1181 Thoracic Outlet Syndrome - A Miss(Ed) Diagnosis-Delayed Diagnosis Of Thoracic Outlet Syndrome Is Common And Leads To Poorer Functional Outcomes

Thoracic outlet syndrome was first defined by Peet in 1956 as “compression of the neurovascular structures in the interscalene triangle corresponding to the possible etiology of the symptoms”.1 Diagnosis of TOCS still remains controversial due to lack of clear referral pathways and our study aims to create one to prevent adverse treatment outcomes.

Method

A retrospective audit in a single vascular centre over a 11-year period correlating time of onset of symptoms to delivery of care and post intervention benefits

Results

Total of 50 patients were analysed during the study. 30 percent of the patients analysed were noted to be referred to a vascular surgeon 3 years post the initial presentation of symptoms. 60 percent were noted to be referred between 6-2.5 years post initial presentation. Remaining 10 percent were noted to be referred in less than 6 years. It was noted that patients belonging to the group Acohort were noted to have recurrence of symptoms, albeit minor post intervention and treatment of TOCS. Whereas recurrence was noted to be nil/ reduced in the patients intervened in less than 2 years from onset of symptoms. Furthermore, the study also noted that more than 50 percent patients with neurogenic/ venous TOCS had a history of preceeding trauma/ shoulder injury and were noted to be not investigated for TOCS.

Conclusions

Our study lends evidence that delayed diagnosis of thoracic outlet syndrome is common and leads to poorer functional and treatment outcomes. Hence a diagnostic pathway must be proposed and implemented at primary care which caters to diagnosis of TOCS, to avoid delays in delivery of adequate care and treatment.

A comparison of airborne bacterial fallout between orthopaedic and vascular surgery

INTRODUCTION The objective of the study was to compare bacterial fallout during vascular prosthesis insertion and orthopaedic major joint replacement performed in conventional and laminar flow ventilation, respectively. MATERIALS AND METHODS A prospective single-centre case control study of 21 consecutive elective vascular procedures involving prosthetic graft insertion and 24 consecutive elective orthopaedic major joint replacements were tested for degree of bacterial fallout using agar settle plates. Preparation time, waiting time and total procedure duration were collected at the time of surgery, and bacterial colony counts on the agar settle plates from airborne bacterial fallout were counted after an incubation period. RESULTS Bacterial fallout count in vascular prosthetic graft insertion was 15-fold greater than in orthopaedic prosthetic joint insertion (15, (IQR 15) vs 1, (IQR 3) respectively, P < 0.0001, Wilcoxon). Waiting time and patient transfer did not significantly increase bacterial fallout counts during the procedure (P = 0.9). CONCLUSIONS Vascular surgical theatres have significantly higher bacterial fallout compared with orthopaedic theatres. This may be partly explained by orthopaedic surgery being routinely performed in laminar flow ventilation, a practice which has not been widely adopted for vascular surgery, in which prosthetic infection may also result in significant mortality and morbidity.

Effect of upper- and lower-limb exercise training on circulating soluble adhesion molecules, hs-CRP and stress proteins in patients with intermittent claudication

OBJECTIVES

To investigate the effects of exercise training on levels of circulating biomarkers associated with the progression of atherosclerosis and risk of cardiovascular events in patients with intermittent claudication.

METHODS

Circulating levels of soluble adhesion molecules (sVCAM-1, sICAM-1, sE-selectin), high sensitivity C-reactive protein (hs-CRP) and stress proteins (Hsp60 and Hsp70) in patients randomised to a 24-week programme of arm- or leg-cranking exercise were compared with those in usual care controls.

RESULTS

Arm and leg exercise similarly improved lower-limb aerobic exercise capacity (20% vs 19%, respectively; P<0.001) and maximum walking distance (30% vs 35%, respectively; P<0.001). Improvements in training limb-specific peak oxygen consumption were attenuated for patients in the highest vs lowest quartile for circulating sVCAM-1 levels at baseline (3% vs 25% respectively, P<0.001). Although circulating hs-CRP levels tended to be lower in the arm-cranking group (-1.55 [95% CI: -1.06 to -2.26]mgl(-1)), exercise training had no effect on circulating levels of soluble adhesion molecules or stress proteins.

CONCLUSIONS

These findings suggest that high levels of circulating sVCAM-1 are associated with an attenuated exercise training response and that arm-cranking exercise may provide an effective stimulus for evoking systemic anti-inflammatory adaptations in patients with intermittent claudication.

Assessment of operative competence during carotid endarterectomy

Background

Objective Structured Assessment of Technical Skills (OSATS) has been used to assess operative competence. The aim was to evaluate its role in carotid endarterectomy (CEA).

