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SUMMARYSyndromic surveillance systems in England have demonstrated utility in the early identification of seasonal gastrointestinal illness (GI) tracking its spatio-temporal distribution and enabling early public health action. There would be additional public health utility if syndromic surveillance systems could detect or track subnational infectious disease outbreaks. To investigate using syndromic surveillance for this purpose we retrospectively identified eight large GI outbreaks between 2009 and 2014 (four randomly and four purposively sampled). We then examined syndromic surveillance information prospectively collected by the Real-time Syndromic Surveillance team within Public Health England for evidence of possible outbreak-related changes. None of the outbreaks were identified contemporaneously and no alerts were made to relevant public health teams. Retrospectively, two of the outbreaks – which happened at similar times and in proximal geographical locations – demonstrated changes in the local trends of relevant syndromic indicators and exhibited a clustering of statistical alarms, but did not warrant alerting local health protection teams. Our suite of syndromic surveillance systems may be more suited to their original purposes than as means of detecting or monitoring localized, subnational GI outbreaks. This should, however, be considered in the context of this study's limitations; further prospective work is needed to fully explore the use of syndromic surveillance for this purpose. Provided geographical coverage is sufficient, syndromic surveillance systems could be able to provide reassurance of no or minor excess healthcare systems usage during localized GI incidents.

Withaferin A (WA), a natural product derived from Withania somnifera, has been used in traditional oriental medicines to treat neurological disorders. Recent studies have demonstrated that this compound may have a potential for cancer treatment and a clinical trial has been launched to test WA in treating melanoma. Herein, WA's chemopreventive potential was tested in a chemically-induced skin carcinogenesis mouse model. Pathological examinations revealed that WA significantly suppressed skin tumor formation. Morphological observations of the skin tissues suggest that WA suppressed cell proliferation rather than inducing apoptosis during skin carcinogenesis. Antibody Micro array analysis demonstrated that WA blocked carcinogen-induced up-regulation of acetyl-CoA carboxylase 1 (ACC1), which was further confirmed in a skin cell transformation model. Overexpression of ACC1 promoted whereas knockdown of ACC1 suppressed anchorage-independent growth and oncogene activation of transformable skin cells. Further studies demonstrated that WA inhibited tumor promotor-induced ACC1 gene transcription by suppressing the activation of activator protein 1. In melanoma cells, WA was also able to suppress the expression levels of ACC1. Finally, results using human skin cancer tissues confirmed the up-regulation of ACC1 in tumors than adjacent normal tissues. In summary, our results suggest that withaferin A may have a potential in chemoprevention and ACC1 may serve as a critical target of WA. © 2015 Wiley Periodicals, Inc.

SUMMARYA new surveillance system for outbreaks of norovirus in English hospitals, the hospital norovirus outbreak reporting system (HNORS), was launched in January 2009. On site investigators were enabled to enter data on outbreaks of norovirus directly onto a tailored system via an internet-based front end. A standard dataset was designed to collect information describing the key epidemiological characteristics of each outbreak. In the period 1992–2008, 1817 suspected and confirmed outbreaks of norovirus in English hospitals were reported to national surveillance. After introduction of the new system there were 3980 reports of outbreaks of suspected and confirmed norovirus received in the years 2009–2011. Data from the new reporting system demonstrates that transmission of norovirus levies a heavy burden on English hospitals. On average, reported outbreaks are associated with 13 000 patients and 3400 staff becoming ill, 8900 days of ward closure and the loss of over 15 500 bed-days annually.

Background Listeriosis is an opportunistic bacterial infection caused by Listeria monocytogenes and predominantly affects people who are immunocompromised. Due to its severity and the population at risk, prompt clinical diagnosis and treatment of listeriosis is essential. A major step to making a clinical diagnosis is the collection of the appropriate specimen(s) for testing. This study explores factors that may influence the time between onset of illness and collection of specimen in order to inform clinical policy and develop necessary interventions. Methods Enhanced surveillance data on non-pregnancy associated listeriosis in England and Wales between 2004 and 2013 were collected and analysed. The difference in days between onset of symptoms and collection of specimen was calculated and factors influencing the time difference were identified using a gamma regression model. Results The median number of days between onset of symptoms and collection of specimen was two days with 27.1 % of cases reporting one day between onset of symptoms and collection of specimen and 18.8 % of cases reporting more than seven days before collection of specimen. The median number of days between onset of symptoms and collection of specimen was shorter for cases infected with Listeria monocytogenes serogroup 1/2b (one day) and cases with an underlying condition (one day) compared with cases infected with serotype 4 (two days) and cases without underlying conditions (two days). Conclusions Our study has shown that Listeria monocytogenes serotype and the presence of an underlying condition may influence the time between onset of symptoms and collection of specimen. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1638-4) contains supplementary material, which is available to authorized users.

Platelets are the main cellular component in blood responsible for maintaining the integrity of the cardiovascular system via hemostasis. Platelet dysfunction contributes to a wide range of obvious pathological conditions, such as bleeding or thrombosis, but normal platelet function is also linked to diseases not immediately associated with hemostasis or thrombosis, such as cancer. Since the description of Trousseau syndrome in 1865, various experimental and clinical studies have detailed the interaction of platelets with primary tumors and circulating metastatic tumor cells. Observations have suggested that platelets not only augment the growth of primary tumors via angiogenesis but endow tumor cells physical and mechanical support to evade the immune system and extravasate to secondary organs, the basis of metastatic disease. Many laboratory and animal studies have identified specific targets for antiplatelet therapy that may be advantageous as adjuncts to existing cancer treatments. In this review, we summarize important platelet properties that influence tumorigenesis, including primary tumor growth and metastasis at the molecular level. The studies provide a link between the well-studied paradigms of platelet hemostasis and tumorigenesis.

A wintertime peak of norovirus activity occurs each year, affecting institutions including schools and hospitals. Traditional laboratory and outbreak surveillance systems for norovirus are too vulnerable to reporting delay to act as a timely signal of activity in the community. Calls to the National Health Service (NHS) telephone service NHS Direct have the potential to be an early warning tool for public health purposes. We investigated whether NHS Direct vomiting calls can be used as a reliable indicator of norovirus activity and, if so, whether the increase in calls precedes the epidemic of hospital outbreaks. Laboratory reports were used as the reference standard to define the norovirus season. From 2004 to 2008, four series of NHS Direct call data were compared with laboratory data held at the Health Protection Agency Centre for Infections in order to identify the best predictor of the season start. The four series included: (1) modelled and extracted the proportion of calls likely to be for 'non-rotavirus' gastroenteritis; (2) the mean proportion of weekly vomiting calls in children aged

Surveillance for norovirus is challenging because the nature of illness due to norovirus is such that the majority of people who are infected will not have any contact with medical services and are highly unlikely to have a sample collected for diagnosis. Public health advice urges people to not visit hospitals or their family physicians, to prevent the risk further spread. The recognition of the importance of this pathogen was quickly established following the introduction of surveillance of outbreaks of gastrointestinal infection in England and Wales in 1992. This period saw >1800 outbreaks of norovirus infection reported in hospitals in England, affecting >45 000 patients and staff. A new system for reporting outbreaks of norovirus infection in hospitals, the Hospital Norovirus outbreak Reporting Scheme (HNORS), began in January 2009. Summary information on outbreaks is provided by infection control staff at hospitals and includes questions on the date the first and last person in the outbreak became symptomatic and whether closure of a bay or ward was needed. In the first 3 years (2009-2011) of the HNORS surveillance scheme, 4000 outbreaks were reported, affecting 40 000 patients and 10 000 staff. Over the last 3 years, these outbreaks have been associated with an average of 13 000 patients and 3400 staff becoming ill, with 15 000 lost bed-days annually. With the possible introduction of a vaccine on the horizon, targeted research with a more integrated approach to laboratory testing and outbreak reporting is essential to a greater understanding of the epidemiology of norovirus.

