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ABSTRACT:Beginning with Edward Said's 1984 milestone "Reflections on Exile," this essay argues that exile remains the political problem of our time. Stretching back to Hannah Arendt's and Simone Weil's writings of the mid-twentieth century, forward through the long history of the dispossession of the Palestinian people, to the present, the essay turns to contemporary readings of the Iliad to make the case that at the heart of the violence of forced exile is the question of human community.

The article examines the increased popularity of political philosopher Hannah Arendt in the 21st century in response to the international political climate. Topics covered include Arendt's biographical background, her 1951 book "The Origins of Totalitarianism," and the use of her philosophy by Germany's far-right political party Alternative fur Deutschland (AfD).

The Critics: Books Time of the Magicians: The Invention of Modern Thought 1919-1929 Wolfram Eilenberger Allen Lane, 432pp, £25 In 1936, writing from exile in Paris, the German-Jewish writer Walter Benjamin looked back at the storms of the recent past with clear-eyed despair. In these ten years, four European men - Ludwig Wittgenstein, Martin Heidegger, Ernst Cassirer and Walter Benjamin - thought intently, obsessively and sometimes dangerously about how to answer the oldest questions of philosophy. By the later part of the 20th century, the works of Wittgenstein, Heidegger and Benjamin had all found their places on the pine shelves of independent bookshops. In the audience of lecture room 11 was the student he would sleep with before the end of the semester, the young political philosopher Hannah Arendt (the major thinker in this book sometimes referred to by her first name). [Extracted from the article]

The article focuses on the undermining issue of the human rights concept. Topics include an overview of human rights, the acknowledgment of its political context, its international agreements, its association with empathy, the impact of literature on human rights, and the remake of human rights following the second world war.

Duplex ultrasound (DU) remains the gold standard for identification and grading of infrainguinal vein graft stenosis. However, DU-based graft surveillance remains controversial. The aim of this study was to develop a decision tree to identify high-risk grafts which would benefit from DU-based surveillance.

The article reports on the humanitarian crisis in Europe due to several refugees from various countries worldwide including Pakistan, Lebanon and Ethiopia. It states the social conditions of refugees in Europe where they failed to accommodate the refugees due to their historical roots. Also mentioned are the misfortunes of modern refugees in other countries due to political, moral and existential faultline.

A number of surgical strategies and graft enhancements have been trialled to improve the performance of prosthetic grafts. Neointimal hyperplasia may, in part, be a normal cellular response to an abnormal (turbulent) flow environment. This first-in-many study assesses the safety and medium-term patency performance of a new graft designed to induce stable laminar flow through the distal anastomosis.

Although his post-war images of bespectacled men in glass boxes have led many to assume he did, Francis Bacon never directly painted Adolf Eichmann. One of Bacon’s first glass-encased portraits was produced in 1949, a good 12 years before Eichmann’s trial. This essay uses Bacon as a hinge first, historically, to think about the different kinds of perpetrator occults in the Nuremberg Tribunal and the Eichmann trial, and second, interpretatively, to draw out a contrast between a kind of looking (generic to the war crime trial) that keeps the perpetrator behind glass, and a more implicated looking that allows us to begin to think about the types of perception and imagination, and the kinds of reflective judgements, we might bring to the war criminal.If Bacon seems an appropriate artist to draw into contemporary discussions about the perpetrator, this is not just because of the historical associations between his work and the trial. Bacon’s painting is uniquely situated between, on the one hand, the rise of the documentary photograph within the history of the Holocaust, and on the other, a powerful drenching of nameless emotion in his work that is also often so present in representation of perpetrators, but rarely acknowledged in legal or historical discourse. Bacon’s work sits uncomfortably between history and nightmare, documentary evidence and an image of hell as, I argue, do the perpetrators of the Holocaust in the juridical imaginary.

Introduction The primary patency rate of arteriovenous (AV) grafts is limited by distal venous anastomosis stenosis or occlusion due to intimal hyperplasia associated with distal graft turbulence. The normal blood flow in native arteries is spiral laminar flow. Standard vascular grafts do not produce spiral laminar flow at the distal anastomosis. Vascular grafts which induce a spiral laminar flow distally result in lower turbulence, particularly near the vessel wall. This initial study compares the hemodynamic effects of a spiral flow–-inducing graft and a standard graft in a new AV carotid to jugular vein crossover graft porcine model.Methods Four spiral flow grafts and 4 control grafts were implanted from the carotid artery to the contralateral jugular vein in 4 pigs. Two animals were terminated after 48 hours and 2 at 14 days. Graft patency was assessed by selective catheter digital angiography, and the flow pattern was assessed by intraoperative flow probe and color Doppler ultrasound (CDU) measurements. The spiral grafts were also assessed at enhanced flow rates using an external roller pump to simulate increased flow rates that may occur during dialysis using a standard dialysis needle cannulation. The method increased the flow rate through the graft by 660 ml/min. The graft distal anastomotic appearances were evaluated by explant histopathology.Results All grafts were patent at explantation with no complications. All anastomoses were found to be wide open and showed no significant angiographic stenosis at the distal anastomosis in both spiral and control grafts. CDU examinations showed a spiral flow pattern in the spiral graft and double helix pattern in the control graft. No gross histopathological effects were seen in either spiral or control grafts.Conclusion This porcine model is robust and allows hemodynamic flow assessment up to 14 days postimplantation. The spiral flow–-inducing grafts produced and maintained spiral flow at baseline and enhanced flow rates during dialysis needle cannulation, whereas control grafts did not produce spiral flow through the distal anastomosis. There was no deleterious effect of the spiral flow–-inducing graft on macroscopic and histological examination. The reducing effect of spiral flow on intima hyperplasia formation will be the subject of further study using the same AV graft model at a longer period of implantation.

