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Venous thromboembolism (VTE) is the most common cause of preventable in-hospital mortality and all hospitalized patients should be VTE risk assessed. The VTE risk should be weighed up against risk of bleeding on an individualized basis to guide choice of prophylaxis. The most common method of mechanical thromboprophylaxis is graduated compression stockings, although others, such as intermittent pneumatic devices, are available. Stockings have the greatest benefit when used in combination with pharmacological prophylaxis. However, stockings are contraindicated in some patients, including those with stroke or peripheral arterial disease. Various options for pharmacological thromboprophylaxis are available. The most commonly used agents are the low-molecular-weight heparins, but newer orally active agents may play an increasing role in the future. [ABSTRACT FROM AUTHOR]

Post-thrombotic syndrome (PTS) can be debilitating to patients and have a major economic impact on health-care services. It arises after deep venous thrombosis (DVT) due to residual venous obstruction or valvular reflux, leading to increased venous pressure in the microcirculation. While the inflammatory process at the time of DVT may aid thrombus resolution, it may also promote destruction of venous valves. The diagnosis of PTS is principally clinical and patients typically complain of leg heaviness, swelling, pain, itching, cramps, ulcer and signs of lipodermatosclerosis. Several clinical scales or classifications have been used but it is recommended that Villalta scale is the most suitable. Risk factors for PTS include a proximal DVT and recurrent thrombosis as well as obesity and prior varicose veins. Poor quality of anticoagulation control may also be a factor. Established PTS is usually managed along the same lines as chronic venous hypertension with compression therapy and leg elevation. Surgery has only a limited role but may benefit some patients. Further trials are desperately needed to define the role of acute thrombolysis and mechanical thrombectomy, which seem to be promising treatments in the studies to date. For patients who have had a DVT more attention should be given to prescribing and using compression hosiery. [ABSTRACT FROM AUTHOR]

Mesenteric venous thrombosis is a rare condition associated with a high rate of morbidity and mortality. There have been no randomized trials, but most recent authors advocate the combination of a high clinical index of suspicion combined with noninvasive imaging with computerized tomography to make the diagnosis. When there is no evidence of perforation or peritonitis the condition is best managed conservatively with anticoagulation treatment. [ABSTRACT FROM AUTHOR]

Objective: To review current approaches to investigation and management of Paget-Schroetter syndrome (PSS). Methods: Relevant clinical studies and reports were searched for using MEDLINE and Embase databases and cross-referenced articles. Articles were extracted using keywords by the two authors independently. Principal findings: There is growing evidence of functional or positional anatomical defects, which lead to subtle intimal injury and a tendency for recurrence or poor outcome. Management of PSS remains controversial. Anticoagulation as a stand-alone treatment has lost favour. Active treatment with thrombolysis followed by consideration of thoracic decompression is recommended by most in the recent literature. Thrombolytic therapy appears to be a safe and efficacious method of establishing immediate patency of the axillary/subclavian vein. The timing and indications of decompression surgery are yet to be defined clearly. There are no randomized trials of treatment or management strategies in PSS. Conclusions: Treatment of PSS remains contentious. Most authors recommend active treatment with thrombolysis followed by thoracic decompression. Multicentre randomized trials are needed. [ABSTRACT FROM AUTHOR]

Focuses on the natural history of atherosclerotic renal artery stenosis (ARAS). Effect of ARAS on renal function and control of blood pressure; Impact of the revascularization of patients on mortality rate due to the disease; Measurement of serum creatinine, kidney length and diastolic blood pressure.

Presents a study that examined cases of pseudoaneurysm formation following prolonged radial catheter placement with evidence of local methicillin resistant staphylococcus aureus (MRSA) infection. Use radial artery catheters for blood pressure monitoring and arterial blood gas sampling; Need for vigilance in addressing the MRSA complication; Evaluation of the treatment used in pseudoaneurysm cases.

Extended treatment [ABSTRACT FROM AUTHOR]

An abstract of the article "Anatomic Factors in Patient Selection for Carotid Artery Stenting (CAS): A New Scoring System," by R. Williams et al is presented.

Examines the therapeutic use of aspirin. Variability in antiplatelet effects of aspirin; Resistance of certain individuals to aspirin; Pharmacokinetics and pharmacodynamics of the medicine.