Norovirus is recognized as the leading cause of diarrheal disease in many countries. A study of the published literature shows that in the United Kingdom it is estimated to cause around 3 million cases each year (1). In the Netherlands, it has been estimated that norovirus is responsible for 11% of the 4.5 million diarrhea cases annually (2). In Canada, the estimated number of cases of gastrointestinal disease attributed to norovirus overall was a little over 3.3 million (3), accounting for 42% of gastrointestinal disease. A review by Hall et al. suggests that the number of people infected with norovirus in the United States is between 19 and 21 million each year (4). In the Southern Hemisphere, norovirus is the most common cause of gastrointestinal disease; one study from New Zealand suggests that norovirus was responsible for 26% of outbreaks, and in Australia norovirus causes the highest number of cases of gastrointestinal disease (5). A recent systematic review suggests that globally, norovirus is responsible for 20% of the burden of gastrointestinal disease (6).

Introduction Classification of endoleak is determined by the mechanism by which the endograft fails to exclude the aneurysm. In some instances, the endoleak may be very subtle or not visible; yet, the aneurysm continues to expand. This report presents our experience in identifying unstable abdominal aortic aneurysm sacs associated with endoleaks or endotension in early and late monitoring using color duplex ultrasound (CDU) in a series of more than 1000 endograft patients. Aims We sought to (1) describe ultrasound features of atypical endoleaks and endoleaks from unusual sources and (2) characterize other CDU features that may be associated with endotension. Methods Philips HDI 5000 and IU22 machines were used during routine post-endograft surveillance scans of the abdominal aorta. Color, spectral, and power Doppler analysis were also performed to identify evidence of perigraft flow, graft stenosis, thrombus, kink, or migration. Secondary diagnostic maneuvers were conducted in the presence of perigraft flow to characterize the type of endoleak. Particular attention was also paid to the abdominal aortic aneurysm sac contents, size, and pulsatility. Correlation was made to angiography and computed tomography imaging in a series of 22 patients who underwent secondary endograft procedures or open conversion. Results Technically satisfactory studies were achieved in approximately 90% of patients. We detected type II endoleaks in 10% of patients assessed and graft migration in 12 cases. Endotension was characterized by sac enlargement and/or shape change without identifiable perigraft flow and correlated highly with device migration. Suggestive features of graft/sac instability included increased sac pulsatility, prominent areas of echolucency within the sac, and occasional low-amplitude atypical color signals within the sac thrombus close to the graft wall. Conclusion Reliable CDU assessment for late endograft follow-up requires careful scrutiny of the aneurysm sac contents and wall, as well as the graft device. Endoleak may not always be obvious yet CDU features can assist in identifying the source of endoleak or the presence of endotension. There are suspicious ultrasound features that may alert one to graft/sac instability and potentially dangerous outcome.

Introduction We have recently observed an interesting phenomenon of prominent arterial neovascularization (ANV) within the thrombus and vein wall of patients with major venous thrombosis, sometimes intense enough to mimic small arteriovenous fistula. A prospective study was therefore conducted in 50 patients to further characterize this process. Aims We sought to determine the incidence of ANV; to characterize the process in more detail; and to determine whether there was an eventual recanalization of the thrombosed vein and favorable clinical outcome Methods All patients presenting with lower-extremity venous thrombus were prospectively imaged with Philips HDI 5000 and IU22 ultrasound systems using a standard protocol, including spectral and color Doppler analysis. Blood flow patterns in and around the thrombus were closely observed and recorded. In each patient, the phenomenon was assigned a grading from 0 to III according to prominence and penetration of the neovascularization process into the thrombosed vein. Results A total of 50 consecutive patients (age range; 35–80 years) were included in the study. 32 patients had DVT and 18 patients had superficial venous thrombus (SVT). ANV was observed as small vessels demonstrating a low-resistive arterial signature appearing predominantly on the vein wall and/or within the thrombus. The typical vessel diameter was 0.3–3.0 mm. ANV was present in 80% of patients examined and in 97% of cases with thrombus aged less than a year old. It was more common with SVT (100%). The process was most prominent at the 2–4 month interval after venous thrombosis. Conclusion There is a process of neovascularization that commonly occurs in association with venous thrombus. This was detected in 97% of patients with thrombus less than a year old. ANV appears to be a normal component of the recanalization process and may result from an inflammatory reaction. Further studies will be required to determine if the grade of this process can be correlated with favorable long-term outcome.

Introduction The aim of this study was to review our experience of popliteal aneurysms using endovascular techniques. Methods Thirty popliteal aneurysms in 25 patients were treated over an 11-year period. Median aneurysm diameter was 26 (16–48) mm. Five were symptomatic and 25 asymptomatic. Patients were treated with the Haemobahn/Viabahn stent-graft (26), Passager (two), Aneurx (one), and PTFE homemade device (one). Data were assessed using life table analysis, and expressed as cumulative patency rates and standard error (SE). Results Median follow-up was 24 (range 1–95) months. Primary patency was 92.9% (SE 4.5%), 84.7% (SE 6.8%), 80% (SE 8.2%), 74.5% (SE 9.4%) and 74.5% (11.3%) at 1, 6, 12, 24 and 36 months, respectively. Cumulative secondary patency was 96.5% (SE 3.3%), 88.7% (SE 6.0%), 88.7% (SE 8.6%), 83.2% (SE 8.0%) and 83.2% (SE 9.8%) at 1, 6, 12, 24 and 36 months, respectively. Conclusion Endovascular treatment of popliteal aneurysms in this series achieved patency rates similar to open surgery. Aneurysm repair was performed without peroperative deaths and the risks associated with open surgery.

Our objective was to evaluate the role of Valsalva's maneuver during MDCT for the diagnosis and characterization of abdominal wall hernias.From September 2002 to May 2003, 100 consecutive patients (37 men and 63 women; mean age, 53 years) with suspected anterior abdominal wall hernias underwent 4-, 8-, or 16-MDCT with and without Valsalva's maneuver. Patients received both oral and IV contrast material. On a workstation, three independent reviewers evaluated each scan obtained during rest and during Valsalva's maneuver for the following parameters: anteroposterior (AP) diameter of the abdomen; presence, location, and contents of the hernia; and transverse diameter of the fascial defect. The scans were compared to assess for changes in hernia size and contents and to determine whether the hernia would have been overlooked without Valsalva's maneuver. Fisher's exact test, the McNemar test, and Cohen's kappa coefficient were used to assess for significant differences.The three reviewers identified a mean of 72 abdominal wall hernias (72%). The reviewers agreed (kappa = 0.723) with respect to the presence of a hernia. AP diameters increased an average of 1.33 cm during Valsalva's maneuver (p0.001). The transverse diameter of the fascial defect increased an average of 0.66 cm and the AP diameter of the hernia sac increased an average of 0.79 cm during Valsalva's maneuver (p0.001). Fifty percent of the hernias became more apparent with Valsalva's maneuver. Ten percent of the hernias could be detected only on the scan obtained during Valsalva's maneuver. Conversely, in no patients was the hernia detected only on the rest scan.As opposed to scans obtained at rest, scans obtained during Valsalva's maneuver aid in the detection and characterization of suspected abdominal wall hernias. A single scan obtained during Valsalva's maneuver is sufficient to detect 100% of anterior abdominal wall hernias identified on CT.

