Greenfield filters. Because of its wide strut span, the Bird's Nest filter (BNF) has been successfully placed in patients having an oversized IVC. However, the effects of the BNF on caval blood flow and its clot-capturing ability in an oversized IVC are not clearly understood. The authors created a flow phantom simulating an oversized IVC with "iliac" tributaries of normal inner diameter to analyze flow turbulence, pressure gradients, and the clot-capturing ability of the BNF, tested within the "caval" segment of the phantom, and the Greenfield, Vena Tech-LGM, and Simon nitinol filters, tested in the "iliac" segments. All filters were tested for flow disturbances before and after clot capture. The authors' results demonstrate that within an oversized IVC, the BNF creates less flow disturbance and is less occlusive with clot capture than biiliac filters. The BNF displayed a clot-capturing ability equal to that of biiliac filters. Thus, for patients with an oversized IVC, these results suggest that placement of a single intracaval BNF is preferable to biiliac placement of filters.

Vena Tech vena cava filter: experience and early follow-up

Vena caval filters, such as the Vena Tech filter, that employ low-profile introducer systems have provided physicians with a variety of options for percutaneous placement. From April 1989 to April 1990, 81 patients underwent percutaneous placement of the Vena Tech filter at the authors' institution. Follow-up has been obtained to evaluate the filter with regard to the prevention of pulmonary embolism, the maintenance of caval patency, and mechanical stability. Two cases of pulmonary embolism have been seen following filter placement. Three cases of caval thrombosis have occurred, with recanalization of the cava seen in two of these cases. There have been one broken filter and one case of incomplete filter opening. Limited filter tilting and migration have occurred, though in no case has filter tilt or migration been clinically significant. This experience with the Vena Tech filter suggests that it is safe and effective for the prevention of pulmonary embolism.

Use of the Bird's Nest filter in oversized inferior venae cavae

An inferior vena cava (IVC) diameter of greater than 28 mm has been considered a contraindication to the intracaval placement of Greenfield, LG-Medical (LGM), and Simon nitinol filters, necessitating biiliac placement of these devices. With the Bird's Nest filter (BNF), the maximum span of the struts, which immobilize the device, is 60 mm; this allows the placement of the BNF in an oversized IVC having a diameter of greater than 28 mm. Over a 44-month period, 799 IVC filters (547 BNF, 136 Greenfield filters, and 116 LGM filters) were inserted. BNFs were placed in 18 patients (2.3%) with an oversized IVC (diameter range, 29-42 mm); all filters were placed via the femoral route. Patient records were reviewed to determine if problems were associated with filter insertion (including insertion site femoral vein thrombosis) and to determine the prevalence of filter migration, caval thrombosis, and new or recurrent pulmonary emboli (PE) after insertion. No difficulties were encountered during insertion. There was no documented case of device migration, caval thrombosis, or clinically apparent new or recurrent PE. The data suggest that the BNF is the filtering device of choice in patients with an oversized IVC.

Left femoral vein approach for the percutaneous placement of the Bird's Nest Filter

The Bird's Nest Filter femoral catheter set has proven to be too short in some patients to permit placement in close proximity to the renal veins via the left femoral vein approach. The use of the longer, but otherwise identical Bird's Nest Filter jugular catheter set via the left femoral vein eliminates this problem.

Incomplete opening of LGM (Vena Tech) filters inserted via the transjugular approach

Over a 12-month period, 216 LGM vena caval filters were placed in 216 patients at four institutions. The transjugular approach was used in 31 of 216 insertions (14%); 185 of 216 filters (86%) were inserted via the femoral route. Incomplete opening of filters was encountered in 13 of 31 transjugular insertions (41%) and none of 185 transfemoral insertions. Delayed spontaneous filter opening occurred in three of 12 cases (25%) of incomplete opening (in which follow-up was available) at 5 minutes, 4 days, and 2 months after insertion. One filter opened completely after catheter manipulations. Several mechanisms explaining this complication are proposed. In its present form, the LGM filter should not be inserted via the jugular route. Since the filtering capabilities of the incompletely opened LGM device have been shown to be diminished in vitro, it may be advisable to place a second filter cephalad to an incompletely opened LGM filter.

A new technique for direct percutaneous jejunostomy tube placement

We describe a case in which we employed a new method of using intraluminal balloon support for direct percutaneous placement of a jejunostomy tube. Standard interventional radiologic techniques and readily available equipment and materials were used.