Editorial. Looks at the evidences of the effect of high concentration of serum homocysteine as a risk factor for clinical vascular disease. Information on homocysteine; Clinical findings of nutritional studies on patients with vascular disease.

A response by the author to a letter to the editor about his article in the august, 2012 issue about cancer is presented.

The article focuses on the etiology and treatment of Paget-Schroetter Syndrome or primary upper limb deep venous thrombosis. In most cases, the disease is caused by the compression and chronic damage to the subclavian vein within a narrow thoracic outlet. Thrombolytic therapy is considered as safe and efficacious method of establishing patency of the subclavian vein. Balloon angioplasty may be useful in cases of residual stenosis after surgical thoracic outlet decompression.

The author reflects on the need for further research and public awareness about primary upper limb deep vein thrombosis or Paget-Schroetter Syndrome (PSS) in Great Britain. The proposal of interventional management is designed to combat reduced quality of life resulting from long-term disability. He believes that many cases of PSS in the country were treated inappropriately.

Venous thromboembolism (VTE) is a term including deep vein thrombosis (DVT) and pulmonary embolism (PE). Timely and accurate diagnosis of both is essential as delayed or missed diagnoses can result in death or longer term complications. Patients with suspected DVT should initially undergo a pretest probability Wells score. Depending on pretest probability Wells score they should then either proceed to two-point ultrasound scanning or D-dimer testing. Likewise, patients suspected of PE should undergo a two-level PE Wells score, and, if scored likely, a computed tomography pulmonary angiogram (CTPA), or, if there is a low pretest probability score, D-dimer testing. If positive, patients should undergo CTPA. Ventilation perfusion scanning (V/Q scan) or V/Q SPECT should be considered in place of CTPA if there is allergy to contrast media or renal impairment. [ABSTRACT FROM AUTHOR]

Background: The aim was to establish national data for lower-limb revascularization and major amputation procedures performed in England. Methods: Data for lower-limb revascularization procedures and major amputations were collected from the Hospital Episode Statistics (finished consultant episodes) which is published yearly by the Department of Health. Transluminal procedures were analysed from 1998 onwards. Age adjustment was performed according to figures for the resident population of England in the interval studied. Results: In all age groups, revascularization rates initially increased to a peak in the mid-1990s. This was followed by a steady decline in procedures to the present day. However, amputations gradually increased in the 45-64-years age group and showed only a slight decline in the 65-74-years age group. Among patients aged over 75 years there was a marked decline from the mid-1990s to present-day. Data for diabetics showed similar trends. Conclusion: The national rate of amputation initially rose despite an increasing number of vascular interventions. It is significant, however, that among patients aged over 75 years this has been followed by a decrease in both revascularization procedures and amputation rates to present levels, the lowest for 14 years. [ABSTRACT FROM AUTHOR]

Background: Surgical-site infections (SSIs) are common after major abdominal and groin bypass surgery. Tissue oxygen tension has been shown to predict these infections accurately. This study assessed whether a non-invasive measurement of tissue oxygenation, tissue oxygen saturation as measured by spectrophotometry, was as accurate. Methods: Fifty-nine patients having major abdominal or groin bypass surgery had tissue oxygen saturation measured by near-infrared spectrophotometry at the incision site and in the arm before operation, and at 12, 24 and 48 h after surgery. Masked outcome assessments for SSI were made at 7 and 30 days after operation. Results: In this retrospective analysis, 17 patients (29 per cent) developed an SSI. At 12 h after operation there was a significant difference in tissue oxygen saturation at the surgical site between patients who developed an SSI and those who did not (mean(s.d.) 43·4(18·1) versus 55·8(22·0) per cent; P = 0·032). These oxygen saturation readings were found to be more specific and sensitive in predicting SSIs than the National Nosocomial Infection Surveillance system. Discussion: There is a difference in postoperative surgical-site oxygen saturation between patients who subsequently develop SSIs and those who do not. Prediction of SSIs provides opportunities for intervention and prevention. Copyright © 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective: To assess the views of surgeons in the UK concerning the surgical management of patients with bilateral varicose veins (BVV) requiring surgery. Methods: A postal questionnaire was sent to members of the Vascular Society of Great Britain and Ireland. Questions concerned the use of BVV surgery in general, its use on day-case patients and which factors influenced decision-making in this area. Results: In all, 63% of surgeons never or only occasionally performed BVV surgery as a day case, whereas only 27% never or only occasionally performed BVV surgery on inpatients. The majority (70.2%) were not influenced by patient age or occupation (81.9%). The patient's general health was, however, a factor in decision-making for the majority (60.1%), as was the extent of the varicosities (52.8%). Other important factors were the availability of a second surgeon and a perception that there was likely to be increased morbidity with BVV surgery. Conclusions: There appears to be considerable variation between individual surgeons in the UK with regard to BVV surgery. This is manifested mainly as a reluctance to perform BVV as a day case by a significant number of surgeons. As there is no randomized trial(s) in this area, no firm guidance can be given. The issue is worthy of further study and may have significant health economic implications. [ABSTRACT FROM AUTHOR]