Methods

Over 2 years, 17 trainees and 11 consultants were assessed by a single observer using a task-specific checklist and global ratings. Operating time and previous experience were also recorded.

Results

Trainees had previously performed fewer CEAs than consultants (median (interquartile range, i.q.r.) 15 (7–24) versus 94 (61–133) respectively; P &lt; 0·001) and they took longer to perform operations (median (i.q.r.) 128 (119–143) versus 90 (82·5–98·5) min; P &lt; 0·001). Trainees achieved lower task-specific (median (i.q.r.) 23 (17–26) versus 25 (24·5–27·5); P = 0·031) and global (33 (30–35) versus 40 (36·5–43); P = 0·001) scores than consultants. There was a strong positive correlation between task-specific scores and experience for trainees (r = 0·83, P &lt; 0·001), but not for consultants. Global ratings correlated with experience for trainees (r = 0·69, P = 0·002) and more so for consultants (r = 0·82, P = 0·002). There was a positive correlation between task-specific and global scores for trainees (r = 0·67, P = 0·003), but not for consultants.

Conclusion

Task-specific checklists were more discriminatory between trainees and may be useful for formative assessment (training). Global ratings were more discriminatory for consultants and may be useful for summative assessment (examination or revalidation).

VEGF and VEGF receptor expression in human chronic critical limb ischaemia

OBJECTIVE

This study quantified endogenous VEGF and VEGF receptor expression in limbs of patients with chronic critical limb ischaemia (CLI).

METHODS

Skin and muscle biopsies were obtained from the legs of 25 patients undergoing limb amputation for CLI. Samples were obtained at the amputation level (thigh or calf) and, distally, from the foot and in the vicinity of ischaemic ulcers and gangrene. Control biopsies were obtained from patients undergoing amputation for non-arterial reasons or knee arthroplasty (n=7). VEGF protein levels in tissue lysates were measured by ELISA, and VEGF and KDR mRNA levels were determined using quantitative PCR.

RESULTS

At the amputation level, VEGF protein and VEGF and KDR mRNA levels in CLI limbs were similar to those in controls. In the foot VEGF mRNA in skin (P=0.005) and VEGF protein levels in muscle (P=0.02) were elevated compared to levels in a proximal biopsy from the same limb. VEGF and KDR mRNA levels in the vicinity of gangrene/ulcers (VEGF P=0.01, KDR P=0.03) also were elevated.

CONCLUSIONS

VEGF expression is not deficient in CLI. Indeed, it is elevated at distal sites in the ischaemic limb. These findings question the rationale for VEGF supplementation in CLI.

High dose intravenous oestrogen (fosfestrol) in the treatment of symptomatic, metastatic, hormone-refractory carcinoma of the prostate

OBJECTIVE

High dose intravenous stilboestrol has a direct cytotoxic effect on prostatic carcinoma cells. The purpose of this study was to assess subjective and objective responses in a select group of patients with metastatic, hormone-refractory carcinoma of the prostate with severe generalized bone pain in association with symptoms of advanced local disease.

PATIENTS AND METHODS

Seventeen patients with metastatic carcinoma of the prostate, who had relapsed following a good initial response to androgen ablation, were treated as inpatients with once daily intravenous injection of 1104 mg diethylstilboestrol diphosphate (Honvan, Asta Medica, Cambridge, UK) for 7 days. The hormone-refractory status was confirmed by castrate serum testosterone levels. All the patients had failed to respond to second-line hormone manipulation and had progressive disease. All the patients had generalized bone pain, 11 also had symptoms of bladder outlet obstruction, 3 had recurrent haematuria and 3 had both. The mean age was 74 years (range 59-83), mean time to chemical relapse (rising PSA) was 29 months (range 1-70), and mean time to clinical relapse was 37 months (range 6-98). The WHO pain score, performance status score, and a patient-specific quality of life (daily living activity) were used as the subjective measures and the serum PSA as an objective marker. All the parameters were recorded before, during and up to three months after treatment.

RESULTS

Two patients had a transient relief of bone pain with the pain score reducing by two points. Overall, the pain and performance scores and the local symptoms did not improve. The PSA level continued to rise in all patients. Despite parenteral pre-medication with pethidine and cyclizine, all the patients suffered nausea and pain following the injection. One patient died on the fifth day of treatment from a myocardial infarction and 4 developed deep vein thrombosis. All the patients required further symptom control measures.

CONCLUSION

High dose intravenous stilboestrol causes considerable morbidity without any objective or subjective response in the treatment of patients with symptomatic, hormone-refractory metastatic carcinoma of the prostate.