ObjectiveThe purpose of this single-center study was to compare findings at presentation and surgical outcome in patients in whom abdominal aortic aneurysms (AAAs) ruptured after endovascular repair and patients in whom AAAs ruptured before any treatment, over a defined period.MethodsFrom May 1992 to September 2003, 1043 patients underwent elective repair of intact infrarenal AAAs. Endovascular repair was performed in 609 patients, and open repair in 434 patients. Eighteen of 609 patients (3%) who underwent endovascular AAA repair required treatment because of rupture of the aneurysm after a mean of 29 months (group 1). During the same 11-year period, another 91 patients without previous treatment required urgent repair of a ruptured AAA (group 2). Rupture was diagnosed at contrast material–enhanced computed tomography or by presence of extramural extravasation of blood at open repair. Except for a higher incidence of women in group 2, patients in both groups were similar with regard to demographics and clinical characteristics but differed in findings at presentation. Eight patients in group 1 had a known endoleak before AAA rupture, whereas contrast-enhanced computed tomography, performed in 15 patients at presentation, demonstrated an endoleak in all. Hypotension (systolic blood pressure

In a recent series of papers Gisselquist and colleagues challenge the consensus that heterosexual transmission has accounted for 90% of HIV infections in African adults. They argue that nearly half of HIV infections have resulted from health care exposures mainly through contaminated injections. This is not just a theoretical debate among epidemiologists. Its conclusion has farreaching implications for HIV prevention in Africa. But have experts just been ‘seeing what they wanted to see’ as is claimed or does the work of Gisselquist and colleagues lack scientific credibility? In this article we consider Gisselquist et al.’s review entitled ‘Let it be sexual: how health care transmission of AIDS in Africa was ignored’ and summarize points that arose in a subsequent debate between Dr David Gisselquist and Dr Barry Evans. This is simply not the case in Africa. Countries that have very high rates of HIV infection such as Kenya and South Africa have low rates of HCV. While the prevalence of HIV continued on an upward curve in South Africa throughout the 1990s HCV prevalence has remained low. Gisselquist and colleagues argue that HCV data derived in a systematic review are not robust enough to show this conclusively. In countries with a relatively high prevalence of both HCV and HIV infections proportionally more health care-associated HIV infection may have occurred. However without further studies this cannot be assumed nor quantified as individuals with HIV may not be those also infected with HCV; if individuals are coinfected HCV infection may have arisen from receiving health care for HIV-related symptoms— reverse causality. (excerpt)

Background: Because a large percentage of patients surviving carotid endarterectomy (CEA) subsequently die from a vascular cause, the aim of the present paper was to determine risk factor management for a cohort of patients 4 years after their CEA. Methods: Surviving patients who had a CEA within the region administered by the Central Sydney Area Health Service in 1995 were asked to complete a self-administered questionnaire to determine vascular risk factors. Results: Of the 181 patients eligible to participate, 162 returned questionnaires (response rate: 90%). While 106 (65.4%) patients recalled that they had been diagnosed with high blood pressure either before or after their CEA, only 79.2% recalled that their latest blood pressure reading was ‘about right for my age’. Nearly one in five (16.7%) who had had their cholesterol level checked in the last 12 months (n = 120) indicated that the reading was ‘too high’. Only 76.5% reported taking medications to ‘thin the blood’. Almost one-fifth of patients (17.3%) were current smokers. Only 35.2% of patients participated in a level of physical activity sufficient to confer a health benefit. Further, 30.2% of patients were overweight and 14.8% were obese. The majority of patients (98.1%) reported having a regular general practitioner (GP). Of these, 98.7% had visited their GP at least once within the previous 6 months. Conclusions: Vascular risk factor management following CEA is suboptimal, inviting the implementation and evaluation of strategies to improve outcomes.

Maggi Boult, Wendy Babidge, John Anderson, Michael Denton, Robert Fitridge, John Harris, Michael Lawrence-Brown, James May, Kenneth Myers and Guy Maddern

OBJECTIVE: To examine the maternal and foetal risks of adverse pregnancy outcome in relation to maternal obesity, expressed as body mass index (BMI, kg/m2) in a large unselected geographical population. DESIGN: Retrospective analysis of data from a validated maternity database system which includes all but one of the maternity units in the North West Thames Region. A comparison of pregnancy outcomes was made on the basis of maternal BMI at booking. SUBJECTS: A total of 287 213 completed singleton pregnancies were studied including 176 923 (61.6%) normal weight (BMI 20–24.9), 79 014 (27.5%) moderately obese (BMI 25–29.9) and 31 276 (10.9%) very obese (BMI≥30) women. MEASUREMENTS: Ante-natal complications, intervention in labour, maternal morbidity and neonatal outcome were examined and data presented as raw frequencies and adjusted odds ratios with 99% confidence intervals following logistic regression analysis to account for confounding variables. RESULTS: Compared to women with normal BMI, the following outcomes were significantly more common in obese pregnant women (odds ratio (99% confidence interval) for BMI 25–30 and BMI≥30 respectively): gestational diabetes mellitus (1.68 (1.53–1.84), 3.6 (3.25–3.98)); proteinuric pre-eclampsia (1.44 (1.28–1.62), 2.14 (1.85–2.47)); induction of labour (2.14 (1.85–2.47), 1.70 (1.64–1.76)); delivery by emergency caesarian section (1.30 (1.25–1.34), 1.83 (1.74–1.93)); postpartum haemorrhage (1.16 (1.12–1.21), 1.39 (1.32–1.46)); genital tract infection (1.24 (1.09–1.41), 1.30 (1.07–1.56)); urinary tract infection (1.17 (1.04–1.33), 1.39 (1.18–1.63)); wound infection (1.27 (1.09–1.48), 2.24 (1.91–2.64)); birthweight above the 90th centile (1.57 (1.50–1.64), 2.36 (2.23–2.50)), and intrauterine death (1.10 (0.94–1.28), 1.40 (1.14–1.71)). However, delivery before 32 weeks' gestation (0.73 (0.65–0.82), 0.81 (0.69–0.95)) and breastfeeding at discharge (0.86 (0.84–0.88), 0.58 (0.56–0.60)) were significantly less likely in the overweight groups. In all cases, increasing maternal BMI was associated with increased magnitude of risk. CONCLUSION: Maternal obesity carries significant risks for the mother and foetus. The risk increases with the degree of obesity and persists after accounting for other confounding demographic factors. The basis of many of the complications is likely to be related to the altered metabolic state associated with morbid obesity.

This paper considers the historical aspects of endovascular aneursym repair; the major findings of our Departments experience over an 812-year period and reviews recent developments in endovascular prostheses. Analysis of 400 patients undergoing primary repair of abdominal aortic aneurysm between 1992 and 2000 revealed a perioperative mortality rate of 2.7% and primary conversion rate of 5%. With sequential studies it was shown that the outcome was better with bifurcated/aorto uni iliac grafts than tube grafts; better with second generation prostheses than first generation protheses and that survival in consecutive patients treated concurrently by open repair and endoluminal repair was superior in the endoluminal group. Endoluminal AAA repair is at a critical point of its development. It is unquestioned that it can dramatically reduce the need for intensive care and length of hospital stay and more recently it has been reported that survival is improved compared with open repair. The need for lifetime surveillance, the probability of graft failure and need for re-intervention, however, negate some of the advantages. The small incidence of unpredictable rupture following endoluminal AAA repair is a timely reminder of the need for continued careful follow-up.

Purpose: Recurrent stenosis after carotid endarterectomy (CEA) is often regarded as an optimal application of carotid artery angioplasty and stenting (CAS). The extended durability of CAS for recurrent carotid artery stenosis after CEA is unknown. We present the intermediate-term surveillance results for all eight CAS procedures performed over a 28-month period at a single tertiary referral center. Methods: Patients had recurrent carotid stenosis after CEA, whether symptomatic or asymptomatic, of 80% to 99% stenosis on preprocedural carotid duplex scan examination. Uncovered, self-expanding metal stents, in conjunction with angioplasty, were used in all patients. Baseline and scheduled interval follow-up duplex ultrasound scan was used to assess intrastent restenosis. Further angiography was reserved for those patients obtaining additional intervention. Results: One transient ischemic attack was observed 1 day after the procedure, and no cerebral infarcts occurred. All patients had angiographic resolution of the stenosis and postprocedural duplex scan studies without residual stenosis. Subsequent interval surveillance duplex scan examinations revealed significant (60%-79%) to critical (80%-99%) recurrent stenosis in six (75%) of eight patients, two of whom went on to further interventions. Of those with intrastent restenosis, four (75%) progressed to critical (80%-99%) stenosis. Mean follow-up was 20.2 months (range, 12-37 months). The two lesions that have not yet shown restenosis are those with the shortest follow-up interval, each at 12 months. Conclusions: In contrast to the optimistic claims in other series, this limited series suggests that angioplasty with stenting for recurrent carotid artery occlusive disease after CEA, although relatively safe in the short term, has significant limitations in terms of durability of results. (J Vasc Surg 2001;33:1008-14.)