Background: Antiplatelet agents may prevent vascular events and death in patients with peripheral vascular disease (PVD). Methods: A systematic review of 39 randomized controlled trials of antiplatelet therapy in patients with PVD was performed. Results: For patients with PVD the number suffering a non-fatal myocardial infarction, non-fatal stroke or vascular death in the antiplatelet group was 6·5 per cent compared with 8·1 per cent in the placebo group (odds ratio 0·78 (95 per cent confidence interval (c.i.) 0·63–0·96); P = 0·02), favouring antiplatelet treatment. For infrainguinal bypass surgery (ten trials) and balloon angioplasty (two) the differences were still in favour of antiplatelet therapy, but they did not reach statistical significance. In five trials of aspirin against another antiplatelet agent, 8·4 per cent in the aspirin group suffered a vascular event compared with 6·6 per cent in the second antiplatelet group (odds ratio 0·76 (95 per cent c.i. 0·64–0·91); P < 0·01), favouring ticlopidine/clopidogrel/aspirin + dipyridamole against aspirin alone. Conclusion: Antiplatelet therapy reduces serious vascular events and vascular death in patients with PVD. For infrainguinal arterial surgery or balloon angioplasty the benefit remains unproven, but the number of trials to date is small. There is also evidence to support the use of antiplatelet drugs other than aspirin for the prevention of vascular events in those with PVD. [ABSTRACT FROM AUTHOR]

Background: A systematic review and network meta-analysis was undertaken to consider the evidence for the efficacy and tolerability of placebo, cilostazol, naftidrofuryl oxalate and pentoxifylline in patients with intermittent claudication due to peripheral arterial disease (PAD). Methods: MEDLINE, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Conference Proceedings, BIOSIS, National Research Register and MetaRegister databases were searched. Eligible studies were randomized controlled trials (RCTs) and published systematic reviews of patients with intermittent claudication due to PAD and whose symptoms persisted despite a period of conservative management. Study selection was conducted by one reviewer with involvement from a clinician. Data were extracted by one reviewer with no blinding to authors or journal, and checked by a second reviewer. Outcome measures were maximum walking distance (MWD) and pain-free walking distance (PFWD). Results: The review identified 1876 citations; 26 RCTs met the inclusion criteria for the systematic review. Eleven trials provided data relevant for the meta-analysis. Naftidrofuryl oxalate was ranked first for both MWD and PFWD (probability of 0·947 and 0·987, respectively, of being the best treatment) followed by cilostazol and pentoxifylline. For naftidrofuryl oxalate, cilostazol and pentoxifylline, MWD increased by 60 (95 per cent credible interval 20 to 114) per cent, 25 (11 to 40) per cent and 11 (−1 to 24) per cent respectively relative to placebo, and PFWD increased by 49, 13 and 9 per cent. Conclusion: Naftidrofuryl oxalate and cilostazol are both effective treatments for claudication; naftidrofuryl oxalate is likely to be the most effective, with minimal serious adverse events. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives: Since 2009 the National Health Service (NHS) has been collecting patient- reported outcome measures (PROMs) following varicose vein interventions. The objective of this manuscript was to interrogate the one-year PROMs data with respect to varicose vein intervention and to discuss its potential impact on the provision of service. Methods: We interrogated the one-year PROMs data with respect to potential impact on the provision of service. Results: In total, 37,521 varicose vein operations were performed during the study period (1April 2009-30 April 2010). A total of 15,808 preoperative questionnaires were completed and returned and 12,509 were linked to Hospital Episode Statistics episodes. A total of 8127 postoperative questionnaires were completed and linked to the preoperative questionnaires. For the EuroQuol (EQ) 5D questionnaire average preoperative score across the completed data-set was 0.773. The postoperative health gain was 0.094. Fifty-three percent of patients had improved postoperative scores, 33% reported no change, while 14% reported a reduction in their postoperative EQ-5D score. Pain/discomfort was the only domain where patients reported any negative symptoms; 72% (5390) reported pain/ discomfort preoperatively and 37% (2804) postoperatively. In total, 62.6% (4685) reported no pain/discomfort following surgery A total of 7167 complete, linked and eligible data- sets were observed for the Aberdeen Varicose Vein Questionnaire (AVVQ). The average preoperative score was 18.75. The average postoperative score was 10.76. This represented a reduction in symptom scores of one-half following intervention. The lowest improvements were witnessed in patients with the lowest preoperative scores (least severe symptoms). Additional postoperative questions highlighted the improvements conferred from varicose vein surgery with 90.3% of patients reporting an improvement in their problems from varicose veins following surgery and 85% describing their operative results as excellent, very good or good. Conclusion: These data have shown variable improvements following venous interventions. PROMs are likely to have significant implications for health care in the NHS on a number of levels including provision of funding and future planning of services. [ABSTRACT FROM AUTHOR]

