Search

In June 2022, Alabama legalized fentanyl test strips (FTS). In response to this new opportunity to prevent overdoses, Project Linkage, Education, and Prevention (LEAP)—an academic–community partnership providing substance use prevention services—quickly purchased FTS and started distributing them in the Birmingham area. We describe how the Addiction Prevention Coalition, a substance use education and harm reduction provider, distributed 7300 FTS in the first year of legalization via Project LEAP and discuss its efforts to decrease substance use among young people. (Am J Public Health. 2024;114(8):785–788. https://doi.org/10.2105/AJPH.2024.307681) [ABSTRACT FROM AUTHOR]

Recent studies have shown social determinants of health (SDOH) to impact HIV care engagement. This cross-sectional study (Oct 20-Apr 21) assessed the impact of a range of SDOH on HIV care engagement using data from HIV Care Connect, a consortium of three HIV care facility-led programs (Alabama, Florida, Mississippi). The exposures were captured using the PRAPARE (Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences) scale. The outcome was captured using the Index of Engagement in HIV Care scale. Participants (n = 132) were predominantly non-White (87%) and male (52%) with a median age of 41 years. Multivariable logistic regression adjusted for various sociodemographics showed lower HIV care engagement to be associated with being uninsured/publicly insured, having 1-3 unmet needs, socially integrating ≤five times/week, and having stable housing. Factors such as unmet needs, un-/underinsurance, and social integration may be addressed by healthcare and community organizations. Plain Language Summary: Assessing How Social Drivers of Health Affect Engagement in HIV Care in the Southern United States It has been found that social factors that have a direct impact on health affect engagement in HIV Care among people living with HIV. We included various social drivers of health to see how they affect engagement in HIV Care. We used data between October 2020 and April 2021 from a project titled HIV Care Connect, which is a group of three facilities providing HIV care in Alabama, Florida, and Mississippi. We used social drivers of health as risk factors from a scale called PRAPARE (Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences). Engagement in HIV care was measured by using a scale called Index of Engagement in HIV Care. A total of 132 participants were included. Majority of the participants were of races other than white (87%), male (52%) and were aged 41 years on average. Statistical analysis showed that participants without insurance or with public insurance, participants with 1-3 unsatisfied needs, participants that met with other people less than or equal to five times a week, and participants that had reliable housing had lower engagement in HIV care. These factors have a potential to be addressed by healthcare and community organizations. [ABSTRACT FROM AUTHOR]

Background: Alabama is one of seven priority states for the National Ending the HIV Epidemic Initiative due to a disproportionate burden of rural infections. To reverse growing infection rates, the state must increase its focus on prevention efforts, including novel strategies. One such approach is to utilize dashboards that visualize real-time data on the pre-exposure prophylaxis (PrEP) care continuum to assist in prioritizing evidence-based preventative care for those most vulnerable for HIV infection. Methods: We conducted a mixed methods evaluation to ascertain stakeholders' perceptions on the acceptability, feasibility, appropriateness, and usability of a PrEP care continuum dashboard, as well as gain insight on ways to improve the activities necessary to sustain it. Clinicians, administrators, and data personnel from participating sites in Alabama completed surveys (n = 9) and participated in key informant interviews (n = 10) to better understand their experiences with the prototype data dashboard and to share feedback on how it can be modified to best fit their needs. Results: Surveys and interviews revealed that all participants find the pilot data dashboard to be an acceptable, feasible, and appropriate intervention for clinic use. Overall, stakeholders find the pilot dashboard to be usable and helpful in administrative efforts, such as report and grant writing; however, additional refining is needed in order to reduce burden and optimize usefulness. Participants voiced concerns about their site's abilities to sustain the dashboard, including the lack of systematized PrEP protocols and limited funds and staff time dedicated to PrEP data collection, cleaning, and upload. Conclusion: Study participants from clinics providing HIV prevention services, including PrEP, in Alabama voiced interest in sustaining and refining a data dashboard that tracks clients across the PrEP care continuum. Despite viewing the platform itself as an acceptable, feasible, and appropriate intervention, participants agreed that efforts need to be focused on standardizing PrEP data collection protocols in order to ensure consistent, accurate data capture and that limited funds and staff time are barriers to the sustained implementation of the dashboard in practice. [ABSTRACT FROM AUTHOR]

Objective methods are needed to quantify digital artery disease in systemic sclerosis (SSc) for clinical trials of vascular therapies. Our primary aim was to examine feasibility of a novel tomographic three-dimensional-(3-D) ultrasound (tUS) with high-frequency ultrasound (HFUS) or ultra-high-frequency ultrasound (UHFUS) to assess the digital arteries in patients with SSc compared to healthy controls. A secondary objective was to compare the total wall volume (TWV) as a measure of intimal/medial thickness. Eighteen patients with a confirmed diagnosis of SSc were studied by tUS HFUS (17.5 MHz, n = 10) or tUS UHFUS (48 and 70 MHz, n = 8) with equal numbers of healthy controls of similar age and gender. The majority of patients had limited cutaneous SSc and were representative of a spectrum of digital vasculopathy, with over half (n = 6 HFUS and n = 5 UHFUS) having previous digital ulceration. Over half were receiving oral vasodilatory therapy. TWV was measured in both digital arteries of the middle finger bilaterally. At least, two digital arteries could be identified at 17.5 MHz in all patients and healthy controls. Whereas, at least two digital arteries could be identified in relatively fewer patients compared to healthy controls using 48 MHz (n = 6 and 10) and especially 70 MHz (n = 4 and 10) UHFUS. The median difference in TWV between patients and healthy controls was -6.49 mm3 using 17.5 MHz, 1.9 mm3 at 48 MHz, and -0.4 mm3 at 70 MHz. tUS using UHFUS is a feasible method to measure TWV of digital arteries in SSc. Transducer frequency plays an important factor in successful digital artery measurement, with 48 MHz being the optimal frequency. [ABSTRACT FROM AUTHOR]