Major vascular surgery involves a high risk of major cardiovascular morbidity and mortality. A method of predicting perioperative myocardial events is required. Preoperative B-type natriuretic peptide (BNP) has been evaluated for this purpose. The aims of this study were to determine the postoperative course of BNP levels and correlate these levels with the outcome.

Peripheral arterial disease (PAD) patients are at high risk of cardiac death. Coincidental but silent coronary disease is obviously a major contributor but left ventricular hypertrophy (LVH) could be a second major contributor.

Amid the debates about how we might return to work, what is being forgotten is that work is a crucial part of what the 20th-century political philosopher Hannah Arendt called the human condition. Arendt's vita activa has three components: labour, work and action. Already in the 1950s, Arendt was worried that capitalist consumption would transform work into sheer labour. [Extracted from the article]

Spiral or helical arterial blood flow patterns have been widely observed in both animals and humans. The absence of spiral flow has been associated with carotid arterial disease. The aim of this study was to detect the presence of aortic spiral flow using magnetic resonance imaging (MRI) and to evaluate the relationship of the presence of spiral aortic flow with renal arterial disease and renal function in the follow-up of patients with suspected renal atheromatous disease.

Background: Upper gastrointestinal (GI) endoscopy is a widely used procedure that is generally considered to be safe. Methods: Of a total of 33,854 patients who underwent upper gastrointestinal endoscopy during 1999 under the care of surgeons in Scotland, 153 (0.004%) died. We reviewed the case notes of these 153 patients. Results: Death was directly related to endoscopy in 20 of 153 cases (13%), most commonly due to gastrointestinal perforation or acute pancreatitis. Ninety-one percent (139) of the patients undergoing endoscopy were American Society of Anesthesiologists grades (ASA) 3–5, and 88% received intravenous sedation; an anesthetist was present in 31 cases (20%). Oxygen was administered to 45% of patients during the endoscopy. In 56% of the procedures, there was monitoring of electrocardiograms (ECG), pulse oximetry, or blood pressure readings. Conclusions: Although deaths after endoscopy may be unavoidable, clinicians undertaking upper GI endoscopy or endoscopic retrograde cholangiopancreatography (ERCP) in ASA 3–5 patients should provide oxygen therapy and cardiovascular monitoring, and keep accurate records. The involvement of an anesthetist in airway management and the administration of intravenous sedation should be actively considered.

Background and aims Bystanders should be protected against aerosols, droplets, saliva, blood and vomitus during resuscitation after cardiac arrest The SARUS (safer - airway - resuscitation) CPR airway hood™ is a clear plastic cover and integrated mask that envelopes the head and torso. Our objectives were to test leakage using saline aerosol generation tests, then assess the performance of the hood during mock cardio-pulmonary resuscitation on a manikin.Methods A checklist was validated by comparing the performance of 10 novices against 10 experts during mock resuscitation. Thereafter, 15 novices were tested with and without the hood, in a randomised cross-over study, one week apart.Results Laboratory analysis showed a > 99% reduction of saline particles detected 5 cm, 75 cm and 165 cm above volunteers wearing the hood. On manikins, experts scored better compared to novices, 8.5 (0.7) vs 7.6 (1.2), difference (95%CI) 0.9 (0.4–1.3), P = 0.0004. Novice performance was equivalent using the hood and standard equipment, 7.3 (1.4) vs 7.3 (1.1) respectively, difference (90%CI) 0.0 (−0.3 - 0.3), P = 0.90.Conclusion Aerosol transmission reduced in the breathing zone. Simulated resuscitation by novices was equivalent with and without the hood.

In a pilot study, we have estimated the crude prevalence of asymptomatic peripheral arterial occlusive disease (PAOD) in diabetic patients attending a hospital clinic, using the sensitive Doppler ultrasound measurement of systolic ankle brachial pressure index (ABPI). This was compared with the available clinical methods of PAOD detection, ie peripheral pulse palpation. We have also investigated whether the measurement of toe systolic pressure (TSP) improved the detection rate of PAOD amongst those who had a normal ABPI. Of the 48 patients studied, 12 had palpable dorsalis pedis and posterior tibial pulse and 36 had absent pulse. Patients were of both types of diabetes mellitus, had no history of cardiovascular or cerebrovascular disease and did not have symptoms suggestive of intermittent claudication. An ABPI value of>0.9 was taken as normal. TSP was assessed by a strain gauge method. All patients who had palpable pulses had an ABPI > 1.0 with median (range) 1.10(1.01–1.30). Of those who had impalpable pulses, 18 patients had evidence of significant peripheral arterial insufficiency with an ABPI median (range) of 0.76 (0.49–0.89) and 18 patients had a normal ABPI with median (range) of 1.08 (0.92–1.25). TSP measurements were not different from the ankle systolic pressure. The study groups were no different in terms of their duration of diabetes, smoking habit, Body Mass Index or glycated haemoglobin levels, but those in the group with a low ABPI were significantly older, p<0.05. The prevalence of asymptomatic PAOD in our study cohort was 33% We conclude that palpable pulses are a predictor of normal ABPI, but impalpable pulses are not a strong predictor of PAOD.

