740 Transrenal Endovascular Abdominal Aortic Aneurysm Repair in Infrarenal Abdominal Aortic Aneurysms with Anatomically Challenging Neck outside the Indications for Use: A Novel Approach

Introduction

Transrenal Endovascular Abdominal Aortic Aneurysm Repair (EVAR) is a novel approach for Infrarenal Abdominal Aortic Aneurysms (AAA) with unfavourable neck anatomy. This study aims to evaluate the long and short-term outcomes of Transrenal EVAR.

Method

Data of patients who underwent Transrenal EVAR in a single centre over 6 years were collected. Follow up on complications and mortality for 3 years post-procedure were analysed.

Results

A total of 36 patients were identified with a mean age of 77 years (61–89 years).

Neck

anatomy

Outcome

Conclusions

In view of the acceptable short term and long-term outcomes, trans renal EVAR can be offered for patients with infrarenal AAA with technically challenging neck anatomy but unfit for open repair in centres with adequate expertise.

742 Conventional Surgery vs Endovascular Abdominal Aortic Aneurysm Repair in the Management of Mycotic Abdominal Aortic Aneurysms

Introduction

This study aimed to look into the short and long-term outcomes in Mycotic Abdominal Aortic Aneurysms (MAAA) managed by Conventional Surgery (CS) and Endovascular Abdominal Aortic Aneurysm Repair (EVAR)

Method

Data of 17 patients who underwent CS or EVAR for MAAA from 2001 to 2017 in a single centre were collected. Complications and mortality at 3 years post-procedure were also analysed.

Results

Mean age was 66 (54 - 82 years), 15 (88.2%) were males. Mean aortic anterior-posterior diameter was 5.8cm (2.1 – 9.0 cm). 10 patients (58.8%) presented with rupture. 6 (35%) patients demonstrated positive cultures. 4 patients (23.5%) underwent CS and 13 (76.5) had EVAR of which 4 were surgeon modified EVARs. 5 (29%) patients developed complication within 30 days. 4 patients (23.5%) developed graft infection in long term. Total mortality was 5 (29.4%) of which one patient died within 30 days and two within 3 years of procedure. Long-term mortality was found to be significantly higher in patients treated with CS compared to EVAR (p-value 0.022).

Conclusions

CS for MAAA has a high mortality rate compared to EVAR. EVAR might be a simple and good alternative for this critical condition in centres with adequate expertise.

751 Preoperative Factors Influencing Functional Rehabilitation After Major Lower Limb Amputation

Introduction

To identify the preoperative factors that influence functional rehabilitation after Major Lower Limb (MLL) amputation.

Method

This retrospective study analyzed all patients referred post-amputation to an amputee rehabilitation centre over a period of 1 year. The level of functional outcome at 6 and 12 months were recorded using SIGAM (Special Interest Group in Amputee Medicine) grading. Data on various preoperative factors were collected and analyzed for association with functional outcome.

Results

A total of 71 cases were analyzed. The mean age was 65.18 (range 24 - 91) years and 45 were males (63.4 %). Peripheral arterial disease was the major cause of amputation (80.3%). The level of amputation was above / through knee in 60.6%. Contralateral limb problems were present in 28.2%. Functional mobility was achieved by 38% of the MLL amputees within 6 months of rehabilitation, which increased to 46.5% at 12 months. Pre amputation mobility was a significant factor for a good functional outcome (p-value 0.002). An increasing value of BLARt (Blatchford Leicester Allman-Russell Tool) score showed a significant correlation with poor functional outcome.

Conclusions

Pre amputation mobility and BLARt score can be used in the prediction of functional outcome and can aid in better pre-operative decision making and rehabilitation planning.

Gun-shot injuries in UK military casualties - Features associated with wound severity

INTRODUCTION

Surgical treatment of high-energy gun-shot wounds (GSWs) to the extremities is challenging. Recent surgical doctrine states that wound tracts from high-energy GSWs should be laid open, however the experience from previous conflicts suggests that some of these injuries can be managed more conservatively. The aim of this study is to firstly characterise the GSW injuries sustained by UK forces, and secondly test the hypothesis that the likely severity of GSWs can be predicted by features of the wound.