Background: The main indication for carotid endarterectomy (CEA) is severity of carotid artery stenosis, even though most strokes in carotid disease are embolic. The relationship between carotid plaque volume (CPV) and symptoms of cerebral ischaemia, and the measurement of CPV by minimally invasive tomographic ultrasound imaging, were investigated. Methods: The volume of the endarterectomy specimen was measured using a validated saline suspension technique in patients undergoing CEA. Time from last symptom and severity of stenosis measured by duplex ultrasonography were recorded. Middle cerebral artery emboli were counted using transcranial Doppler imaging (TCD) in a subset of patients. Results: Some 339 patients were included, 270 with symptomatic and 69 with asymptomatic carotid stenosis. Mean(s.d.) CPV was higher in symptomatic than in asymptomatic patients (0·97(0·43) versus 0.74(0·41) cm3; P < 0·001). CPV did not correlate with severity of carotid stenosis (P = 0·770). Mean CPV was highest at 1·03(0·46) cm3 in the 4 weeks following cerebral symptoms, declining to 0·78(0·36) cm3 beyond 8 weeks. Among 33 patients who had TCD, mean CPV was 1·00(0·48) cm3 in the 27 patients with ipsilateral cerebral emboli compared with 0·67(0·16) cm3 in those without (P = 0·142). There was excellent correlation between CPV measured by tomographic ultrasound imaging and the endarterectomy specimen in 34 patients (r = 0·93, P < 0·001). Conclusion: CPV correlated with symptoms of cerebral ischaemia, but not carotid stenosis. It could be a potential indicator for CEA. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE) during chemotherapy is common, with 7% mortality in metastatic breast cancer (MBC). In a prospective cohort study of patients with breast cancer, we investigated whether vascular endothelial cell activation (VECA), and whether apoptosis, is the cause of chemotherapy-induced VTE. Methods: Serum markers of VECA, E-selectin (E-sel), vascular cell adhesion molecule 1 (VCAM-1) and d-dimer (fibrin degradation and hypercoagulability marker) were measured prechemotherapy and at 1, 4, and 8 days following chemotherapy. Clinical deep vein thrombosis (DVT) or pulmonary embolism and occult DVT detected by duplex ultrasound imaging were recorded as VTE-positive (VTE+). In patients with MBC, hypercoagulable response to chemotherapy was compared between patients with and without cancer progression. Development of VTE and cancer progression was assessed 3 months following starting chemotherapy. Results: Of the 134 patients, 10 (7.5%) developed VTE (6 [17%] of 36 MBC receiving palliation, 0 of 11 receiving neoadjuvant to downsize tumor, and 4 [5%] of 87 early breast cancer receiving adjuvant chemotherapy, P = .06). Levels of E-sel and VCAM-1 decreased in response to chemotherapy (P < .001) in both VTE+ and patients not developing VTE (VTE−). However, decrease in VECA markers was similar in VTE+ and VTE− patients, implying this is not the cause of VTE. In patients with MBC following chemotherapy, d-dimer (geometric mean) increased by 36% in the 21 patients with MBC responding to chemotherapy but steadily decreased by 11% in the 15 who progressed (day 4, P < .01), implying patients with tumor response (apoptosis) had an early hypercoagulable response. Conclusions: During chemotherapy for breast cancer, VECA is induced; however, this is not the primary mechanism for VTE. Chemotherapy-induced apoptosis may enhance hypercoagulability and initiate VTE. [ABSTRACT FROM PUBLISHER]