Objectives:to investigate the levels of interleukin-8 (IL-8) in patients with peripheral arterial occlusive disease (PAOD) and healthy control subjects both before and after an acute exercise test. Materials and methods:twenty-six patients with intermittent claudication and 22 matched healthy control subjects each had IL-8 levels measured before and after a standard acute treadmill-exercise test. Subjects walked for 10 min or until stopped by claudication pain. Serum IL-8 levels were measured before exercise was commenced and 1, 5 and 10 min after exercise was stopped.Results:patients with PAOD had statistically significantly higher levels of IL-8 than healthy control subjects, before and after an acute exercise test (p <0.00001, Mann–Whitney). Ratios of the change of IL-8 levels post-exercise showed a statistically significant difference at the post-5-min time point (/E2>p =0.005), showing a difference in the change of IL-8 levels at this time point between the patient group and control group. Conclusions:The increased levels and the failure of the cytokine levels to fall by the same extent after exercise in the patient group may be due to a combination of increased neutrophil activation, reduced blood flow and increased cytokine production during ischaemia–reperfusion, which is not observed in the healthy controls.

Purpose:To assess the technical success, initial clinical outcome, and intermediate follow-up of the Memotherm nitinol self-expanding stent in aortic bifurcation reconstruction.

This article reviews the epidemiological, anatomical and physiological background to infrainguinal arterial reconstruction in the diabetic patient. There is no firm evidence in the literature for the existence of a surgically significant occlusive ‘small-vessel’ disease in diabetic patients, either as an aetiological component in the pathogenesis of diabetic foot lesions or as a factor limiting the success of infrainguinal bypass grafting. Recent published results of infrainguinal vascular reconstruction in patients with diabetes are reviewed. These are encouraging; early aggressive treatment of lower-limb occlusive disease may be warranted in the diabetic patient.

Between 1978 and 1987, 587 cases of abdominal aortic aneurysm were operated on in the Vascular Unit of the Royal Infirmary of Edinburgh. Over this ten-year period there was a dramatic increase in the number of patients treated. Rupture had occurred in 278 patients. Of the 309 patients with non-ruptured aneurysm 175 were asymptomatic, 84 were symptomatic and 50 were acutely symptomatic. Two hundred and fifty-nine patients underwent elective operation and the 50 acutely symptomatic patients were operated on as emergencies. The overall mortality for the non-ruptured series was 2·9 per cent. The mortality in patients undergoing elective surgery was 1·9 per cent (1·1 per cent in asymptomatic and 3·6 per cent in symptomatic patients) and 4·0 per cent for patients undergoing emergency surgery.

Forty-three patients undergoing superficial and perforating vein ligation for recurrent venous ulceration underwent preoperative and postoperative foot volumetry and postoperative duplex ultrasonography. Patients were followed for a median of 66 (range 18–144) months. Of nine patients who developed recurrent ulceration, six had femoral vein incompetence and all had popliteal vein incompetence demonstrated by duplex ultrasonography. Of the 34 patients who remained ulcer-free, five had femoral vein incompetence and a single patient had popliteal vein incompetence on duplex scanning, giving positive predictive values for recurrent ulceration of 55 per cent (femoral vein incompetence) and 90 per cent (popliteal vein incompetence). Patients with saphenofemoral incompetence on late follow-up were also more likely to suffer recurrence. Preoperative foot volumetry with tourniquet occlusion of superficial veins showed that the median expulsion fraction of patients who developed recurrent ulcer during follow-up was 0.8 (range 0.6–2.3) per cent compared with 1.5 (range 0.4–2.9) per cent for those who remained ulcer-free (P= 0.025); the median half-refilling time of patients with recurrent ulcer was 1.5 (range 0.5–5.5) s compared with 5.0 (range 0.5–23.0)s for those without recurrence (P< 0.01). Postoperative foot volumetry showed similar differences. Deep venous incompetence, particularly of the popliteal segment, as demonstrated by duplex ultrasonography and foot volumetry, is a useful predictor of recurrent ulceration after subfascial perforator and superficial venous ligation.

1. Blood flow patterns are poorly understood despite their impact on arterial disease. There have been few measurements in vivo of the three-dimensional blood flow patterns; we present the results of such studies using a new non-invasive in-vivo method of examining biplanar arterial blood flow patterns. 2. Multiple colour Doppler ultrasound directional velocity images were obtained at two different beam target angles from the artery in the plane perpendicular to its axis. Ensemble average images were constructed; the absolute velocity and direction were calculated by compounding the left and right averaged images. Simple directional, non-directional velocity and vector maps were constructed. 3. Flow patterns were sampled in 11 healthy male volunteers at four points of the pulse cycle; peak systole, systolic downswing, diastolic reverse flow and diastolic forward flow and at three sites; the right common and distal superficial femoral and the left common femoral arteries. 4. Stable rotational flow was observed in all subjects, the direction of rotation varying between sides and individuals. 5. There are theoretical advantages to spiral laminar blood flow; the forward-directed, rotationally induced stability and reduction of laterally directed forces may reduce turbulence in the tapering branching arterial tree and at stenoses and have a beneficial effect on mechanisms of endothelial damage and repair.