METHODS

The UK Military trauma registry was searched for cases injured by GSW in the five years between 01 January 2009 and 31 December 2013: only UK personnel were included. Clinical notes and radiographs were then reviewed. Features associated with energy transfer in extremity wounds in survivors were further examined with number of wound debridements used as a surrogate marker of wound severity.

RESULTS

There were 450 cases who met the inclusion criteria. 96 (21%) were fatally injured, with 354 (79%) surviving their injuries. Casualties in the fatality group had a median New Injury Severity Score (NISS) of 75 (IQR 75-75), while the median NISS of the survivors was 12 (IQR 4-48) with 10 survivors having a NISS of 75. In survivors the limbs were most commonly injured (56%). 'Through and through' wounds, where the bullet passes intact through the body, were strongly associated with less requirement for debridement (p<0.0001). When a bullet fragmented there was a significant association with a requirement for a greater number of wound debridements (p=0.0002), as there was if a bullet fractured a bone (p=0.0006).

CONCLUSIONS

More complex wounds, as indicated by the requirement for repeated debridements, are associated with injuries where the bullet does not pass straight through the body, or where a bone is fractured. Gunshot wounds should be assessed according to the likely energy transferred, extremity wounds without features of high energy transfer do not require extensive exploration.

Medium-term outcomes following limb salvage for severe open tibia fracture are similar to trans-tibial amputation

Extremity injuries define the surgical burden of recent conflicts. Current literature is inconclusive when assessing the merits of limb salvage over amputation. The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to equivalent outcomes for unilateral trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 and 2010, as described in a previously published series, were contacted. Consenting individuals conducted a brief telephone interview and were asked to complete a SF-36 questionnaire. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation between 2004 and 2010. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria. Telephone follow-up and SF-36 questionnaire data was available for 30 patients (61%). The median follow-up was 4 years (49 months, IQR 39-63). Ten of the 30 patients required revision surgery, three of which involved conversion from initial fixation to a circular frame for non- or mal-union. Twenty-two of the 30 patients (73%) recovered sufficiently to complete an age-standardised basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35-54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores between the limb salvage and amputation groups (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma.

Acute bilateral leg amputation following combat injury in UK servicemen

BACKGROUND

This study aims to characterise the injuries and surgical management of British servicemen sustaining bilateral lower limb amputations.

METHODS

The UK Military Trauma Registry was searched for all cases of primary bilateral lower limb amputation sustained between March 2004 and March 2010. Amputations were excluded if they occurred more than 7 days after injury or if they were at the ankle or more distal.

RESULTS

There were 1694 UK military patients injured or killed during this six-year study period. Forty-three of these (2.8%) were casualties with bilateral lower limb amputations. All casualties were men with a mean age of 25.1 years (SD 4.3): all were injured in Afghanistan by Improvised Explosive Devices (IEDs). Six casualties were in vehicles when they were injured with the remaining 37 (80%) patrolling on foot. The mean New Injury Severity Score (NISS) was 48.2 (SD 13.2): four patients had a maximum score of 75. The mean TRISS probability of survival was 60% (SD 39.4), with 18 having a survival probability of less than 50% i.e. unexpected survivors. The most common amputation pattern was bilateral trans-femoral (TF) amputations, which was seen in 25 patients (58%). Nine patients also lost an upper limb (triple amputation): no patients survived loss of all four limbs. In retained upper limbs extensive injuries to the hands and forearms were common, including loss of digits. Six patients (14%) sustained an open pelvic fracture. Perineal/genital injury was a feature in 19 (44%) patients, ranging from unilateral orchidectomy to loss of genitalia and permanent requirement for colostomy and urostomy. The mean requirement for blood products was 66 units (SD 41.7). The maximum transfusion was 12 units of platelets, 94 packed red cells, 8 cryoprecipitate, 76 units of fresh frozen plasma and 3 units of fresh whole blood, a total of 193 units of blood products.