Purpose: The aim of this study was to compare the outcome of consecutive patients with abdominal aortic aneurysm (AAA) treated concurrently by means of open repair (OR) and endoluminal repair (ER) with second-generation prostheses by the same surgeons during a defined interval. Methods: Between May 1995 and December 1998 second-generation (low profile, fully supported, modular) endoprostheses were implanted in 148 patients. These patients, together with 135 patients treated concurrently with OR during the same period, comprised the study group of 283 patients. Patient selection was based on aneurysm morphology. Those patients who were anatomically suitable for ER were treated with this method. The ER and OR groups were similar with regard to age, sex, and size of AAA. The ER group contained high-risk patients considered unfit for OR (n = 46), and the OR group contained high-risk patients who were anatomically unsuitable for ER (n = 19). Outcome criteria in both groups were survival and successful aneurysm repair. Success in the ER group was defined as exclusion of the aneurysm sac and stability or reduction in AAA maximum transverse diameter. Persistent endoleaks were classified as failures, regardless of whether they were subsequently corrected with secondary endovascular intervention. Data were analyzed with the life table method. The minimum period of follow-up for all patients was 18 months. Results: The perioperative mortality rate was 5.9% in the OR group and 2.7% in the ER group (not significant). There was a statistically significant difference between the survival curves of the two groups in favor of the ER group when analyzed with the log-rank test (P = .004). The Kaplan-Meier curve for graft failure for the ER group revealed a 3-year graft success probability of 82%. Survival probability with successful repair in the OR group at 3 years was 85%. Conclusions: A concurrent comparison of ER with second-generation prostheses versus OR demonstrated a significant difference in survival in favor of the ER group. The probability of survival with successful repair at 3 years was similar in both groups. (J Vasc Surg 2001;33:S21-6.)

Objective To determine the maternal and fetal risk of adverse outcome during pregnancy in relation to low maternal body mass index in an unselected population. Design Retrospective analysis. Methods Information for the years between 1988 and 1997 was extracted from a validated maternity database, including all but one of the maternity units in the North West Thames Region; 215,105 completed singleton pregnancies were studied. Comparison of pregnancy outcome was made on the basis of maternal body mass index at booking. There were 176,923 with a normal weight body mass index (= 20 < 25). There were 38,182 with an underweight body mass index (< 20). Comparisons included antenatal complications (e.g. gestational diabetes, pre-eclampsia); intervention in labour, maternal morbidities (e.g. infection, postpartum haemorrhage, pulmonary thromboembolism); and neonatal outcome (admitted to special care baby unit at 24 hour of age, gestation at delivery, birthweight, stillbirth). Data are presented as percentages of outcomes in the normal and underweight groups with adjusted odds ratios and confidence intervals according to body mass index group. Results In the underweight group only antenatal anaemia, preterm delivery and birthweight below the 5th centile were more frequent than in women of normal body mass index. The prevalence of certain complications, including development of gestational diabetes mellitus, pre-eclampsia, obstetric intervention and postpartum haemorrhage, were significantly lower in those with low body mass index. Conclusion Low maternal body mass index is associated with increased prevalence of some pregnancy complications, notably preterm delivery and low birthweight, but overall the outcome is favourable and several adverse outcomes are less common in this group of women.

Objective: To quantify the age-related risks of adverse outcome during pregnancy in women less than 18 years old. Methods: We analyzed data from 341,708 completed singleton pregnancies in the North West Thames region between 1988 and 1997. Pregnancy outcomes were compared by age at delivery in women less than 18 years old ( n = 5246) and 18–34 years old ( n = 336,462); women 35 years old or older ( n = 48,658) were excluded. Data are presented as percentages of women less than 18 and 18–34-year-old women, with adjusted odds ratios (OR) and 99% confidence intervals (CI). Results: Pregnancy in women less than 18 years old was associated with increased risk of preterm labor before 32 weeks’ gestation (OR 1.41, CI 1.02, 1.90), maternal anemia (OR 1.82, CI 1.63, 2.03), chest infection (OR 2.70, CI 1.21, 6.70), and urinary tract infection (OR 1.60, CI 1.11, 2.31), but less obstetric intervention. Operative vaginal delivery (OR 0.46, CI 0.41, 0.56), elective cesarean (OR 0.47, CI 0.35, 0.65), or emergency cesarean (OR 0.45, CI 0.38, 0.53) were all less likely in women aged less than 18 years. Women less than 18 years old were no more likely to have stillbirths (OR 0.75, CI 0.42, 1.34) or small-for-gestational-age infants (OR 0.95, CI 0.82, 1.09) than women aged 18–34 years. Conclusion: Pregnant women less than 18 years old were more likely to deliver preterm than older women. In most other respects they have less maternal and perinatal morbidity and were more likely to have normal vaginal deliveries.

The outcome of endoluminal repair of abdominal aortic aneurysms with two generations of prostheses was analyzed and compared.Between May 1992 and December 1998, 266 patients underwent elective endoluminal repair of an AAA. First-generation prostheses were used in 118 patients (group I), and second-generation prostheses were used in 148 patients (group II). The two groups were similar in age, sex, and size of AAA. The proportion of patients with comorbidities was higher in group I than in group II, but not significantly. First-generation devices were characterized by large (24F internal diameter) delivery systems, one-piece construction, and a lack of metallic support throughout their length. Second-generation devices had smaller (21F or smaller internal diameter) delivery systems, modular construction, and a metallic frame throughout the length of the prostheses. The major end-point criteria were survival and successful endoluminal repair. Success was defined as the exclusion of the aneurysm sac from the circulation, with stability or the reduction in AAA maximum transverse diameter. Persistent endoleaks were classified as failures, irrespective of whether they were subsequently corrected by means of secondary endovascular intervention. The minimum follow-up period was 5 months for each of the 266 patients. Analysis was performed by means of the life-table method.Perioperative mortality was not significantly different between group I (4.2%) and group II (2.7%). There was a statistically significant difference between the survival curves of the two generations, which favored group II (P =.012). There was a significant (P.001) difference between the two generations of patients in their conditional probability of graft failure when the competing risk of all-cause mortality was considered. Second-generation patients were at a lower risk of graft failure than first-generation patients. The probability of failure, expressed as a proportion of grafts failing at 2 years, was 0.15 for patients with second-generation prostheses and 0.33 for patients with first-generation prostheses.Endoluminal AAA repair is a safe procedure, whether first- or second-generation prostheses are used. Survival and probability of graft success were significantly higher with second-generation prostheses than with first-generation prostheses. This improvement in outcome resulted from a combination of increasing clinical experience and advances in technology. A more accurate evaluation of the role of the endoluminal method in AAA repair would be achieved by studying patients in whom second-generation devices were used, rather than longer term studies in which first- and second-generation devices were used.

Aim the aim of this study was to analyse the effect of supplementary endovascular intervention on the outcome of primary endoluminal repair of abdominal aortic aneurysm (AAA). Methods between May 1992 and December 1998, 266 patients underwent endoluminal repair of AAA. Minimum period of follow-up was 6 months. Those patients in whom the endoprosthesis could not be deployed were converted to open repair at the primary operation. Patients developing an early endoleak, within 31 days, were treated by a period of observation and secondary endovascular intervention in persistent cases. Patients developing a late endoleak were treated similarly, without a period of observation. Outcome was analysed by the life-table method. Primary success was defined as exclusion of the aneurysm from the circulation resulting from the original operation. Assisted success occurred when aneurysms with endoleaks became excluded from the circulation as a result of supplementary endovascular intervention. Results endoluminal repair failed in 17 patients requiring conversion to open repair at the original operation. Supplementary endovascular intervention was undertaken in 26 patients, with early endoleaks ( n =6) and late endoleaks ( n =20). Interventions involved deployment of secondary endoluminal grafts within the primary grafts ( n =22), and coil embolisation ( n =4). Successful exclusion of the aneurysm sac was achieved in 22 of 26 (85%) patients undergoing supplementary endovascular procedures. Conditional cumulative incidence of primary graft failure and secondary graft failure in the presence of all-cause mortality at 6 years was 47% and 25% respectively. Conclusions supplementary endovascular intervention is an important adjunct to endoluminal AAA repair with the potential to improve outcome and avoid conversion to open repair. Successful supplementary endovascular intervention was achieved in 85% of patients in whom it was attempted. Life-table analysis showed these supplementary procedures to be durable in the long term.