Background Mortality results for elective abdominal aortic aneurysm (AAA) repair are published by the Vascular Society of Great Britain and Ireland. These mortality results are not currently risk-adjusted. The objective of this study was to develop a national risk prediction model for elective AAA repair. Methods Data for consecutive patients undergoing elective AAA repair from the National Vascular Database between April 2008 and March 2011 were analysed. Multiple logistic regression and backwards model selection were used for model development. The study outcome measure was in-hospital mortality. Model calibration and discrimination were assessed for all AAA repairs, and separately for open repair and endovascular aneurysm repair (EVAR) subgroups. Results There were 312 in-hospital deaths among 11 423 AAA repairs (2·7 (95 per cent confidence interval (c.i.) 2·4 to 3·0) per cent): 230 after 4940 open AAA repairs (4·7 (4·1 to 5·3) per cent) and 82 after 6483 EVARs (1·3 (1·0 to 1·6) per cent). Variables associated with in-hospital death included in the final model were: open repair, increasing age, female sex, serum creatinine level over 120 µmol/l, cardiac disease, abnormal electrocardiogram, previous aortic surgery or stent, abnormal white cell count, abnormal serum sodium level, AAA diameter and American Society of Anesthesiologists fitness grade. The area under the receiver operating characteristic (ROC) curve was 0·781 (95 per cent c.i. 0·756 to 0·806) with a bias-corrected value of 0·774. Model calibration was good ( P = 0·963) based on the Hosmer-Lemeshow goodness-of-fit test, (bias-corrected) calibration curves, risk group assessment and recalibration regression. Conclusion This multivariable model for elective AAA repair can be used to risk-adjust outcome analyses and provide patient-specific estimates of in-hospital mortality risk for open AAA repair or EVAR. [ABSTRACT FROM AUTHOR]

Background: Cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capacity. The aim of this study was to assess whether preoperative CPET identifies patients at risk of early death following elective open and endovascular abdominal aortic aneurysm (AAA) repair. Methods: Prospective data were collected from a pilot study between September 2005 and February 2007, and from all patients who underwent CPET before elective AAA repair at two vascular centres between February 2007 and November 2011. Symptom-limited, maximal CPET was performed on each patient. Univariable and multivariable analyses were used to identify risk factors for 30- and 90-day mortality. Results: Some 415 patients underwent CPET before elective AAA repair. Anaerobic threshold (AT), peak oxygen consumption (peak V̇ O2) and ventilatory equivalents for carbon dioxide were associated with 30- and 90-day mortality on univariable analysis. On multivariable analysis, open repair (odds ratio (OR) 4·92, 95 per cent confidence interval 1·55 to 17·00; P = 0·008), AT below 10·2 ml per kg per min (OR 6·35, 1·84 to 29·80; P = 0·007), anaemia (OR 3·27, 1·04 to 10·50; P = 0·041) and inducible cardiac ischaemia (OR 6·16, 1·48 to 23·07; P = 0·008) were associated with 30-day mortality. Anaemia, inducible cardiac ischaemia and peak V̇ O2 less than 15 ml per kg per min (OR 8·59, 2·33 to 55·75; P = 0·005) were associated with 90-day mortality on multivariable analysis. Patients with two or more subthreshold CPET values were at increased risk of both 30- and 90-day mortality. Conclusion: An AT below 10·2 ml per kg per min, peak V̇ O2 less than 15 ml per kg per min and at least two subthreshold CPET values identify patients at increased risk of early death following AAA repair. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: There is no consensus on the best risk prediction model for mortality following elective abdominal aortic aneurysm (AAA) repair. The objective was to evaluate the performance of five risk prediction models using the UK National Vascular Database (NVD). Methods: Data on elective AAA repairs from the NVD between January 2008 and December 2010 were analysed. The models assessed were: Glasgow Aneurysm Score (GAS), Vascular Biochemical and Haematological Outcome Model (VBHOM), physiological component of the Vascular Physiological and Operative Severity Score for enUmeration of Mortality (V-POSSUM), Medicare and Vascular Governance North West (VGNW). Overall model discrimination and calibration in equally sized risk-group quintiles were assessed. Results: The study cohort included 10 891 patients undergoing elective AAA repair (median age 74 years, 87·3 per cent men). The in-hospital mortality rates following endovascular and open repair were 1·3 and 4·7 per cent respectively (2·9 per cent overall). The Medicare and VGNW models both showed good discrimination (area under receiver operating characteristic (ROC) curve 0·71), whereas the GAS, VBHOM and V-POSSUM models showed poor discrimination (area under ROC curve 0·60, 0·61 and 0·62 respectively). The VGNW model was the only one to predict the overall mortality rate in the cohort (3·3 per cent predicted versus 2·9 per cent observed; P = 0·066). The VGNW model demonstrated good calibration, predicting risk accurately in four risk-group quintiles. The Medicare, V-POSSUM and VBHOM models accurately predicted risk in three, two and no risk-group quintiles respectively. Conclusion: The Medicare and VGNW models contain similar risk factors and showed good discrimination when applied to the NVD. Both models would be suitable for risk prediction after elective AAA repair in the UK. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective evidence that avotermin works [ABSTRACT FROM AUTHOR]

Outcome can be predicted [ABSTRACT FROM AUTHOR]