CONCLUSIONS

Our findings detail the severe nature of these injuries together with the massive surgical and resuscitative efforts required to firstly keep patients alive and secondly reconstruct and prepare them for rehabilitation.

Home-made explosive found inside injured Afghan

There is extensive literature on metal fragments from improvised explosive devices being embedded in patients but there are no reports describing the clinical and radiological appearances of embedded home-made explosive (HME). We present a case of partially detonated HME being found inside a patient's forearm. We discuss the medical management of the injury, the ongoing risk to the patient and surgical team associated with the explosive and the safe disposal of the substance.

Hypotonicity-induced anion fluxes in cells expressing the multidrug-resistance-associated protein, MRP

Anion transport in human multidrug-resistant large cell lung tumour cells (COR-L23/R) which overexpress the multidrug-resistance-associated protein (MRP) has been compared with that in cells of the parent line (COR-L23/P). Whole-cell patch-clamp recordings reveal variability between individual cells in basal anion conductance and in anion conductance increases following exposure to hypotonic media. The increase of stimulated over basal conductance is significantly larger for resistant cells than for parent cells. The chloride channel blocker, diisothiocyanatostilbene-2-2'-disulphonic acid (DIDS), rapidly and reversibly inhibits the increase in outward but not inward conductance when applied externally at 10(-4) M during recording, but it is without effect when introduced into the cells via the patch pipette. Preincubation with DIDS greatly reduces both inward and outward conductance. 125I- efflux has been used to measure anion movement in cell populations. Basal efflux is similar in the two cell lines, but following a hypotonic challenge, the increase in rate constant for efflux from COR-L23/R cells is at least double that from COR-L23/P cells. This increase in efflux is greatly reduced by incubation with DIDS at 10(-4) M. Replacement of external chloride by gluconate does not affect efflux, thus excluding the possible involvement of DIDS-sensitive chloride exchange. Results from both techniques suggest that DIDS-sensitive, hypotonicity-induced anion channel activity is augmented in COR-L23/R multidrug-resistant variant cells which overexpress MRP. This augmentation may be caused by MRP itself or by other genes coexpressed with MRP.

Cloning and functional analysis of the TATA binding protein from Sulfolobus shibatae

Archaea (formerly archaebacteria) comprise a domain of life that is phylogenetically distinct from both Eucarya and Bacteria. Here we report the cloning of a gene from the Archaeon Sulfolobus shibatae that encodes a protein with strong homology to the TATA binding protein (TBP) of eukaryotes. Sulfolobus shibatae TBP is, however, almost as diverged from other archaeal TBPs that have been cloned as it is from eukaryotic TBPs. DNA binding studies indicate that S.shibatae TBP recognizes TATA-like A-box sequences that are present upstream of most archaeal genes. By quantitatively immunodepleting S.shibatae TBP from an in vitro transcription system, we demonstrate that Sulfolobus RNA polymerase is capable of transcribing the 16S/23S rRNA promoter weakly in the absence of TBP. Most significantly, we show that addition of recombinant S.shibatae TBP to this immunodepleted system leads to transcriptional stimulation and that this stimulation is dependent on the A-box sequence of the promoter. Taken together, these findings reveal fundamental similarities between the transcription machineries of Archaea and eukaryotes.

The TATA-binding protein: a general transcription factor in eukaryotes and archaebacteria

The TATA-binding protein TBP appears to be essential for all transcription in eukaryotic cell nuclei, which suggests that its function was established early in evolution. Archaebacteria constitute a kingdom of organisms distinct from eukaryotes and eubacteria. Archaebacterial gene regulatory sequences often map to TATA box-like motifs. Here it is shown that the archaebacterium Pyrococcus woesei expresses a protein with structural and functional similarity to eukaryotic TBP molecules. This suggests that TBP's role in transcription was established before the archaebacterial and eukaryotic lineages diverged and that the transcription systems of archaebacteria and eukaryotes are fundamentally homologous.