• We have previously shown that intraoperative angioscopy is a safe, useful, and effective method for monitoring infrainguinal bypass grafts. The videotaped recordings of the intraoperative angioscopy studies of 25 failed infrainguinal bypass grafts inserted between May 1987 and July 1989 and 3 failing grafts that were angioscoped during the subsequent graft salvage procedure were reviewed in a systematic fashion according to a fixed protocol, to identify any endovascular findings either initially missed or in which the relevance to graft failure had been unappreciated at the time of bypass grafting. We were able to identify new venous pathologic characteristics and highlight endoluminal features, of both a technical and nontechnical nature, which have a probable causal relationship to graft failure. However, the significance of some of the endovascular findings that were seen during infrainguinal bypass grafting has yet to be fully defined.(Arch Surg. 1990;125:749-755)

At sites of thrombosis and vascular injury, interactions occur among platelets, leucocytes and endothelial cells. Patients with peripheral arterial occlusive disease (PAOD) have been shown to have raised total serum cholesterol and serum triglycerides and increased sP-selectin levels when compared with controls. A total of 31 patients with PAOD and hypercholesterolaemia took part in this three-staged study. Soluble P-selectin (sP-selectin) levels were significantly lowered after 12 weeks of fluvastatin treatment (157.0 ng/ml versus 113.77 ng/ml, p = 0.01), whereas 12 weeks of placebo treatment had no statistically significant effect on sP-selectin levels (150.0 ng/ml versus 139.4 ng/ml). An unpaired t-test almost reached statistical significance (p = 0.051) when the levels by which sP-selectin fell after 12 weeks of active or placebo treatment were compared. The placebo group was then put onto long-term, active treatment and sP-selectin levels were significantly lowered by fluvastatin when compared to pre-treatment levels (150.0 ng/ml versus 110.0 ng/ml, p = 0.03). By lowering the levels of P-selectin, fluvastatin may not only attenuate atherosclerotic progression but may also decrease the platelet activation associated with PAOD.

Objectivethe objective of our study was to investigate whether such an incision results in a reduction in blood flow, and therefore haemoglobin oxygen saturation, across the wound.Designmicrovascular oxygenation was measured with lightguide spectrophotometry in 21 patients undergoing femoropopliteal or femorodistal bypass procedures. A series of measurements were made in the groin, medial and lateral to the surface marking of the femoral artery. The mean oxygen saturation on each side was calculated, and the contra-lateral groin was used as a control. The measurements were repeated at 2 and 7 days postop.Resultsoxygen saturation in the skin of the operated groins was increased significantly from baseline at 2 days postop (f=25.80, p<0.001) and had begun to return to normal by day 7. The rise was more marked on the lateral side of the wound than on the medial (f=12.32, p<0.001). There was no such difference in the control groins. All wounds healed at 10 days.Conclusionsthese results show a significant difference in skin oxygenation between the lateral and medial sides of the groin following longitudinal incision. This may contribute to the relatively high incidence of postoperative infection in these wounds.

Rosalind E. Krauss, The Optical Unconscious (Cambridge, MA: MIT Press, 1993, 1994), 353 pp., £15.50 (paperback)Joan Copjec, Read My Desire: Lacan against the Historicists (Cambridge, MA: MIT Press, 1994), 272 pp., £11.95 (paperback)Paul Virilio, The Art of the Motor, trans. Julie Rose (Minneapolis and London: University of Minnesota Press, 1995), 168 pp., £12.95 (paperback)Christine Buci-Glucksmann, Baroque Reason: The Aesthetics of Modernity, trans. Patrick Camiller, with an Introduction by Bryan S. Turner (London: Sage, 1993), 173 pp., £11.95 (paperback)Peter Carravetta, Prefaces to the Diaphora (West Lafayette, Indiana: Purdue University Press, 1991), 345 pp., £28.50 (hardback)Nicholas Zurbrugg, The Parameters of Postmodernism (Carbondale and Edwardsville: Southern Illinois University Press, 1993), 128 pp., $19.95 (hardback)Laure, The Collected Writings, trans. from the French by Jeanine Herman (San Francisco: City Lights Books, 1995), 314 pp., $13.95 (paperback)Fred Inglis, Raymond Williams (London and New York: 1995), Routledge, 333 pp., £19.99 (hardback)Bonnie Kime Scott, Refiguring Modernism; vol. 1, The Women of 1928; vol. 2, Postmodern Feminist Readings of Woolf, West, and Barnes (Bloomington and Indianapolis: Indiana University Press, 1995), xliii + 318 pp., £14.99 (paperback); xviii + 217 pp., £12.50 (paperback)T.E. Hulme, The Collected Writings of T.E. Hulme, edited by Karen Csengeri (Oxford: Clarendon Press, 1994), xxxvi + 489 pp., £60.00 (hardback)