Purpose: As paradoxical embolism is associated with stroke in young adults, migraine, and decompression sickness, the detection of venous-to-arterial circulation shunt (v-aCS), such as patent foramen ovale (PFO), is increasingly important. We compared a rigorous transcranial Doppler (TCD) protocol with transesophageal echocardiography (TEE) to develop criteria for PFO. Methods: Standardized TCD was performed 2 weeks before simultaneous TEE and TCD in 39 patients aged 15-39 following ischemic stroke (n = 33) or myocardial infarction (n = 6). V-aCS was investigated by contrast sonography. During standardized TCD, contrast injections were performed twice, at rest and with cough and Valsalva maneuvers. TCD and TEE were recorded and analyzed independently by 'blinded' observers. Results: All 16 of the 39 patients with PFO on TEE had more than 15 micro-emboli on standardized TCD; in 14 of these 16, paradoxical embolization required no provocation. Three of 9 patients with 'major' v-aCS (>50 microbubble emboli at rest or >10 at rest with >80 on provocation) on standardized TCD were not identified by TEE as having large shunts. Conclusion: The standardized TCD protocol is sensitive in the diagnosis of PFO and with the use of provocation maneuvers measures the functional importance of v-aCS more accurately than TEE. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE) following breast cancer chemotherapy is common. Chemotherapy-induced alterations in markers of haemostasis occur during chemotherapy. It is unclear how rapidly this occurs, whether this is upregulated in patients developing VTE and whether changes predict for VTE. Markers of haemostasis, functional clotting assays and vascular endothelial growth factor were measured before chemotherapy and at 24 h, 4 days, 8 days and 3 months following commencement of chemotherapy in early and advanced breast cancer patients and in age- and sex-matched controls. Duplex ultrasound imaging was performed after 1 month or if symptomatic. Of 123 patients, 9.8% developed VTE within 3 months. Activated partial thromboplastin time (APTT), prothrombin time (PT), D-dimer, fibrinogen, platelet count, VEGF and fibrinogen were increased in cancer. Fibrinogen, D-dimer, VEGF and tissue factor were increased, at baseline, in patients subsequently developing VTE. D-dimer of less than 500 ng ml(-1) has a negative predictive value of 97%. Activated partial thromboplastin time, PT and thrombin-antithrombin showed significantly different trends, as early as within 24 h, in response to chemotherapy in patients subsequently developing VTE. Markers of coagulation and procoagulants are increased, before chemotherapy, in patients who subsequently develop VTE. A group of patients at minimal risk of VTE can be identified, allowing targeted thrombopropylaxis to the higher risk group. [ABSTRACT FROM AUTHOR]

The study aimed to examine the relationship between spontaneous cerebral emboli (SCE), patent foramen ovale (PFO) and white matter hyperintensities (WMH) on cerebral MRI in patients with Alzheimer's disease (AD) and vascular dementia (VaD). SCE were identified by transcranial Doppler of the middle cerebral artery for 1 h. A "significant" v-aCS (venous-to-arterial circulation shunt indicative of PFO; ⩾15 embolic signals within 12 cardiac cycles) was detected by intravenous injection of "air in saline" ultrasound contrast. Deep white matter hyperintensities (DWMH) and periventricular hyperintensities (PVH) were assessed using Schelten's scale. After correction for cardiovascular risk factors, both DWMH and PVH were significantly associated with the presence of a PFO in AD (β=0.31, p=0.02 for DWMH, odds ratio 8.7, p=0.011 for PVH) but not in VaD. No consistent relationship was found between SCE and WMH in AD. In VaD, the severity of DWMH was negatively correlated with SCE (β=-0.55; p=0.001). In conclusion, the presence of a significant venous-to-arterial shunt is associated with more severe DWMH in AD, and may play a part in the aetiology of the disorder. In addition, there is a significant negative correlation between SCE and DWMH in VaD, which supports the hypothesis that VaD may be the result of ischaemic injury, predominantly reflecting embolic aetiology. [ABSTRACT FROM AUTHOR]

Background: We investigated the reproducibility of contrast transcranial Doppler (TCD), a safe non-invasive test for investigation of venous-to-arterial circulation shunts (v-aCS), usually patent foramen ovale, in young stroke patients. We also investigated whether microbubble contrast was reproducible and whether the addition of blood to agitated saline contrast affected the number of microbubbles produced. Methods: TCD investigation for v-aCS was repeated in 42 patients using a standardised protocol (i) by the same investigator and (ii) by a different investigator. Agitated saline was produced by mixing saline and 1 ml of air between two 10-ml syringes. The effect of adding blood and increasing the number of agitations was evaluated by microscopy examination using a haemocytometer to assess bubble numbers and sizes. Results: TCD: no difference was found in the highest microbubble count for the same investigator and between different investigators (p > 0.05). Reproducibility for the detection of v-aCS consistent with a patent foramen ovale was also good (κ values >0.8). Contrast: both the number of contrast mixes before injection and the presence of blood significantly increased the number of bubbles counted. On average, 18 agitations produced 1.86 (95% CI 1.62–2.13) times more bubbles than 6 agitations. Mixtures with blood produced on average 3.8 times more bubbles (3.08–4.69). The size of the bubbles was similar for all mixtures. Conclusions: Contrast TCD is reproducible and reliable for the detection of v-aCS. The addition of blood and 18 mixes rather than 6 significantly increased the number of microbubbles produced and may increase the effectiveness of microbubble contrast. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: No randomized trial has yet studied venous thromboembolism (VTE) prophylaxis in patients undergoing surgery for breast cancer. Method: Relevant articles were identified using Medline searches. Secondary articles were identified from the reference lists of key papers. Results and conclusion: The absence of randomized trials comparing different methods of VTE prophylaxis with controls makes an evidence-based consensus among breast cancer surgeons difficult. Intermittent pneumatic compression (IPC) and graduated compression (GC) are effective in reducing VTE without the haemorrhagic complications associated with heparin; their effects are additive. The authors suggest the following strategy. All patients undergoing surgery for breast cancer should receive both IPC and GC, with heparin reserved for those at very high risk. A controlled trial should randomize women to receive heparin or not, and all women should have both IPC and GC. The primary endpoints should be the development of VTE and/or haemorrhagic complications. [ABSTRACT FROM AUTHOR]