Purpose: To determine the prevalence of incidental findings detected on the focused abdominal sonogram for trauma. Methods: From November 1996 to February 1998, 1914 radiologist-assisted trauma ultrasound examinations were performed. Incidental findings were tabulated by retrospective review of the trauma radiology daily logbooks. Results: Incidental nontraumatic findings were detected in 160 (8.36 %) of the acutely injured patients. Most findings were benign, including echogenic liver, renal cysts, and cholelithiasis. However, significant pathology was detected in several patients, including renal masses, hepatic metastases, and gynecologic disease. Conclusion: The radiologist-assisted trauma ultrasound examination can provide valuable diagnostic information beyond the detection of free fluid. This may have important implications, as nonradiologists are increasingly involved in the practice of trauma ultrasonography. Even in the setting of trauma, significant occult pathology can be detected on a targeted ultrasound examination.

Purpose: To evaluate the incidence and extent of length changes during implantation of endovascular grafts in a prospective study of patients undergoing endovascular abdominal aortic aneurysm (AAA) repair. Methods: Data regarding the occurrence of intraoperative technical difficulties and device complications were recorded prospectively for the Vanguard or AneuRx self-expanding, bifurcated endovascular grafts in 64 patients (56 males; mean age 75 years). Graft length was measured in the sheath system before deployment and again immediately after deployment by fluoroscopic comparison to a graduated marking catheter. Results: Graft shortening ≥ 15 mm was documented in 22 (56%) of 39 Vanguard cases and 11 (44%) of 25 AneuRx endografts. Additional extension grafts were required to correct endoleak caused by inadequate graft length in 9 (14%) patients, but no conversion to open repair was necessary. Conclusions: There appears to be a high incidence of intraprocedural graft shortening with 2 current designs of self-expanding endoluminal grafts.

Temporary control of the aorta at the level of the diaphragm above the origins of the major visceral arteries is of proven value in the management of complex aortic disease including ruptured aneurysm, 're-do' aortic surgery and for aortic trauma. The value of the technique in elective non-aortic surgery is less well known. Two patients, one with a massive leiomyosarcoma of the stomach and the other with blood loss complicating a distal splenorenal shunt, are described in which proximal aortic control was of use.

Objectives: To evaluate the effects on the aortic wall of balloon dilatation as utilised in deployment of stent-graft devices during endoluminal repair of infrarenal abdominal aortic aneurysm. Methods: Large dilatation balloons were expanded within the aorta of 41 cadavers. Testing was done to evaluate the effect of differing degrees of balloon oversizing, at pressures in the range of 0.15–2.5 atm. The aorta was then opened for macroscopic inspection. Results: In group 1 (mild atherosclerosis) no macroscopic abnormalities were detected with up to 6 mm oversized balloon. In group 2 (moderate atherosclerosis) fracture of atherosclerotic plaque occurred in seven of 14 aortas (50%) with 2.5 mm–4 mm oversized balloon. In group 3 (severe atherosclerosis) fracture of atherosclerotic plaque occurred in six of seven (85%) with 2.5 mm to 4 mm oversized balloon and rupture of the aorta occurred at 6 mm oversizing. Conclusions: This study suggests that balloon overdilatation of the aorta by 2 mm, at pressures less than 2 atmospheres, allows safe deployment even in the presence of severe atheroma. Larger amounts of overdilatation are relatively safe in mildly atherosclerotic aorta. Aortic rupture is unlikely with overdilatation up to 6 mm, especially in less calcified vessels.

The incidence and indications for conversion from endoluminal to open repair of abdominal aortic aneurysms are changing. This paper is based on a 5-year experience in which endoluminal repair of abdominal aortic aneurysms was undertaken in 156 patients. Primary conversion at the original operation was required in 14 patients and secondary conversion at a subsequent operation was required in 9 patients. The reasons for primary conversion were access problems (n = 2), balloon related problems (n = 2), endograft migration (n = 4), endograft thrombosis (n = 1) and failed deployment of a bifurcated endograft (n = 5). Twelve of 14 primary conversions occurred in the first half of the study period, in which 59 endoluminal abdominal aortic aneurysms repairs were undertaken. Improvements in technology and interventional techniques for overcoming obstacles, as well as increasing experience, has resulted in primary conversion being limited to two patients in the most recent 2.5-year period in which 97 endoluminal repairs were undertaken. The reasons for secondary conversion were renal arteries covered by the endograft (n = 2), increasing abdominal aortic aneurysm diameter in the absence of endoleak (n = 1) and persistent endoleak (n = 6). The latter group comprised three patients with intact aneurysms and three with known endoleaks who presented with ruptured aneurysms. The current indications for primary conversion include: (i) rupture of the aorta; (ii) complete migration of the endograft resulting in obstruction of the iliac arteries; and (iii) irreversible twisting of a non-modular bifurcated endograft. The current indications for secondary conversion include: (i) persistent endoleak; (ii) sealed endoleak with continued abdominal aortic aneurysms expansion; (iii) apparently successful endoluminal repair without evidence of endoleak but continued abdominal aortic aneurysms expansion; and (iv) infected endograft.

Purpose: The aim of this study was to compare the outcome of consecutive patients with abdominal aortic aneurysm (AAA) treated concurrently by open operation and endoluminal intervention by the same surgeons during a defined interval. Methods: Between May 1992 and May 1996, 362 consecutive patients with AAA underwent repair. Fifty-three patients who underwent open operations for ruptured AAA plus two patients who underwent endoluminal repair of false AAA and four patients who underwent secondary endoluminal repair of AAA were excluded, leaving 303 patients who underwent elective repair of true AAA in the study. The elective operations were conventional open repair (OR) in 195 patients (151 men, 44 women; mean age, 69 years) and endoluminal repair (ER) in 108 patients (100 men, 8 women; mean age, 70 years). The decision to perform ER was based on comorbidities that precluded open repair (n = 48) and patient choice (n = 60). Graft configuration in the open repair group was tubular (n = 180) and bifurcated (n = 15), and in the ER group tubular (n = 48), aortoiliac/femoral (n = 25), and bifurcated (n = 35). All procedures were performed in the operating department, and radiographic guidance was used in the ER group. Follow-up was by interview, examination, and telephone. In addition, contrast-enhanced computed tomography was performed within the first 10 days after operation, 6 months and 12 months after operation, and then annually thereafter in the ER group. Outcome measures were successful exclusion of the aneurysm sac from the general circulation and survival. Data were analyzed by the life table method. Other outcome measures were length of hospital stay, length of intensive care unit stay, and operative blood loss. Results: No significant difference was found between the perioperative mortality rate for OR (11 deaths [5.6%] in 195 patients) and ER (six deaths [5.6%] in 108 patients). Three of the six deaths in the latter group occurred in patients with successful ER, and three occurred in 18 patients with failed ER who were converted to OR. Similarly, no significant difference was seen in the survival rate between the endoluminal and open repair groups when analyzed by the log-rank test (p = 0.14). The rate of graft failure, however, was significantly higher in the ER group than in the OR group (Fisher's exact test, p < 0.001). Success in the ER group was defined as continuing graft function without endoleak or conversion to open repair. Kaplan-Meier curve for graft failure times for the endoluminal group revealed a 3-year graft success probability of 70%. Conclusions: This study suggests that ER is safe, sharing the same perioperative mortality risk as OR despite 44% of the ER group being rejected as unfit for OR. Conventional open repair is the most reliable method of successfully managing AAA. The endoluminal method, however, results in shorter length of hospital stay, shorter length of intensive care unit stay, and less blood loss than the open method. Patients who opt for the endoluminal method of repair should be made aware that the minimally invasive technique carries the disadvantage of a higher failure rate. (J Vasc Surg 1998;27:213-21.)