Objective:: To delineate the natural history of infrarenal aortic aneurysms with respect to growth rate. Methods:: A referral based series of 233 patients with abdominal aortic aneurysm was serially assessed by abdominal ultrasound. Results:: The mean age was 71 years and the median follow up 26 months (range 6-146). The mean growth rate of the series was 3.2mm/year. Division of the initial size into those less than 41 mm (128 patients), between 41-60 mm (92 patients) and those above 60 mm (13 patients) in AP diameter showed mean growth rates per year were 2.6 mm/year, 4.1 mm/year and 6.5 mm/year. Examination of the relationship between aneurysm size and subsequent growth rate over the whole study period revealed a rank correlation of 0.19 (p = 0.002). Aneurysms were also observed to expand at an erratic rate both in terms of time and size. Conclusions:: When the initial decision is to observe the patient, serial ultrasound examinations facilitate later judgements on the balance of risks in relation to surgical treatment.

A trial was established at Wagga Wagga, New South Wales in 1967 to examine the value of the bipyridilium herbicides as substitutes for mechanical weed control in an extended cropping phase of a cereal/clover ley rotation. The experiment was continued for seven years and the results indicate that herbicides can successfully substitute for mechanical weed control. Direct drilling with a tined combine/seeder into a sprayed but undisturbed seed bed yielded an average of 1.97 tonnes of grain per hectare over seven years compared with 2.02 tonnes per hectare in the mechanically prepared or cultivated seed bed. The difference in yield was not significant. Direct seeding with a triple disc seeder following spraying of an undisturbed seed bed gave significantly lower yields than the other minimum tillage treatments. This minimum cultivation treatment was not successful because of poor plant establishment, possibly emphasized by restricted root growth. A reduced cultivation technique-cultivate-spray-drill-which was included in the trial over the last five years, gave comparable yields, 2.1 7 compared with 1.90 tonnes per hectare, to those obtained by conventional cultivation methods. There were no significant increases in yield with added nitrogen in a dry season, but in four out of the other six years there was significant linear increase in yield with increasing nitrogen rate. There was no significant interaction between cultivation method and applied nitrogen, indicating that neither minimum nor reduced cultivation increased the requirement for nitrogen fertilizer. The results are discussed in terms of mechanical aspects that will allow greater disturbance of the soil beneath the seed with a view to obtaining optimum root development.

Objective: To determine the reproducibility of duplex ultrasound in the measurement of reflux duration in lower limb veins.Design: Repeatability study.Setting: Vascular clinic in a tertiary referral centre.Participants: Twenty-one patients with severe venous disease.Interventions: Patients were scanned using duplex ultrasound by two of three observers, then rescanned by a different pair of observers after a mean interval of 51 days.Main outcome measures: Duration of venous reflux.Results: On a Wilcoxon signed rank test, observers 2 and 3 showed no significant interobserver variability. The other pairs of observers agreed at the majority of segments, but differed at the popliteal vein (p≤0.001), and superficial femoral and common femoral veins (p≤0.05). Observer 2 showed no significant intraobserver variability, but observer 1 differed at the common femoral and superficial femoral veins (p≤0.05), and observer 3 differed at the short saphenous vein (p≤0.05).Conclusions: Reproducibility was reasonable at certain sites, but appeared to be influenced by position of the vein.

Objectives:: To determine the patency and acceptability of the Memotherm endovascular stent in the treatment of iliac arterial occlusions. Materials and methods:: Twenty-two patients (12 males and 10 females) underwent stenting of iliac occlusions of the aortoiliac bifurcation, the common iliac artery and the external iliac artery. All patients were reassessed at 3, 6 and 12 month intervals and then yearly to evaluate their symptoms and Doppler pressure measurements. Comparison was made with results from other studies treating iliac occlusions by angioplasty alone or combined with stenting. Results:: Out of 22 patients, 21 had an immediate and sustained improvement over the whole of the follow-up period. The Ankle-brachial Index (ABI) increased from a mean value of 0.49 to 0.81 3-months postprocedure and improved to 0.85 at 12 months (paired t-test p<0.001). At 6 and 12 months the stent patency remained at 95.5%, which compares favourably with other studies. There were four minor and one major complication associated with the stenting procedure. Conclusions:: The Memotherm self-expanding stent is a useful, safe and effective device suitable for the majority of iliac occlusions. Further long-term evaluation is warranted to confirm its advantages over open surgery.