Background: There are considerable overlaps between vascular dementia and Alzheimer's disease (AD), with a suggestion that cerebrovascular disease (CVD) contributes to the neurodegenerative pathology of AD. Paradoxical embolization of venous emboli into the systemic circulation through a venous to arterial circulation shunt (v-aCS), the most commonly a patent foramen ovale (PFO), is known to cause cryptogenic stroke in younger people. We reviewed the potential role of paradoxical embolization in AD. Methods: A review of the literature on paradoxical embolization in neurological disorders and techniques to detect v-aCS and PFO, supplemented by data from our own studies. Results: Before our research, the role of paradoxical embolism in dementia had not been studied. The potential role of embolization in cerebral damage was highlighted by studies in patients undergoing coronary artery bypass or carotid surgery. Paradoxical embolization was found to occur in patients with cryptogenic stroke, migraine, decompression sickles and during hip surgery. The methods for detecting v-aCS or PFO had not been standardized. We found 'significant' v-aCS (equivalent to PFO) in 32% of AD patients compared with 22% of controls, but the study was not sufficiently powered to test the statistic significance of this difference. In AD, there was evidence of an association between 'significant' v-aCS and the severity of white matter hyperintensities on magnetic resonance imaging (MRI). Conclusion: Paradoxical embolization through a v-aCS may be a potentially preventable or treatable cause of CVD in AD. [ABSTRACT FROM AUTHOR]

Leukoaraiosis (LA) has been associated with abnormalities of both large and small blood vessels. This study attempts to clarify the pathogenesis of LA by testing the hypothesis that increased frequency of LA with occlusive extra-cranial arterial disease results directly from global reduction in cerebral blood flow (CBF). Thirty-five normal subjects and 55 patients with carotid stenosis (>70%) were studied using MR. CBF was measured using phase contrast MR angiography and LA was scored using previously validated scoring system. Patients were divided into those with evidence of previous infarction on MRI and those without. LA was more severe in patients than in normal subjects ( P < 0.01) and correlated with age in normal subjects but not in patients. CBF in patients with (809 ± 214 ml/min) and without infarction (mean 792 ± 181 ml/min) was significantly lower than in normal subjects (mean 1073 ± 194 ml/min). There was no correlation between the severity of LA and measured CBF in any group. The severity of LA is greater in patients with severe carotid stenosis but is not correlated to reductions in CBF. This suggests that microvascular abnormality is the dominant pathogenetic factor in LA even in the presence of severe stenotic/occlusive large vessel disease. [ABSTRACT FROM AUTHOR]

Objective: Current treatment of venous leg ulcers (VLU) includes four-layer bandaging, appropriate superficial venous surgery and leg elevation. The aims of this study were to: investigate a device designed to measure leg elevation; assess how long patients elevate; and to assess the effect of elevation on ulcer healing, femoral vein velocity (FVV) and popliteal vein cross-sectional area (PVCSA), and venous pressure. Patients and methods: A datalogger and accelerometer were manufactured to measure leg elevation. The device was validated in eight control subjects; elevation was measured in 24 patients with VLU. Ulcers were traced over six weeks in 29 patients and elevation measured to correlate healing with elevation. Ten patients and 10 controls underwent duplex measurement of FVV and PVCSA to measure flow in relation to posture; nine patients underwent measurement of venous pressure with postural changes. Non-parametric statistical analysis was used. Results: The datalogger accurately recorded all episodes of elevation. Median (range) elevation time was 53 (0–350) mins/24 h; correlation between ulcer healing and elevation was poor at 0.103 (P=0.616, Spearman); change in posture from sitting to supine produced a significant increase in median (range) FVV from 11 (7–24) to 34 (22–66) in VLU (P=0.005) and 15 (12–34) to 38 (16–69) in controls (P=0.005, Wilcoxon). Change in posture from supine to 25 degrees elevation produced no change in FVV in either group (P=0.173 in VLU, P=0.327 in controls, Wilcoxon). In VLU, sitting PVCSA was 1.07 (0.51–1.45) cm2. Supine position significantly reduced the area to 0.46 (0.27–1.01) cm2 (P=0.005, Wilcoxon). On elevation to 25°, PVCSA was further reduced to 0.28 (0.07–0.63) cm2 (P=0.058, Wilcoxon). In controls, sitting PVCSA was 0.79 (0.31–1.56) cm2, supine was reduced to 0.46 (0.27–1.09) cm2 (P=0.047, Wilcoxon) and on elevation was reduced to 0.23 (0.10–0.44) cm2 (P=0.005, Wilcoxon). Venous pressure standing was 99 (73–116) mmHg, reduced to 76 (53–113) mmHg on sitting (P=0.084), and further reduced to 23 (7–36) mmHg supine (P=0.008, Wilcoxon). Conclusions: Leg elevation in patients with VLU is poor but can be accurately measured. Elevation in the presence of compression may not improve ulcer healing. Postural changes of the leg can produce an increase in deep venous flow and a reduction in venous pressure. [ABSTRACT FROM AUTHOR]