Aim: Homocysteine (HCY) is an independent risk factor for occlusive vascular disease, the relationship of hyperhomocysteinaemia with aneurysms has not been established. The aim of this study was to assess the incidence of elevated HCY in patients with aortic aneurysms compared to controls, and patients with occlusive arterial disease. Methods: We measured HCY levels in 200 patients, 43 age- and sex-matched patients without vascular disease, 97 with aortic aneurysms (64 thoracoabdominal and 33 infrarenal) investigated for surgical intervention, and 60 patients with limb ischaemia (35 claudicants and 25 with critical limb ischaemia). Fasting blood samples were taken; serum separated and stored at -70 °C, HCY levels were measured using fluorescence polarization immunoassay (Abbott IMx® assay). Results are presented as mean ± SEM with 95 per cent confidence intervals, and the Mann–Whitney U -test was used for statistical analysis. Results: Nine per cent of controls were hyperhomocysteineaemic (>15 µm L-1 ); the mean HCY level was 9.35 ± 0.64 (95 per cent CI: 8.06–10.65) µm L-1 . Thirty-two per cent of the patients with aneurysms had elevated homocysteine, 13.20 ± 0.62 (95 per cent CI: 11.97–14.43) µm L-1 , and 26 per cent of patients with limb ischaemia were hyperhomocysteinaemic 13.24 ± 0.68 (95 per cent CI: 11.88–14.61) µm L-1 . HCY levels in both aneurysmal and occlusive disease were significantly higher than controls (P < 0.0001), and there was no difference between the occlusive and aneurysmal group. Conclusion: Homocysteine is prevalent in both aneurysmal and occlusive vascular disease. The treatment of hyperhomocysteinaemia is cheap, simple and inexpensive, and may represent a mechanism to modify the disease process. [ABSTRACT FROM AUTHOR]

