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Background Treatment of superficial venous reflux in addition to compression therapy accelerates venous leg ulcer healing and reduces ulcer recurrence. The aim of this study was to evaluate the costs and cost-effectiveness of early versus delayed endovenous treatment of patients with venous leg ulcers. Methods This was a within-trial cost-utility analysis with a 1-year time horizon using data from the EVRA (Early Venous Reflux Ablation) trial. The study compared early versus deferred endovenous ablation for superficial venous truncal reflux in patients with a venous leg ulcer. The outcome measure was the cost per quality-adjusted life-year (QALY) over 1 year. Sensitivity analyses were conducted with alternative methods of handling missing data, alternative preference weights for health-related quality of life, and per protocol. Results After early intervention, the mean(s.e.m.) cost was higher (difference in cost per patient £163(318) (€184(358))) and early intervention was associated with more QALYs at 1 year (mean(s.e.m.) difference 0·041(0·017)). The incremental cost-effectiveness ratio (ICER) was £3976 (€4482) per QALY. There was an 89 per cent probability that early venous intervention is cost-effective at a threshold of £20 000 (€22 546)/QALY. Sensitivity analyses produced similar results, confirming that early treatment of superficial reflux is highly likely to be cost-effective. Conclusion Early treatment of superficial reflux is highly likely to be cost-effective in patients with venous leg ulcers over 1 year. Registration number: ISRCTN02335796 (http://www.isrctn.com).

Temporal artery biopsy (TAB) is requested in an attempt to confirm the diagnosis of temporal arteritis (TA). Patients symptoms and signs are highly variable and TA is often focal and potentially missed in a small biopsy. The study aimed to determine if TAB helps in the management of patients with suspected TA.The case records of sixty-six consecutive patients who had undergone temporal artery biopsy were recalled and examined for presenting symptoms, management, therapy, results and outcome.There were 23 men and 43 women with a mean age of 70.2 and 71.1 years respectively. Presenting symptoms varied with unilateral headache in 53, scalp tenderness in 16, muscle weakness in 10, visual disturbance in 16, jaw claudication in 5 and peri-orbital pain in 1 patient. The temporal artery was tender in 21 patients and thickened in 4 patients. Thirty-eight patients were commenced on steroids prior to biopsy and 6 more before the histology became available. Only 8% of biopsies were positive for TA. Of the patients started on steroids with a negative biopsy, the steroids were continued in 26 and stopped in 9. In the patients not put on steroids [22], biopsy was positive in 2; they were commenced on steroids. Therefore, the histological diagnosis resulted in a change in patient management in only 18% of patients.The results of TAB do not appear to affect the clinical management of most patients with suspected temporal arteritis. We must therefore question the routine use of this invasive investigation.

ObjectiveTo investigate the effect of HES, used as a plasma volume expander, on endothelial cell activation induced by ischaemia-reperfusion in humans.Material and MethodsForty patients undergoing elective infrarenal aneurysm repair were randomised to receive either gelatine or hydroxyethyl starch solution as plasma expanders. The anaesthetic technique was standardised. All patients received the same crystalloid as per standard protocol. Urine samples and blood samples were collected at various times for assessment of microalbuminuria and von Willebrand factor (vWf) and CRP.ResultsThe peak C-reactive protein was significantly lower in the patients treated with HES than those treated with gelofusine [142mg/L (113,196mg/L) vs 246mg/L (189,291mg/L)mg/L, P

Item does not contain fulltext BACKGROUND: The effect of intensified platelet inhibition for patients with unstable angina or myocardial infarction without ST-segment elevation who do not undergo revascularization has not been delineated. METHODS: In this double-blind, randomized trial, in a primary analysis involving 7243 patients under the age of 75 years receiving aspirin, we evaluated up to 30 months of treatment with prasugrel (10 mg daily) versus clopidogrel (75 mg daily). In a secondary analysis involving 2083 patients 75 years of age or older, we evaluated 5 mg of prasugrel versus 75 mg of clopidogrel. RESULTS: At a median follow-up of 17 months, the primary end point of death from cardiovascular causes, myocardial infarction, or stroke among patients under the age of 75 years occurred in 13.9% of the prasugrel group and 16.0% of the clopidogrel group (hazard ratio in the prasugrel group, 0.91; 95% confidence interval [CI], 0.79 to 1.05; P=0.21). Similar results were observed in the overall population. The prespecified analysis of multiple recurrent ischemic events (all components of the primary end point) suggested a lower risk for prasugrel among patients under the age of 75 years (hazard ratio, 0.85; 95% CI, 0.72 to 1.00; P=0.04). Rates of severe and intracranial bleeding were similar in the two groups in all age groups. There was no significant between-group difference in the frequency of nonhemorrhagic serious adverse events, except for a higher frequency of heart failure in the clopidogrel group. CONCLUSIONS: Among patients with unstable angina or myocardial infarction without ST-segment elevation, prasugrel did not significantly reduce the frequency of the primary end point, as compared with clopidogrel, and similar risks of bleeding were observed. (Funded by Eli Lilly and Daiichi Sankyo; TRILOGY ACS ClinicalTrials.gov number, NCT00699998.).