We investigated the contribution of swab washing to the efficiency of red cell recovery by intraoperative cell salvage (ICS) in 10 patients undergoing elective aortic aneurysm repair.Volumes and haemoglobin (Hb) concentrations were recorded in the blood recovered by direct suction and from washed swabs, both before and after processing with a Haemonetics Cell Saver 5.The mean ± standard deviation (SD) estimated blood loss was 991 ± 403 ml, resulting in a mean ± SD salvaged RBC volume of 380 ± 124 ml. The median[interquartile (IQR) range] Hb collected from suction was 84·9 (61·8–131·4) g, of which 50·1 (45–71·5) g was returned to the patient after processing, a median yield of 68 (49–77)%. The swab wash produced a median (IQR) Hb of 39·4 (28·4–64·9) g, of which 26·2 (16·8–31) g was reinfused, a 67 (33–98)% yield. Swab wash thus contributed with a median (IQR) of 31 (24–39)% of the total RBC recovery.Washing swabs improves the efficiency of red cell recovery by ICS. [ABSTRACT FROM AUTHOR]

Objective: To prioritize varicose vein (VV) waiting lists, superficial venous reflux was timed in patients with primary VVs using hand-held Doppler (HHD) and classified as 'severe' (≤4s), 'moderate' (>4; ≤6s) or 'mild' (>6s). Only patients with severe reflux were offered surgery. The progression of reflux in those not offered surgery was investigated over two years. Methods: Patients seen in the VV clinic between November 1999 and October 2000 with reflux ≥4s were re-assessed two years later. Reflux was timed at the saphenofemoral (SFJ) and saphenopopliteal (SPJ) junctions using HHD. Patients completed a basic symptom questionnaire. The severity of VVs and skin changes of venous insufficiency were graded. Results: In all, 38/54 patients attended for review at two years. There were 44 limbs with 48 sites of reflux, 38 at the SFJ and 10 at the SPJ. Reflux improved at 27 sites, remained the same at five and deteriorated at 16. Reflux became 'severe' in eight limbs, but only four patients requested surgery. Median (interquartile range) reflux time was 6.0 (5–6)s in 1999–2000 and 7.0 (4–10)s in 2002 (P = 0.13). Median symptom scores for aching and the severity of VV remained unchanged. The cosmetic appearance of VV and skin signs of venous insufficiency significantly improved (P < 0.01). Conclusions: Mild and moderate reflux did not deteriorate in most VV patients. HHD may be a useful adjunct to grade venous reflux and prioritize patients for VV surgery. [ABSTRACT FROM AUTHOR]

Objectives: The gold standard assessment of venous hypertension is ambulatory venous pressure (AVP). Aims of this study were to determine the relationship of AVP with clinical severity of venous disease and whether AVP accurately identifies sites of incompetence. Methods: 117 limbs (93 subjects) underwent classification of venous signs, duplex imaging and AVP measurement. Eleven limbs had no disease, 28 had varicose veins (VVs), 45 had chronic venous insufficiency, 15 had healed ulceration, and 18 had active ulceration. Results: Mean (standard error of the mean) pressure relief index (PRI) showed a step-wise decrease from 1794 (±317) in controls to 167 (±46) in active ulcers (P <0.001, ANOVA). PRI correlated with clinical severity of venous disease (r = -0.60, P <0.01, Pearson). Superficial reflux alone was most common in VVs (60%), deep reflux in active ulceration (11%) and combined reflux in healed ulceration (93%). Tourniquet tests showed an increase in PRI only in combined reflux (P <0.028, ANOVA). Conclusions: AVP correlates with skin condition but is inaccurate in identifying sites of incompetence. [ABSTRACT FROM AUTHOR]

Background and Objectives To develop a transfusion trigger based on tissue oxygenation, near-infrared spectroscopy (NIRS) was evaluated in a model of compensated haemorrhage. Patients and Methods Regional haemoglobin oxygen saturation from the cerebral cortex (CsO2 ) and the gastrocnemius muscle (PsO2 ) was monitored (using an INVOS 4100 near-infrared oximeter) in 30 patients during acute normovolaemic haemodilution to a target haemoglobin of 11 g/dl. Arterial oxygen saturation, end-tidal carbon dioxide tension, mean arterial pressure and haemoglobin concentration were also measured. Results During blood collection, CsO2 and PsO2 fell by a mean (95% CI) of 8 (5·3–10·7)% (P < 0·001) and 5·5 (3·2–7·8)% (P < 0·001), respectively. Arterial pressure and oxygen saturation did not change, whilst the end-tidal carbon dioxide tension fell by 2·3 (0·8–3·8) mmHg (P = 0·004). Haemoglobin concentration correlated with CsO2 (R = 0·76, P < 0·001) and PsO2 (R = 0·63, P < 0·001), as did the volume of blood removed. Conclusions CsO2 and PsO2 fell predictably during compensated blood loss. With further research, NIRS may be developed into a transfusion trigger. [ABSTRACT FROM AUTHOR]