This study evaluates the hemodynamic effects and safety of saline irrigation necessary to obtain high-quality completion angioscopic studies, as compared with standard completion arteriography during infrainguinal bypass grafting. One-hundred ten patients undergoing primary infrainguinal bypass grafting, were prospectively randomized to either arteriography (N=50) or angioscopy (N=60) for a completion study to monitor the bypass procedure. All patients were hemodynamically monitored with pulmonary artery catheters and arterial lines. The arteriography group received an average of 27 ml (range 8–60 ml) of contrast per completion study, with a total administered intraoperative fluid volume of 2095 ml (range 650–4000 ml). The angioscopy group received an average bolus of 321 ml (range 90–650 ml) of irrigation fluid per completion angioscopy study, with a total administered intraoperative fluid volume of 2140 ml (range 850–5000 ml). Transient increases in pulmonary artery systolic and diatolic pressures and central venous pressures were measured during angioscopy. Although these changes reached statistical significance, the changes were of minimal clinical relevance, 1.9 (=4.5), 1.6 (=3.0) and 1.4 (=2.3) mmHg respectively, and returned to baseline levels within 30 minutes. Intraoperative intervention with vasodilators and diuretics, the perioperative cardiac morbidity, and less than 30 day mortality, was not different between the two groups. Pressures generated within 24 bypass grafts were within physiologic arterial range for most of the study. With careful angioscopic technique applied and high quality care extended to the patient, irrigation with saline solution is simple, effective and safe.

Purpose: A multicenter randomized prospective study was undertaken to determine whether an interposition vein cuff improved the short-term and medium-term patency and limb salvage rates of femoral-above-knee and femoral-below-knee popliteal artery polytetrafluoroethylene (PTFE) bypass procedures. Methods: Two hundred sixty-one bypass operations were randomized (133 to vein cuff and 128 to no vein cuff). One hundred fifty grafts were to the above-knee popliteal artery, 96 to the below-knee popliteal artery, and 15 to tibial vessels. The median follow-up was 617 days. Results: The 12-month patency rates for cuffed and uncuffed above-knee popliteal artery PTFE bypass grafts were 80% and 84%, and the 2-year patency rates were 72% and 70%, respectively. The patency rates for bypass grafts to the below-knee popliteal artery at 12 months were 80% and 65% and at 2 years 52% and 29%, respectively (p = 0.03). At the below-knee site, this was reflected in 24-month difference in limb salvage rates of 84% and 62%, respectively (p = 0.08). Conclusions: There was no improvement in the patency rate with the use of a distal anastomosis interposition vein cuff in femoral-above-knee popliteal PTFE bypass grafts, but there was a statistically significant advantage when PTFE bypass grafts were anastomosed to the popliteal artery below the knee. (J Vasc Surg 1997;26:543-50.)

With the advent of new selective post-emergence grass killers for broad-leaf arable crops, basic changes in cropping practices are likely to occur. Complete ‘post-em’ weed-control programmes could both accelerate the trend towards close-row and broadcast seeding of, for example, soya, and stimulate the use of reduced-cost band-spraying in established wide-row crops. By selectively controlling problem grasses they should encourage the adoption of reduced or zero-tillage systems.

Between January 1988 and December 1990, 56 patients underwent 66 arm vein infrainguinal bypass grafts for limb salvage. Thirty-nine grafts were intraoperatively monitored by the standard methods of continuous wave Doppler alone (30) and arteriography (9). Twenty-seven grafts were prepared and monitored by intraoperative angioscopy. No significant findings requiring intraoperative revision or correction were noted in the grafts monitored by the standard methods. However, in those grafts prepared and monitored by angioscopy, intraluminal abnormalities of the arm veins were detected and corrected in 20/27 (74%). None of the grafts prepared or monitored by angioscopy occluded within 30 days, whereas, in those grafts monitored by continuous wave Doppler and arteriography, 7/39 failed within 30 days, a primary patency rate of 32/39 (82%) (x2 with Yates correction, p=0.055). This study shows that angioscopic preparation and monitoring of arm vein bypass grafts allows the detection and correction of unsuspected intraluminal abnormalities, which appears to improve the early primary patency of arm vein infrainguinal bypass grafts.

Elevated blood cholesterol is a major risk factor for atherosclerosis. Recent studies show that lowering cholesterol reduces the risk of vascular disease, but the precise mechanisms for vascular improvement are not fully understood. Furthermore, it is not known whether the beneficial effects of cholesterol lowering extend to the skin microvasculature. In this unrandomized, open design study, we used iontophoresis and laser Doppler flowmetry to examine forearm skin perfusion in hypercholesterolaemic patients with PAOD before and after cholesterol-lowering therapy with fluvastatin.Endothelium-dependent and -independent vasodilatation were measured following skin iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP), respectively.Before cholesterol-lowering, vascular responses to ACh and SNP were reduced significantly in patients compared with responses in control subjects (p, 0.001 and p, 0.05, ANOVA, respectively). Fluvastatin therapy (40 mg/day) for 24 weeks significantly reduced total cholesterol (7.3 6 0.3 to 6.0 6 0.2 mmol/l, p, 0.001) and LDL cholesterol (5.4 6 0.5 to 4.2 6 0.4 mmol/l, p, 0.01). Vasodilatation to SNP was significantly improved at week 24 (p, 0.05).In patients with hypercholesterolaemia and PAOD, cholesterol-lowering with statin therapy significantly improved endothelium-independent vascular responses to SNP in skin microvessels. The application of the non-invasive techniques of iontophoresis and laser Doppler flowmetry may provide useful markers for the assessment of microvascular function in this group of patients.