Purpose: To summarize the results of endovascular abdominal aortic aneurysm (AAA) treatment using several endograft designs over a 4.5-year experience and offer comparisons on the various devices. Methods: From May 1992 to August 1996, 121 AAA patients meeting the criteria for an endoluminal repair were treated with 1 of 5 endograft designs in three configurations. The endografts were implanted in the operating room under fluoroscopic control. Follow-up included contrast-enhanced computed tomography within 10 days of operation, 6 months postoperatively, and annually thereafter. Results: Endografts were successfully deployed in 106 patients (88%). Fifteen cases were converted to open repair. Six procedure-related deaths occurred within 30 days owing to myocardial infarction (3), combined renal failure and septicemia (2), and multisystem failure (1). There were 36 local/vascular complications (30%) and 18 systemic/remote complications (15%). Of the 121 patients undergoing endoluminal AAA repair, 93 (77%) are currently alive and well with their AAAs excluded from the circulation. Conclusions: Trends in endoluminal AAA repair and prosthetic design point toward simpler devices and earlier treatment of smaller aneurysms once the long-term outcome of aortic endografting has been determined.

Purpose: To report a > 3-year experience with a modular, balloon-expandable endovascular graft used for aneurysm exclusion in the aorta and other arteries. Methods: The customized White-Yu Endovascular GAD Graft, a woven polyester prosthesis with an intrinsic Elgiloy wire graft attachment system along the body of the graft, is a flexible endograft design available in straight, tapered, and bifurcated versions that can be delivered transluminally through 18F to 24F sheaths. Results: Since July 1993, 93 patients have received the White-Yu endograft for treatment of 76 abdominal aortic, 3 thoracic aortic, 13 iliac, and 1 popliteal aneurysms. Of the 79 aortic procedures, 39 involved straight tube grafts, 20 were tapered aortoiliac models, and 20 were bifurcated devices. Success rates for tube grafts were 81% in the abdominal aorta and 100% for the thoracic aorta; 5 primary endoleaks (14%) and 2 conversions to surgery (5.6%) occurred with this graft type. Aortoiliac grafts were deployed successfully in 95% (19/20) of cases with 1 conversion (5%) due to thrombosis. Seventy-five percent of the bifurcated endograft procedures were successful, with 4 conversions (20%) for technical failures and 1 graft thrombosis. Four additional endografts were deployed to treat two primary and two secondary endoleaks in tube graft patients. Two access-related arterial injuries were treated surgically. There was one case of embolus to the distal femoral artery but no microembolization. Overall perioperative (30-day) mortality was 3.1%. Over a mean 18-month follow-up (range 2 to 39), no late graft thrombosis, stenosis, or graft migration has been seen on CT scans or X ray. Endoleak has not been detected in any aortoiliac or bifurcated graft. Aneurysm size has diminished consistently in successfully treated cases. Conclusions: The White-Yu endograft appears to offer a safe, efficacious, and minimally invasive means of excluding aneurysms from the circulation. Improvements in patient selection, surgical techniques, and equipment have reduced the incidence of endoleak and conversion to open repair over the course of the evaluation.

Purpose: The purpose of this study was to determine the variation in ankle-brachial pressure index (ABPI) measurements in routine clinical practice. Methods: Analysis was done of preoperative and postoperative ABPIs in 130 limbs contralateral to those undergoing femoral bypass grafting in 123 patients over a 15-month period. Results: The mean initial ABPI was 0.72 (range 0.22 to 1.10). The range of observed differences between the preoperative and postoperative ABPIs was from -0.33 to +0.25. The mean (±SD) difference between the first and second ABPIs was 0.00 (±0.11). The 95% confidence limits of the difference were -0.21 to 0.21. There was no trend for the size or direction of the difference in ABPI to vary according to the mean ABPI, brachial blood pressure, or time between tests. Conclusions: ABPI is routinely used as an objective measure of peripheral vascular disease. The variation observed in this study is comparable with values obtained in reproducibility studies and is greater than that accepted in clinical practice. The difference between an ABPI measurement and the actual ABPI and the difference between repeat single measurements are not the same and should be distinguished. Vascular laboratories should determine the accuracy of ABPI measurement on a local basis to guarantee and maintain quality assurance. (J Vasc Surg 1996;24:871-5.)

Purpose: Currently no randomized studies show the relative morbidity and mortality of the open and endoluminal methods of abdominal aortic aneurysm (AAA) repair. The aim of this study was to analyze the outcome of two matched groups of patients with AAA, one undergoing open repair and the other undergoing endoluminal repair.Methods: Two groups of patients who had undergone repair of AAA by open technique (group 1) or by endoluminal methods (group 2) were compared. A historic control cohort of 27 patients was selected from 56 consecutive patients who underwent open repair of AAA between January 1991 and February 1992. Patients considered unsuitable for the endoluminal method on the basis of computed tomography and aortography were excluded (n = 29). Between May 1992 and November 1994 prospective data were recorded for 62 consecutive patients who underwent endoluminal repair by tube or bifurcated endografts. Twenty-eight patients who had been specifically referred for endoluminal AAA repairs because of preexisting severe medical comorbidities were excluded. Six of the endoluminal cases had failure, requiring conversion to open operation, and were excluded for separate analysis, leaving 28 patients in group 2. Patients in both groups were thus fit and suitable for either open or endoluminal repair and were comparable in relation to age, sex, risk factors, dimensions, and form of AAA.Results: The mean values for operation time, blood loss, intensive care stay, and hospital stay for group 1 and group 2 were 2.6 versus 3.1 hours, 1422 versus 873 ml,* 1.8 versus 0.7 days,* and 12.4 versus 11.1 days, respectively (*p < 0.05). Local/vascular complications occurred in 15% of patients in group 1 compared with 25% in group 2 (p = 0.55), whereas remote/systemic complications occurred in 37% and 29%, respectively (p = 0.3). Five of 28 patients in the endoluminal group had complications requiring early operative repair (n = 3) or late revision (n = 2). When comparison was made on an intention-to-treat basis (with failed procedures included), the incidence of local/vascular complications was significantly greater for endoluminal repair (p = 0.047).Conclusions: The incidence of systemic/remote complications was similar for the two groups in spite of significantly less blood loss and shorter intensive care unit stay with endoluminal repair. The incidence of local/vascular complications had a tendency to be higher for endoluminal compared with standard open method (and was significantly greater if failed procedures were included). In this early experience with prototype devices, patients who were medically suitable for open surgical procedures did not derive benefit from the less invasive endoluminal technique with respect to duration of operation, length of hospital stay, or perioperative morbidity and mortality. On the other hand, because they also did not have worse outcome, a randomized study is now justified in this group. (J VASC SURG 1996;23:201-12.)

Purpose: The aim of this study was to report early experiences with the Sydney and Endovascular Technologies (EVT) prostheses for the treatment of abdominal aortic aneurysms (AAA) deemed suitable for endoluminal tube graft repair. Methods: Consecutive endoluminal tube graft repairs were analyzed over the first 12 months in which the Sydney and EVT prostheses were used. Patients eligible for the EVT prosthesis had type I AAAs: a proximal neck length ≥ 2 cm, a distal cuff length ≥ 1.5 cm, and nontortuous iliac arteries ≥ 8 mm. Selection criteria for the Sydney device were more liberal and included AAAs that had distal cuffs < 1.5 cm. During the study period, 28 of 91 patients evaluated for AAA repair were thus selected for endoluminal grafting: 18 patients received the Sydney endograft and 10 the EVT device. Medical comorbidities were present in slightly less than one third of patients in both groups. Contrast-enhanced computerized tomography (CT) was performed preoperatively, within 10 days of operation, and at 6 and 12 months postprocedure. Results: All endografts were successfully deployed in both groups. Postprocedural CT scans revealed incomplete aneurysm exclusion in four patients with the Sydney endograft. Subsequent deployment of a second endograft sealed these “leaks” in two cases; the other two were converted to open repair (89% clinical success). No leaks were seen with the EVT device. Local/vascular complications occurred in 33% of the Sydney group compared with 20% for the EVT device (p = 0.001); systemic sequelae were more common in the EVT group (30% versus 17% in the Sydney cohort, p = 0.002). There were no deaths within 30 days; three late deaths were not procedure related. Conclusion: AAAs that are suitable for endoluminal tube graft repair may be treated with a high rate of initial success with either the Sydney or EVT prostheses. More liberal selection criteria may increase the likelihood of local/vascular complications.