Background: This study evaluated the costs of acute normovolaemic haemodilution (ANH) and intraoperative cell salvage (ICS) versus homologous blood transfusion in aortic surgery in a prospective multicentre randomized trial. Methods: One hundred and forty-five patients were randomized either to standard transfusion practice (homologous) or to a combination of ANH and ICS (autologous). Costs for each inpatient admission were identified. Cell salvage costs were assigned on the assumption that 50 operations were done each year employing a trained cell salvage operator. The results were analysed statistically using bias-corrected bootstrap analysis. Results: Patients who had transfusion of homologous blood received some 251 units and those having a homologous transfusion received 103 units (P = 0·008). There was no difference in morbidity, mortality and duration of hospital stay. Transfusion-related mean costs were similar at £340 for patients having a homologous transfusion and £357 for those receiving autologous blood (mean difference £17 (95 per cent confidence interval (c.i.) – £184 to £174); P not significant). There was also no significant difference in mean overall costs: £5859 for homologous and £5384 for autologous transfusion (mean difference – £475 (95 per cent c.i. – £2231 to £1342)). Sensitivity analysis showed that costs remained similar for 20 and 150 operations per annum. Exclusion of a dedicated cell salvage operator reduced autologous transfusion costs but did not have a significant impact on overall cost. Conclusion: Autologous transfusion is cost neutral in aortic surgery even when surgical activity is low. [ABSTRACT FROM AUTHOR]

Discusses the abstract of a study evaluating autologous or homologous transfusion in aortic surgery in a multicenter clinical trial. Median blood loss; Blood volume in aortobifemoral bypass; Preoperative haemoglobin concentration.

Discusses the abstract of a study investigating the prognosis following deep vein thrombosis (DVT) and pulmonary embolism (PE) in women taking combined oral contraceptives. Patient characteristics; Mortality among PE group; Percent with calf and iliofemoral thrombosis.

Discusses the abstract of a study investigating the role of duplex imaging and measurement of ambulatory venous pressure in the preoperative assessment of patients with venous insufficiency and primary varicose veins. Confirmation of venous incompetence; Calculation of pressure relief index.

. Our aim was to assess changes in attitudes to autologous transfusion amongst surgeons over a 10-year period in response to scientific evidence, public awareness, published guidelines, management and the increasing cost of blood products. Surgeons across the north-west of England completed questionnaires on knowledge, experience and attitude towards autologous transfusion in 1990, 1994 and 1999. Main outcome measures were changes in knowledge, experience and utilization of autologous transfusion; perceived advantages of autologous transfusion, obstacles to its implementation in surgical practice and preferences for specific techniques (preoperative autologous donation, acute normovolaemic haemodilution, intraoperative and postoperative cell salvage). There has been little change in practice over 10 years. Many more surgeons were keen to employ autologous transfusion than were using it. Autologous transfusion was only used in general, orthopaedic and cardiothoracic surgery. Safety and patient preference were the main arguments for implementation and logistics the main obstacles. Autologous transfusion was used sporadically in surgical practice. Clinical trials are needed to guide clinicians in the choice of transfusion techniques. [ABSTRACT FROM AUTHOR]

To examine the regional variation in incidence and case fatality of myocardial infarction among young women. Cross sectional survey, using population based incidence data. England, Scotland and Wales. Subjects were women aged 16-44 with a diagnosis of myocardial infarction between 1 October 1993 and 15 October 1995. Incidence of myocardial infarction per 100,000 women years, with case fatality as a percentage of total cases. Incidence of myocardial infarction rose steeply from age 33 upwards, (maximum = 20.2 cases per 100,000 women years at age 44). The adjusted incidence rate for myocardial infarction was 3.7 (95% CI 3.2, 4.2) times greater in Scotland than in southern England. In contrast, case fatality was significantly lower in Scotland: 18.5% (95% CI 13.1%, 25.0%), compared with 31.0% (95% CI 25.9%, 36.0%) in southern England. The incidence of myocardial infarction varied widely within the United Kingdom. Case fatality variation may reflect differences in ambulance response, or in diagnostic acumen, within the regions. [ABSTRACT FROM AUTHOR]

Objectives: To determine the extent of risk of myocardial infarction from cigarette smoking in young women, and to examine the relation of smoking with other putative risk factors.Design: Community based case control study.Setting: England, Scotland, and Wales.Patients: Women (n = 448) between 16 and 44 years old with a diagnosis of incident myocardial infarction between 1 October 1993 and 16 October 1995. Controls (n = 1728) were age and general practice matched women without a diagnosis of myocardial infarction.Outcomes Measures: Odds ratios for risk of myocardial infarction associated with smoking and other risk factors.Results: Odds ratios for myocardial infarction in smokers versus non-smokers showed a strong dose response, from 2.47 (95% confidence interval (CI) 1.12 to 5.45) in smokers of 1-5 cigarettes per day to 74.6 (95% CI 33.0 to 169) in smokers of >/= 40 cigarettes per day. There was no interaction of smoking with use of oral contraceptives, but there were additive risks with other clinical risk factors such as hypertension and diabetes. It is estimated that if all women aged 16-44 years were able to stop smoking, 400 cases of myocardial infarction per annum (of whom 112 would die) would be prevented.Conclusions: In young women the risk of myocardial infarction from smoking was considerable, and heavy smokers with other risk factors were especially at risk. [ABSTRACT FROM AUTHOR]