Mouse mammary carcinoma cells were exposedin vitroto increasing concentrations of doxorubicin hydrochloride [adriamycin (ADR)] or 5-fluorouracil (5-FU). Uptake of [75Se]selenomethionine (75SeM) in a methionine-deficient medium measured the resulting inhibition of protein synthesis by the tumour cells. This was compared with the ability of the75SeM labelled tumour cells to localize in mouse lungs and to form pulmonary tumours following intravenous (i.v.) injection into isogenic hosts. These parameters were also related to the ability of the drugs to inhibit pulmonary tumour formationin vivowhen injected into mice which had received tumour cells i.v. Results from five different tumours were pooled for analysis. At the highest drug concentration (10μg/ml ADR, 100μg/ml 5-FU) inhibition of protein synthesis was significantly related to thein vivoaction of the drugs in limiting formation of pulmonary tumours (P<0·02 using the rank difference coefficient). There was also a direct relationship between pulmonary localization of tumour cells following exposure to drugs, their ability to form tumour nodules (P<0·025) and thein vivoaction of the drugs in inhibiting tumour formation (P<0·s05). Thus inhibition of protein synthesisin vitroand pulmonary localization following i.v. injection may be of value in predicting thein vivoeffect of cytotoxic drugs.

Objectives:to determine whether age is associated with survival following major amputation and whether this association is independent or simply reflects selection bias in amputation level.Design and materials:computer linkage of routine discharge and death data on the 2759 patients undergoing major amputation in Scotland between 1989 and 1993 for peripheral arterial disease.Methods:Cox's proportional hazards model and multivariate logistic regression analysis using death as the outcome variable and age, sex, urgency, amputation level and recent arterial reconstructive surgery as predictor variables.Results:proximal amputation was more common in older patients. Survival was associated with both age (p<0.001) and amputation level (p<0.001). Age was an independent predictor of death at 30 days (p<0.0001), 6 months (p<0.001), 12 months (p<0.0001) and 2 years (p<0.0001) postoperation.Conclusions:survival following amputation was poor, with only half the patients alive at 2 years. Above-knee amputation was associated with poorer survival, presumably due to the presence of more severe and widespread disease, and was undertaken more commonly in older patients. However, age remained a predictor of survival after adjustment for amputation level. Higher early mortality suggest that a worse prognosis in elderly patients cannot be attributed wholly to actuarial considerations.

“Spray Seed,” which involves direct combine-drilling of cereals after killing weeds and regenerating pasture grasses with a mixture of bipyridyl herbicides, has been developed in Western Australia as a means of minimizing the loss of grazing land during seedbed preparation at a time of the year when feed is critically short for sheep and other livestock. The results of several years’ field trials are summarized together with practical experience from a farm 120 miles north-east of Perth.

Introduction:All emergency departments (EDs) across Canada can identify a group of high frequency users, which are typically defined in the literature as eight to ten visits per year. Although frequent users of the ED are well-studied in the literature, there is little published in terms of identifying the “super-user” group who present to the ED much more often than 10 visits per year. Faced with multiple co-morbidities and a high mortality rate, the ED is often the most appropriate environment to manage this population. In order to inform future initiatives to improve health outcomes, we aimed to identify the specific characteristics of this super-user group. Methods:A retrospective chart review was conducted using the electronic medical record from the Thunder Bay Regional Health Sciences Centre to identify patients who had at least 25 visits in the year 2017. A total of 75 patients presented to the ED greater than 25 times in 2017. The following data was then collected on each individual patient: demographic characteristics including age, gender, address, access to a primary care provider. In addition, we collected date, time, diagnoses at each visit, admission rate and surgical interventions. Results:Our preliminary results reveal this population presents to the ED on average 32 times per year. The population is 53% male. Most have a private address and half have a primary care provider for all 2017 with one quarter having a primary care provider for part of the year. The percentage of visits for infections was 30%, mental health and addictions presentations comprised 28% of the visits, with gastrointestinal and cardiac visits comprising a total 22% of the visits. Approximately 7% of visits required admission to hospital, and the average length of stay was 5 days. Conclusion:Super-users of the ED are a unique population that are typically well connected with primary care and have a very low admission and surgical rate. The most common reasons for visit are infections and mental health and addictions. The next steps include collecting mortality data. This data should be used to inform ED and community initiatives aimed at improved health outcomes for this population.

Introduction:Most emergency departments (ED) in Canada have a population of high frequency users that present to the ED on a regular basis. These patients are well described in the literature and typically defined by a frequency of 8-10 visits/year. In Thunder Bay, Ontario we have a significant population of patients that present more often that we have termed “super-users”. These patients often are typically from a vulnerable population with multiple co-morbidities and a high mortality rate. Although their risk for poor health outcomes is well recognized, both the chronicity and complexity of their symptoms often contributes to diagnostic dilemmas. The decision to order a computed tomography (CT) scan can be a difficult balance between ruling out life threatening diagnoses and exposing the patient to excessive radiation. Our objective was to describe how often these super-users of the ED received a CT scan and what types of imaging were completed. Methods:The Thunder Bay Regional Health Sciences Centre is a geographically isolated hospital in Northwestern Ontario with the next closest hospital based CT scanner greater than 300 km away. Based on previous literature and our preliminary scoping of the super-user group, we have identified a minimum of 25 visits as the threshold. A retrospective chart review was conducted for the year 2017 using our electronic medical record. Patient demographic data was collected along with the type and number of CT scans into a standardized collection tool. Results:Our preliminary results showed that our total population of super-users was 75 patients with an average of 32 visits to the ED per year. A total of 76% of the patients had a CT scan completed at least once. On average these patients have a CT during 10% of their visits with head CT comprising 50% of the imaging and abdominal/pelvis imaging comprising another 45%. For 20% of these super-users, they had CTs on 20% of their visits. From this population, only 10% of the patients had surgery in 2017 while 7% of visits required admission to hospital. The most common diagnoses for these patient visits relate to mental health/addictions, gastrointestinal complaints and infection. Conclusion:This study has shown that a significant number of our super-user population are receiving multiple CTs. Our next step is collect data on individual radiation doses and calculate exposure risks. We hope to inform policy and decision-makers who are developing programs to treat the underlying cause of their high resource use.