Purpose: The purpose of this study was to test the hypothesis that abdominal aortic aneurysms (AAA) whose morphology makes them unsuited for repair with an endoluminal tube graft can be treated by a combination of a transluminally placed aortofemoral graft and a femorofemoral crossover graft. In addition the technique involves either ligation or balloon occlusion of the contralateral common iliac and internal iliac arteries in such a manner that excludes the AAA from the circulation. Methods: We report the use of this technique in three male patients with 6.4 to 7.0 cm diameter AAA. Two had renal impairment and cardiac function too poor to permit open repair, and the third had an unfavorable abdomen caused by previous surgery and the presence of a permanent colostomy. Each patient had an individually tailored Dacron tube graft constructed on the basis of preoperative arteriograms and computed tomography scans. The grafts were delivered transluminally into the aorta through a sheath in the iliac arteries and anchored proximally with a stainless steel stent under radiographic control. The grafts were then anastomosed distally to the femoral artery. Results: Recovery was complicated by a midgraft stenosis corrected by percutaneous balloon dilation in one patient, an episode of pulmonary edema in the second and an unexplained pyrexia in the third. Follow-up with duplex scanning confirmed normal flow through the grafts and the presence of thrombus between the prosthetic graft and the aneurysmal sac. Conclusions: We conclude that transluminal placement of an aortofemoral graft combined with a femorofemoral crossover graft is feasible in patients who are unsuited to repair with an endoluminal tube graft. The outcome with this technique is not known and requires further careful evaluation. (J VASC SURG 1994;19:924-33.)

Peutz-Jeghers syndrome (PJS) is a rare, though well-described, hereditary polyposis syndrome associated with mucocutaneous pigmentation that typically presents in the second decade of life with complications related to intestinal polyps. We present two cases of teenaged girls presenting with small-bowel intussusceptions within a 3-month period. Sonographic examinations readily revealed small-bowel intussusceptions with secondary small-bowel obstruction. In both the symptoms were less severe than one would expect given the underlying pathology found at subsequent surgery. Sonographic imaging with pathologic correlation is provided.

Leiomyosarcoma of the inferior vena cava is a rare and aggressive tumor, characterized by a slow growth and usually late diagnosis. The mainstay of therapy is surgical resection with limited role for chemotherapy or radiotherapy; resection modalities and the need for caval reconstruction are still matters of debate. In this case report, we describe an asymptomatic intraluminal leiomyosarcoma of the inferior vena cava diagnosed incidentally prior to caval occlusion during a routine ultrasound examination of the upper abdomen.

A 78-year-old man was seen with an expanding 5 cm false aneurysm of the right subclavian artery. This was treated by an intraluminal graft-stent device introduced through the brachial artery via a 16 F sheath. The graft was constructed from two polytetrafluoroethylene patches of 0.4 mm thickness and anchored in the subclavian artery by an 8 mm stainless steel stent. The procedure was monitored by an image intensifier. Completion arteriography and postoperative duplex scanning confirmed normal flow through the subclavian artery with no communication between the lumen and the aneurysmal sac. The patient recovered without complication. (J VASC SURG 1993;18:1056-9.)

Purpose: Isolated limb perfusion with urokinase was used to salvage an acutely ischemic lower limb. Methods: Isolated limb perfusion with urokinase over a 90-minute period was used in the treatment of a 69-year-old female patient with acute ischemia of the left leg after thrombosis of a femoral artery bypass graft. Previous balloon embolectomy and heparin therapy had failed. The flow rate was able to be increased progressively without rise in the line pressure during the course of the perfusion, indicating an increase in capacity of the peripheral arterial bed. Fibrinogen and plasminogen levels in the isolated circulation remained low throughout the perfusion. The concentration of cross-linked fibrin degradation particles (d. dimer) rose progressively in the isolated circulation but remained at normal levels in the systemic circulation during perfusion. Results: Completion angiography demonstrated clearance of thrombus in the popliteal artery and appearance of arteries not seen on preperfusion films. Clinical improvement paralleled the angiographic appearances, with restoration of limb viability. Conclusion: We concluded that isolated limb perfusion with use of urokinase is safe and worthy of further investigation. (J VASC SURG 1993;17:408-13.)

Background: Carotid endarterectomy is known to benefit both symptomatic and asymptomatic patients with high-grade internal carotid artery stenosis. Duplex scanning is the ‘gold standard’ for non-invasive preoperative investigation of carotid artery stenosis. The aim of the present study was to analyse the indications for duplex scanning and to identify other factors that influenced the management of patients with high-grade stenosis who did not undergo carotid endarterectomy. Methods: A total of 271 patients was observed to have > 80% stenosis of the internal carotid artery on duplex scanning during the period of review. Of these patients, 85 did not undergo carotid endarterectomy. The vascular laboratory database and hospital records of these patients were retrospectively reviewed. Results: The indications for requesting a carotid duplex scan in the 85 patients were transient ischaemic attack (22%), stroke (25%), symptomatic bruit (7%), asymptomatic bruit (12%), and stroke and symptomatic bruit combined (7%). Falls and preoperative carotid assessment prior to coronary surgery were the commonest indications in the remaining patients. The main risk factors were cardiac (68%), hypertension (60%), respiratory (21%), diabetes (25%), peripheral vascular disease (19%), neoplasm (16%) and renal disease (16%). Twenty-five per cent of the patients were over 80 years of age. Conclusion: In the present study risk factors associated with increased perioperative morbidity and mortality were the commonest explanation for patients with high-grade stenosis of the internal carotid artery not undergoing surgery. These patients would generally not meet the inclusion criteria for the major carotid endarterectomy trials.

Objective Carotid endarterectomy (CEA) guidelines in symptomatic carotid stenosis are based on NASCET and ECST criteria with 70% or greater carotid stenosis as estimated from a catheter angiogram the major indication. This has several problems: (1) lack of reliable correlation between non-invasive imaging and catheter angiography, which has been largely superseded by non-invasive imaging in investigating carotid stenosis; (2) errors inherent in estimating the degree of stenosis from catheter angiography; (3) disregard for the fact that stroke risk also depends on plaque stability, and number of ischaemic events. Methods A retrospective review of ischaemic events, imaging results, operative findings, surgical complications and stroke-free follow-up in 31 patients presenting over a 23 year period with TIA/stroke (symptoms lasting > 24 h and/or imaging evidence of infarction) who had 70% or less carotid stenosis (on non-invasive imaging), but nonetheless underwent CEA. Results Nineteen patients had small strokes, 7 had TIAs and 5 had ocular events; 28 patients had features of unstable plaque on imaging; 19 patients experienced multiple events before CEA. All had haemorrhagic, ruptured plaque at CEA. One patient suffered an intra-operative stroke, only 1 patient suffered a further stroke/TIA (mean follow-up 4.2 years). Conclusion To predict the likelihood of major stroke in symptomatic carotid stenosis and the benefit of CEA, plaque stability and the number of ischaemic events might be as important as an estimate of the degree of stenosis.

Mycotic false aneurysms due to local arterial injury from attempted intravenous injections in drug addicts are increasing in frequency. The high incidence of HIV and hepatitis B virus in parenteral drug users may present a considerable risk to the treating personnel. This paper reports the unsuspected presence of broken needle-tips in the subcutaneous tissues of an intravenous drug abuser, in association with bilateral mycotic aneurysms of the axillary arteries. Broken needle-tips have the potential to cause needlestick injury to the operating team and the nursing staff, with the associated risk of transmission of HIV and hepatitis B virus infection. The presence of broken needle-tips should be suspected in drug users presenting with false aneurysms associated with local arterial injection injury and a specific history of needle-breakage should be sought. Preoperative plain radiographs should be performed of the planned operative field to exclude the presence of such needle-tips. Any soft tissue swelling in the vicinity of a major artery in an intravenous drug abuser should be suspected of being a false aneurysm until proven otherwise and should prompt immediate referral to a vascular surgeon for investigation and management.