We compared haemoglobin concentration values obtained using a portable haemoglobinometer, the HemoCue, in the operating theatre with the results obtained by the Coulter Max-M in the laboratory. Haemoglobin concentrations were measured on 52 arterial blood samples obtained from 13 patients during aortic surgery, in theatre with the HemoCue and again by the Coulter Max-M. Twenty routine samples from the laboratory were also analysed by both methods. There was no significant difference between results, with a mean of 10.94 g.dl-1 and 10.90 g.dl-1 for the HemoCue and Coulter, respectively (p = 0.12, t = -1.99, df = 70). The limits of agreement of the two methods (mean difference +/- 2 SD) were -0.37 and +0.45 g.dl-1. The coefficients of repeatability of the 20 samples analysed in duplicate on each device were 0.26 g.dl-1 and 0.33 g.dl-1, respectively. The coefficients of variance were 0.74% (HemoCue) and 0.93% (Coulter). With adequate training and monitoring, the HemoCue provides comparable haemoglobin results for near-patient testing in theatre. [ABSTRACT FROM AUTHOR]

Immunolocalisation and histochemical techniques were used to examine mineralised bone deposits within late stage atherosclerotic plaques of human carotid arteries. These specimens showed characteristic features of osteogenesis. Large calcifications were often observed in close association with or integrated within mineralised bone. Smooth muscle cells (alpha-actin positive) were often located around osteoid-like matrix, together with focal accumulations of macrophages (CD68 and HAM56 positive). Local accumulations of mast cells (tryptase positive) were consistently observed in close association with the bone. Multinucleated giant cells in close apposition with mineralised bone demonstrated typical osteoclastic morphology, and were positively stained for acid phosphatase and the macrophage marker CD68. Thus, all the normal features of bone formation and resorption were observed in this microcosm of osteogenesis within atherosclerotic plaque; the term 'osteosome' seems appropriate for the structure. These osteosomes have numerous advantages for experimental studies of the various osteogenic factors responsible for bone metabolism, especially following short-term tissue culture. This ex vivo technique was used to demonstrate the distribution and the multiple cellular sources of bone morphogenetic protein 6. [ABSTRACT FROM AUTHOR]

Reports issues related to medicine. Management of pressure sores; Efficacy of evening primrose oil for the treatment of atopic dermatitis; Controversies in the advertising of cigarettes.

OBJECTIVE--To determine which social and clinical factors are associated with healing in patients with venous ulceration. DESIGN--Patients were questioned about social factors at their first visit to a community ulcer clinic. They were treated by high compression bandage system and were interviewed again after 12 weeks. SETTING--Community leg ulcer clinics held in health centres throughout Riverside Health Authority in London. PATIENTS--All patients referred to five community leg ulcer clinics with venous ulceration over a six month period. MAIN OUTCOME MEASURES--These were factors significantly associated with healing within 12 weeks of beginning treatment, measured by odds ratio (OR) given by logistic regression analysis. MAIN RESULTS--Of 168 patients with venous ulceration, 87 (52%) healed after 12 weeks of treatment. Univariate analysis showed that low social class (OR = 3.44, 95% CI 1.17, 10.14), lack of central heating (OR = 2.22, 95% CI 1.18, 4.18), and being single (OR = 2.77, 95% CI 1.15, 6.69) were all significantly associated with delayed healing. After adjustment for the known risk factors of ulcer size, ulcer duration, and general mobility only lack of central heating was still significant (OR = 2.27, 95% CI 1.11, 4.55). The remaining factors failing to achieve statistical significance because of their inter-relationship with the known risk factors. CONCLUSIONS--Clinical features of the ulcer seem to determine the progress of healing in patients with leg ulceration. Although there were associations between socio-economic factors and poor healing, adjustment for clinical risk factors generally led to lower non-significant associations. Only lack of central heating retained its association and may play a part in prolonging healing of venous ulceration. [ABSTRACT FROM PUBLISHER]

Thrombus formation within arterial aneurysms may lead to embolisation and distal ischaemia. We have investigated the use of 111-indium labelled platelets in the diagnosis of atherosclerotic and false aneurysms. Autologous platelets labelled with 111-indium oxine were injected into patients with eleven proven aneurysms (8 atherosclerotic, 3 false). Gamma camera imaging performed between 24 and 72 hours later was positive for 10 of the aneurysms. In every case there was increased uptake of label over the aneurysm when compared to undiseased blood vessels (p < 0.05). Most aneurysms could be demonstrated within 24 hours of labelling platelets. 111-indium labelled platelets may prove useful in identifying the source of peripheral arterial emboli. [ABSTRACT FROM AUTHOR]