The consequence of exercise on platelets remains controversial and adverse effects may result from repeated ischaemia reperfusion injury. We investigated platelet activation (platelet P-selectin (PS), and activated glycoprotein (Gp) IIb/IIIa), platelet–monocyte aggregates (PMA) and total plasma antioxidant status (TPAS) in claudicants after exercise. Twenty claudicants, taking 75 mg of aspirin daily, were subjected to repeated treadmill testing (3 km/h, 10% inclination). Blood was sampled before and after exercise. Activated GpIIb/IIIa, PS and PMA were quantified with flow cytometry. TPAS was quantified using a decolourisation assay. Percent positive cells for PS (pre-exercise 3.76% vs. 40 min post-exercise 4.10%; P < 0.05) and platelet–monocyte aggregates (pre-exercise: 25.31% vs. 40 min post-exercise 26.99%; P < 0.05) were significantly higher after exercise. Relative median fluorescence (RMF) for activated GpIIb/IIIa was significantly higher 40 min after exercise (pre-exercise: 3.04 vs. 40 min post-exercise: 4.01; P < 0.05). TPAS was significantly higher post-exercise (pre-exercise: 1.31 mmol/l vs. 1 min post-exercise: 1.40 mmol/l and 40 min post-exercise: 1.38 mmol/l; P < 0.01). Following moderate exercise, ‘aspirin treated claudicants’ show marginal platelet activation, PMA formation and a favourable improvement in antioxidant status. Further studies are required to assess the effect of additional antiplatelet agents and the significance of platelet–monocyte interactions. The possibility that aspirin contributes to the TPAS changes following exercise needs to be investigated. [ABSTRACT FROM AUTHOR]

Dextran 40 has been used to prevent post-operative thrombosis. However, its antithrombotic and antiplatelet effects in peripheral arterial disease (PAD) are poorly understood. We studied the in vitro effects of Dextran 40 on platelet function in control subjects and PAD patients using whole blood methods. Platelet function was assessed in 20 control subjects and 20 PAD patients. Spontaneous platelet aggregation (SPA) and agonist-induced platelet aggregation in response to increasing concentrations of Dextran 40 in vitro were measured by whole blood aggregometry. Flow cytometric measurements of platelet P-selectin, GpIIb/IIIa, GpIb and PAC-1 binding were also performed. There was no difference in SPA or ADP-induced aggregation in control patients with Dextran 40 in vitro . However, Dextran 40 inhibited collagen-induced aggregation in control patients ( P <0.05, Friedman test). In PAD patients, SPA and ADP (1 μM)-induced aggregation were significantly reduced by Dextran 40 in vitro ( P <0.001, Friedman test). In PAD patients, collagen-induced platelet aggregation (1 and 5 μg/ml) was significantly reduced by Dextran 40 in vitro ( P <0.01, Friedman test). GpIIb/IIIa, PAC-1 and P-selectin expression were significantly reduced in whole blood samples from PAD patients following incubation with Dextran 40 ( P <0.05, Wilcoxon rank test) but not in samples from control patients. Dextran 40 reduces spontaneous and agonist-induced platelet aggregation as well as the surface expression of markers of platelet activation in PAD patients. This antiplatelet effect may be of benefit to patients undergoing vascular surgical procedures where thrombosis is a significant risk. [ABSTRACT FROM AUTHOR]

Objective: To determine changes in platelet activation during carotid endarterectomy (CEA) and the antiplatelet effect of Dextran 40. Methods: Prospective study in 40 patients undergoing CEA. Platelet activity was measured by whole blood flow cytometry and platelet aggregometry during CEA. The expression of P-selectin and the PAC-1 antigen were used as markers of platelet activation and aggregation. Patients received aspirin (75-300 mg) preoperatively and 5,000 units unfractionated heparin during surgery. High intensity transient signals (HITS) in the ipsilateral middle cerebral artery were monitored using transcranial Doppler (TCD) perioperatively. Results: P-Selectin expression increased after carotid clamping (P < 0.01) and clamp release (P < 0.05). There was higher expression of PAC-1 after carotid clamping (p < 0.05). Spontaneous and ADP-induced platelet aggregation increased after carotid clamping (P< 0.01) and release (P < 0.01). TCD monitoring showed an increased HITS count from preoperative levels, after clamp release (P < 0.01) and during recovery (P < 0.01). After the operation, patients with more than 50 HITS per 30 min were started on an infusion of dextran 40 (n = 6). P-selectin expression decreased 24 h after dextran 40 (P < 0.01). Conclusion: Significant platelet activation and aggregation occurs during CEA despite the current use of antiplatelet treatment. Dextran 40 had an antiplatelet effect after CEA providing further evidence that it may contribute to reducing thromboembolic complications. [ABSTRACT FROM AUTHOR]

Discusses the abstract of a study examining the effects of immunomodulatory agents on the proliferation of rat aortic vascular smooth muscle cells (vSMC). Comparison of vSMC proliferation in control versus study group; Proliferation rate.