The Foodborne Viruses in Europe network has developed integrated epidemiological and virological outbreak reporting with aggregation and sharing of data through a joint database. We analyzed data from reported outbreaks of norovirus (NoV)-caused gastroenteritis from 13 European countries (July 2001 to July 2006) for trends in time and indications of different epidemiology of genotypes and variants. Of the 13 countries participating in this surveillance network, 11 were capable of collecting integrated epidemiological and virological surveillance data and 10 countries reported outbreaks throughout the entire period. Large differences in the numbers and rates of reported outbreaks per country were observed, reflecting the differences in the focus and coverage of national surveillance systems. GII.4 strains predominated throughout the 5-year surveillance period, but the proportion of outbreaks associated with GII.4 rose remarkably during years in which NoV activity was particularly high. Spring and summer peaks indicated the emergence of genetically distinct variants within GII.4 across Europe and were followed by increased NoV activity during the 2002-2003 and 2004-2005 winter seasons. GII.4 viruses predominated in health care settings and in person-to-person transmission. The consecutive emergence of new GII.4 variants is highly indicative of immune-driven selection. Their predominance in health care settings suggests properties that facilitate transmission in settings with a high concentration of people such as higher virus loads in excreta or a higher incidence of vomiting. Understanding the mechanisms driving the changes in epidemiology and clinical impact of these rapidly evolving RNA viruses is essential to design effective intervention and prevention measures.

Background: Surgical therapy for the thoracic aorta carries a high morbidity and mortality. Endovascular therapy for aneurysms and its adaptation to the thoracic aorta over the past 10 years is an exciting advance. This is a retrospective review of endovascular grafting of the thoracic aorta during the past decade at Royal Prince Alfred Hospital and the outcomes achieved over this period. Methods: A retrospective review of all patients at our institution who underwent endovascular grafting of the thoracic aorta between March 1995 and March 2005 was carried out. Data were analysed using Stata version 8.0 (Stata corporation, College Station, TX, USA). Results: Sixty-five patients underwent endovascular stent grafting of the thoracic aorta. The indications were degenerative aneurysm (31), Stanford type B dissection (23) both acute (12) and chronic (11), traumatic transection (9) and penetrating ulcer (2). There were no conversions to open repair. Twenty-two patients required additional procedures, six of which were unplanned. The median age was 65 (range 18–85), 68% of patients were men. The median procedure time was 115 min (range 55–240 min). Mean hospital stay was 9.8 ± 7.3 days and high dependency/intensive care unit stay 1.5 ± 3.2 days. Thirty-day mortality was 0 in 41 for elective cases (one patient (2.5%) died 37 days post-procedure) and 12% (3 of 25) for emergency cases. Complications occurred in 20 of 41 (49%) elective cases and 14 of 24 (58%) emergency cases within the first 30 days. The most frequent major complications were neurological including paraplegia (transient 2 of 65, permanent (2 of 65)) and stroke (4 of 65). Other complications included endoleak (12 of 65), acute renal failure (1 of 65), and brachial artery false aneurysm (1 of 65). The mean length of follow up was 22.5 months (range, 1–97 months). Six patients required further endovascular procedures for persistent endoleak or ongoing perfusion of chronic dissection. Late deaths (>30 days) related to the endovascular treatment occurred in two patients (3%). Conclusion: Endovascular grafting of the thoracic aorta is an evolution in the treatment of thoracic aortic pathology. The results of elective endovascular grafts were acceptable. Emergency procedures had a higher incidence of complications and death. Improvement in graft technology, design and deployment are required.

Background: To make an informed decision about treatment, patients need accurate information about the benefits and risks of treatment and ‘non-treatment’ options. A survey was conducted to determine patients’ recall of the extent and effect of preoperative disclosure by surgeons to patients of risks about carotid endarterectomy (CEA). Methods: A self-administered questionnaire was given to 133 patients undergoing elective CEA in New South Wales. The primary outcome measures were patient recall of preoperative discussion, self-assessed estimates of stroke risk with and without surgery and receipt of written information before CEA. Results: A significantly higher proportion of patients recalled that their surgeon discussed the short-term stroke risk (i.e. within 30 days) if they decided to undergo CEA (86.2%) than if they decided not to have the procedure (76.9%) (P = 0.04). Of those patients who recalled the surgeon discussing their short-term stroke risk with CEA, only 24 (18.0%) were accurately able to quantify this risk. Patients were significantly more likely to recall their surgeon discussing their long-term stroke risk (i.e. within 2 years) if they decided not to have CEA (72.4%) than if they decided to have the CEA (31.5%) (P

To assess retrospectively the added value of coronal reformations from isotropic voxels obtained with 16-section multi-detector row computed tomography (CT) of the abdomen and pelvis in patients with suspected acute appendicitis.This study was approved by the institutional review board, and informed consent was waived. One hundred consecutive patients (21 men, 79 women; mean age, 38 years) with suspected appendicitis underwent 16-section multi-detector row CT (section thickness, 0.625 mm; pitch, 1.75; table speed, 35 mm/sec [17.5 mm per rotation, two rotations]; and gantry speed, 0.5 second per rotation), with coronal reformations. Twenty-four patients had appendicitis; 76 did not. Protocol included 150 mL oral iopamidol administered at 3 mL/sec. Transverse scans were reconstructed with 5-mm-thick sections at 5-mm intervals and 0.625-mm-thick sections at 0.625-mm intervals. The second data set was reformatted coronally, with 3-mm-thick sections at 5-mm intervals. Three independent blinded readers interpreted transverse scans alone and then coronal scans; confidence in visualization of any portion of appendix, entire appendix, wall thickening, distention, inflammation, fluid, and appendicitis was scored with 1-5 scale. Sensitivity and specificity were determined for each reader and compared by means of signed rank test. Agreement between readers was determined with kappa statistic. Differences in mean confidence ratings for each finding were determined with Wilcoxon signed rank test.Mean sensitivity and specificity for all three readers together were 96% and 95% for transverse reformations alone and 95% and 94% for combined transverse and coronal reformations (not significant), respectively. Visualization rates for portion or all of appendix were higher for combined transverse and coronal reformations than for transverse reformations alone (higher mean confidence scores: 0.23 higher [P.009] and 0.51 higher [P.001], respectively). In patients without appendicitis, transverse and coronal reformations together enhanced confidence in exclusion of wall thickening, distention, and fluid (lower confidence scores: 0.21 lower [P.001], 0.17 lower [P.01], 1.00 lower [P.001], respectively). Combined transverse and coronal reformations enhanced confidence in identification of appendix in mean of 57 patients. Combined transverse and coronal scans helped exclude appendicitis in mean of 38 patients and aided diagnosis of it in 15.Sixteen-section multi-detector row CT transverse and coronal reformations are equally sensitive and specific for diagnosis of appendicitis. Coronal reformations improve confidence in visualization of appendix (whether diseased or normal) and in diagnosis or exclusion of appendicitis.

This study used data from the Communicable Disease Surveillance Centre's national HIV database and the Thames Cancer Registry to assess the risk of cancer in HIV-infected people in southeast England. Among 26 080 HIV-infected men with 158,660 person-years follow-up, 1851 cancers, and among 7110 HIV-infected women (31 098 person-years), 171 cancers were identified. The standardised incidence ratio (SIR) for all non-AIDS-defining cancers was significantly increased in HIV-infected men (2.8, 95% confidence interval (CI) 2.6-3.1) but was nonsignificant in HIV-infected women (1.1, 95% CI 0.8-1.6). Most of the cancers observed were in men (n = 1559) and women (n = 127) with AIDS, and among them, the SIR for all non-AIDS-defining cancers was significantly increased in men (8.2, 95% CI 7.2-9.2) and women (2.8, 95% CI 1.6-4.6). The SIR for all non-AIDS-defining cancers was only just significantly increased in men with HIV-infection but not AIDS (1.2, 95% CI 1.0-1.5) and was nonsignificant in such women (0.8, 95% CI 0.5-1.2).