The varicograms of 128 legs were reviewed by a panel of two vascular surgeons and a radiologist with a specialist vascular interest. Varicography effectively elucidates the anatomical basis of recurrence. Recurrent varicose veins were associated with (i) technically unsatisfactory surgery at the saphenofemoral junction (66 per cent) and (ii) failure to remove the long saphenous vein in the thigh (60 per cent). A new classification is offered as a basis for comparison of series, audit and surgical training.

The severity of post-thrombotic symptoms in 111 limbs (107 patients) with previous phlebographically proven deep vein thrombosis (DVT) was correlated with superficial and deep venous function as determined by foot volumetry (n= 90) and duplex ultrasonography (n= 62). The median delay between DVT and assessment was 8 (range 1–34) years. Symptoms were mild (group 1) in 31 limbs (28 per cent), moderate (group 2) in 41 (37 per cent) and severe (group 3) in 39 (35 per cent). There was no significant relationship between the site of DVT, or the time since DVT, and the severity of symptoms. Without tourniquet occlusion of superficial veins, limbs in group 3 had a significantly shorter half-refilling time than those in groups 1 and 2 (P= 0–01). Although a similar trend was observed after tourniquet occlusion of superficial veins, this was not statistically significant. There was no significant difference in the expelled volumes between the three clinical groups. On duplex scanning, deep and superficial venous reflux was detected in just over half of the limbs in each group. Eight patients had entirely normal scans and none of them had severe symptoms (P= 0·04). This study identifies a strong association between severe postphlebitic syndrome and venous reflux, such that it may be considered that venous reflux is necessary for the development of severe post-thrombotic symptoms. However, many patients with severe reflux have only mild symptoms and additional factors must therefore contribute to the development of severe postphlebitic syndrome.

Thirty-six consecutive unselected patients, who had apparently previously undergone saphenofemoral ligation for primary uncomplicated long saphenous varicosities and who had then re-presented with recurrent thigh varices emanating from the groin, underwent preoperative clinical assessment, hand-held Doppler and duplex ultrasonographic examination and varicography to establish the presence or absence of saphenofemoral incompetence as the cause of recurrence. All patients underwent re-exploration of the saphenofemoral junction (SFJ) via a lateral approach. Twenty-six patients had an intact SFJ (type I recurrence) and ten had varices arising from either a thigh perforator, or from abdominal or perineal veins (type II recurrence). Clinical examination alone was poor at distinguishing type I from type II recurrence. Doppler ultrasonography was sensitive (88 per cent) but non-specific (40 per cent). In contrast, duplex scanning was insensitive (42 per cent) but extremely specific (100 per cent) and accurate, with a positive predictive value of 100 per cent. Varicography also had a specificity and positive predictive value of 100 per cent, a sensitivity of 73 per cent and in addition provided a precise anatomical ‘road-map’. A combination of clinical examination and hand-held Doppler ultrasonography seems to be the most appropriate first-line method of preoperative assessment in these patients. Duplex ultrasonography, if available, will provide additional useful information about both the SFJ and the presence of thigh perforators. Contrast examination may be reserved for patients who have equivocal results on non-invasive investigations, who have had more than one previous groin operation or who have, in addition, deep venous disease.

A consecutive series of 118 patients (148 legs) presenting with recurrent varicose veins underwent preoperative clinical and hand-held Doppler ultrasonographic examination by a single observer. The presence of saphenofemoral, mid-thigh perforator and saphenopopliteal reflux was noted. Ultrasonography markedly improved the accuracy of clinical assessment at all three potential sites of reflux compared with operative findings. Of 71 patients undergoing repeat groin dissection, only 20 (28 per cent) had a tied saphenofemoral junction, 31 (44 per cent) had intact major tributaries and 52 (73 per cent) had an intact long saphenous vein (LSV) in the thigh. There was a positive association between mid-thigh perforator reflux giving rise to recurrent varices and the presence of an intact LSV in the thigh. Of 45 legs with saphenopopliteal reflux, only four had previously undergone saphenopopliteal ligation, suggesting that most short saphenous varicosities had either appeared after or had not been recognized at the time of primary surgery. This study indicates that even an experienced vascular surgeon can have difficulty in assessing the presence or absence of recurrent deep to superficial reflux by means of clinical examination alone and that Doppler ultrasonographic examination is mandatory. Recurrence continues to be associated with persistent or recurrent incompetence at the site of previous inadequate surgery.