Summary Background: Warfarin induced skin necrosis is a rare complication with a prevalence of 0·01–0·1 per cent. It was first described in 1943. Methods: A literature review was undertaken using Medline; all relevant papers on this rare compli-cation of warfarin therapy were used. Results: There are several adverse skin manifestations associated with the use of oral anticoagulants, ranging from ecchymoses and purpura, haemorrhagic necrosis, maculopapular vesicular urticarial eruptions to purple toes. This article concentrates mainly on warfarin induced skin necrosis. The syndrome typically occurs during the first few days of warfarin therapy, often in association with the administration of a large initial loading dose of the drug. Although the precise nature of the disease is still unknown, advances in knowledge about protein C, protein S and antithrombin III anticoagulant pathways have led to a better understanding of the mechanisms involved in pathogenesis. Differential diagnosis between warfarin induced skin necrosis and necrotizing fasciitis, venous gangrene and other causes of skin necrosis may be difficult; the disease may also be confused with other dermatological entities. Conclusion: Warfarin induced skin necrosis, while rare, is an important complication. All surgeons should be aware of its existence. [ABSTRACT FROM AUTHOR]

Presents several correspondence on medical education in Great Britain. Consideration of the angiotensin converting enzyme inhibitors and renal artery occlusions; Bone mineral response to brief exercise test; Ethics of clinical research.

Aims: It has been suggested that the presence of Chlamydia pneumoniae in atherosderotic tissue may be related to plaque instability and the triggering of clinical events. The aim of this study was to identify any association between the presence of C. pneumoniae in carotid plaques and 1) ipsilateral symptomatology; 2) degree of stenosis; and 3) necrotic core volume. Methods: Seventy-three carotid plaques causing 70–99% stenosis by duplex were removed en-bloc during carotid endarterectomy. Of those, 45 were related to symptoms (11 to amaurosis fugax-AF, 20 to transient ischaemic attacks-TIAs and 14 to stroke) and 28 were asymptomatic. Nested polymerase chain reaction (PCR) was used to detect the presence of chlamydial DNA and computerised planimetry to quantify the necrotic core volume. The latter was expressed as a percentage of plaque volume. Results: PCR revealed the presence of chlamydial DNA in 26/73 (35%) carotid plaques. The prevalence in symptomatic plaques was 14/26 (54%) and in asymptomatic ones was 12/28 (46% (χ[sup 2] = 1.5, d.f. = 1, P = 0.2). Within the symptomatic group there was a higher prevalence of chlamydial DNA 1) in plaques associated with stroke (8/14, 57%) and TIAs (5/20, 36%) than in those associated with AF (1/11, 7%) (χ[sup 2] = 7.3, d.f. = 2, P = 0.03) and 2) in those causing higher degrees of stenosis (90% versus 85%, P = 0.05)*. Within the asymptomatic group there was a higher prevalence in plaques having a larger necrotic core (21% versus 12%, P = 0.05), Student’s t-test. Conclusions: Our study shows that 35% of carotid plaques contained C. pneumoniae. Although there was no significant difference in the presence of chlamydial DNA between symptomatic and asymptomatic plaques, within the symptomatic group the presence of C. pneumoniae was significantly higher in severely stenotic plaques and in those associated with cerebral ischaemia (TIAs and stroke) and notably reduced in those associated with retinal ... [ABSTRACT FROM AUTHOR]

This article focuses on a study related to coronary heart disease (CHD) in patients with intermittent claudication. CHD is common among patients with peripheral arterial disease (PAD), and death and major morbidity in PAD are often due to coronary events. Risk factor management should be similar in CHD and PAD. Patients with claudication and evidence of CHD appear to receive more evidence-based treatments than non-CHD patients, but overall patients with claudication referred from primary care in Great Britain are not receiving optimal medical risk factor management.

A response from the authors of the article "Systematic review and economic evaluation of cilostazol, naftidrofuryl oxalate, pentoxifylline and inositol nicotinate for the treatment of intermittent claudication in people with peripheral arterial disease" in a 2011 issue is presented.

The article introduces the issue, which is concerned with what is known about the epidemiology, etiology, current and possible future management of chronic venous ulceration.

This study examines the relationship between soluble P-selectin (PS), platelet bound PS by flow cytometry, and conventional markers of platelet activation, such as platelet aggregometry, in patients undergoing physiological stress expected to produce platelet activation. Blood samples were taken following exercise in 20 patients with intermittent claudication, and from 20 patients within 24hrs of an acute ischaemic stroke. the study shows that soluble PS, but not platelet bound PS correlates with direct measurement of spontaneous platelet aggregation.

The high mortality from cardiac and cerebrovascular events in peripheral arterial disease patients is not explained merely by the coronary artery anatomy. These patients have hyperactive platelets predisposing them to vascular events. Exercise has been linked with myocardial events in coronary artery disease patients. In patients with lower limb peripheral arterial disease, supervised exercise has been shown to improve walking distance. The effect of exercise on platelets remains controversial and adverse effects have been postulated as a consequence of repeated ischaemia reperfusion injury. P-selectin is a platelet marker and has been the gold standard for detecting platelet activation. Platelets-monocyte aggregates occur in sepsis, trauma and myocardial infarction and may be a marker of ischaemia reperfusion injury in these conditions.

Aims: Patients with peripheral bypass grafts have highly active platelets and are routinely given aspirin to reduce the risk of thrombotic vascular occlusion. This trial was conducted to determine if the addition of clopidogrel to aspirin enhances antiplatelet therapy in such patients. Methods: A randomized placebo controlled study was performed on 20 patients with functioning infrainguinal bypass grafts. In addition to their regular aspirin therapy, patients were randomized to receive either clopidogrel (Group 1) or placebo (Group 2) for one week. Platelet activation was measured ex vivo by platelet aggregometry and flow cytometry. Results: In Group 1 there was a significant reduction in spontaneous (SPA), adenosine diphosphate (ADP) and arachidonic acid (AA) induced platelet aggregation following treatment; SPA 3 min -21·0% (P = 0·001), ADP 3 min -4·7% (P = 0·007), and with AA 6 min by -27·4% (P < 0·001). No significant change in platelet aggregation was observed in Group 2 during the study. With flow cytometry a statistically significant reduction was observed in Group 1 in both activation dependent pselectin expression (P = 0·017) and GPIIb/IIIa activation (P = 0·031). No significant change was observed in the flow cytometry measures in Group 2 during the study. Conclusions: This study has demonstrated that the addition of clopidogrel to aspirin reduces platelet activation and aggregation, supporting a longer-term trial with clinical endpoints. [ABSTRACT FROM AUTHOR]

SummaryBackground: There is considerable debate over the management of infected infrainguinal grafts. This report describes recent experience in this field and documents the change in clinical practice needed to deal with methicillin-resistant Staphylococcus aureus (MRSA). Methods: All infected infrainguinal grafts between January 1991 and July 1997 were reviewed. In the light of the findings, clinical practice was modified considerably. A further 1 year was audited prospectively up to August 1998. Results: Twenty-six patients were treated for 27 infrainguinal graft infections (25 prosthetic, two vein). Twenty were treated by complete graft excision as the initial therapy; graft preservation was attempted in six patients. Before 1995, the infecting organisms were predominantly Pseudomonas aeruginosa or methicillin-sensitive staphylococci. Subsequently all 14 patients treated up to 1997 had infection with MRSA. The overall amputation rate was 17 of 26; ten amputations were in patients with MRSA. Four patients died, all with MRSA sepsis. As a result of this experience a policy of complete isolation was adopted for all patients infected with MRSA. In the 12 months since this policy was introduced, 77 infrainguinal grafts (61 vein, 16 prosthetic) have been inserted. Two grafts (3 per cent) have become infected, necessitating graft excision and amputation. Conclusion: MRSA infection of an infrainguinal graft is a serious complication with high associated amputation and mortality rates. Isolation and barrier nursing appeared to contain the problem. Presented in part to the annual meeting of the Vascular Surgical Society of Great Britain and Ireland, London, UK, November 1997 and published in abstract form as Br J Surg 1998; 85: 564. [ABSTRACT FROM AUTHOR]