OBJECTIVES--To determine whether biplane transoesophageal imaging offers advantages in the evaluation of mitral prostheses when compared with standard single transverse plane imaging or the precordial approach in suspected prosthetic dysfunction. DESIGN--Prospective mitral valve prosthesis in situ using precordial and biplane transoesophageal ultrasonography. SETTING--Tertiary cardiac referral centre. SUBJECTS--67 consecutive patients with suspected dysfunction of a mitral valve prosthesis (16 had bioprostheses and 51 mechanical prostheses) who underwent precordial, transverse plane, and biplane transoesophageal echocardiography. Correlative invasive confirmation from surgery or angiography, or both, was available in 44 patients. MAIN OUTCOME MEASURES--Number, type, and site of leak according to the three means of scanning. RESULTS--Transverse plane transoesophageal imaging alone identified all 31 medial/lateral paravalvar leaks but only 24/30 of the anterior/posterior leaks. Combining the information from both imaging planes confirmed that biplane scanning identified all paravalvar leaks. Five of the six patients with prosthetic valve endocarditis, all three with valvar thrombus or obstruction, and all three with mitral annulus rupture were diagnosed from transverse plane imaging alone. Longitudinal plane imaging alone enabled diagnosis of the remaining case of prosthetic endocarditis and a further case of subvalvar pannus formation. CONCLUSIONS--Transverse plane transoesophageal imaging was superior to the longitudinal imaging in identifying medial and lateral lesions around the sewing ring of a mitral valve prosthesis. Longitudinal plane imaging was superior in identifying anterior and posterior lesions. Biplane imaging is therefore an important development in the study of mitral prosthesis function.

Recent studies have shown an increased late mortality rate due to cardiovascular causes after transurethral compared with open prostatectomy. This has been linked to the demonstration of haemodynamic changes during transurethral prostatectomy, which may cause ischaemic myocardial injury. We used transoesophageal echocardiography (currently the most sensitive modality for detecting myocardial ischaemia) to study 26 patients during prostatectomy under general anaesthesia. Evidence of myocardial ischaemia (as shown by the development of new regional wall motion abnormalities of the left ventricle) occurred in 4 of 22 patients during transurethral and in 3 of 4 patients during retropubic prostatectomy. An intra-operative fall in systolic as well as diastolic blood pressure occurred in 21 of 22 patients during the transurethral procedure and in all 4 patients during retropubic prostatectomy. The duration of anaesthesia and the operation, and the intra-operative blood loss did not differ significantly between patients with and without evidence of intra-operative myocardial ischaemia. However, the maximum intra-operative fall in systolic and diastolic blood pressure, as well as the mass of the prostatic tissue removed, were significantly greater in patients with than in those without evidence of intra-operative myocardial ischaemia, suggesting that the latter may be related to the extent of surgery and the degree of intraoperative hypotension. In this study, 7 of 26 patients (27%) showed evidence of myocardial ischaemia during prostatectomy. However, it remains difficult to explain why intra-operative myocardial ischaemia should result in an increased cardiovascular mortality rate several years after the operation.

BACKGROUND The flow convergence region (FCR), a zone of progressive laminar velocity acceleration, can be imaged by color Doppler proximal to stenotic and regurgitant orifices. Theoretically, FCR proximal to a discrete circular and planar orifice consists of concentric hemispheric shells of equal and accelerating velocities centered at the orifice. According to the continuity principle, flow rate across any of these isovelocity surfaces equals flow rate through the orifice. The aim of this study was to investigate whether these principles could be applied to quantify left-to-right shunting and the size of atrial septal defects after balloon mitral commissurotomy. METHODS AND RESULTS Biplane transesophageal echocardiography (TEE) with color flow imaging was performed on 36 consecutive patients (mean age, 57 +/- 16 years; range, 14-78 years) immediately before and within 24 hours of balloon (Inoue, n = 33; Mansfield, n = 3) mitral commissurotomy. Left-to-right atrial shunting was detected by TEE in 33 patients (92%) and by oximetry in 11 patients (31%). The radius r of FCR was measured from the first aliasing limit, at a Nyquist velocity reduced to 11 cm/sec by zero-shifting, to the orifice in the atrial septum. FCR was assumed to be hemispherical. Hence, flow rate (Q) was calculated as 2 pi r2 Vr, where Vr is the velocity at a radial distance r. The velocity profile of transatrial flow was assessed by means of high pulse repetition frequency, from which the maximum flow velocity (Vp) and the velocity-time integral (VTI) were obtained. The flow area of the atrial septal defect was calculated as Qm, the maximal flow rate, divided by Vp. Hence, shunt flow was calculated as flow area x VTI x heart rate. FCR was analyzed in two orthogonal planes. Mean Qm (38.1 +/- 26.5 versus 5.3 +/- 2.7 mL/sec), flow area (22.1 +/- 11.2 versus 4.4 +/- 2.0 mm2), and shunt flow (1,590 +/- 1,070 versus 200 +/- 130 mL/min) on transverse plane imaging were all significantly higher in patients with shunts detected by oximetry than in those without. Similar results were obtained from longitudinal plane imaging. Qm correlated well with oximetric shunt flow (r = 0.89-0.94, p < 0.001) and shunt ratio (r = 0.91-0.94, p < 0.001). Flow area correlated closely (r = 0.93-0.94, p < 0.001) with area determined by direct measurement from two-dimensional echocardiography. Shunt flow determined by FCR also correlated closely (r = 0.94-0.98, p < 0.001) with that determined by oximetry and that derived from two-dimensional echocardiography and pulsed Doppler (r = 0.96, p < 0.001). CONCLUSIONS The flow convergence region imaged by TEE color flow mapping provides new and accurate quantitative information on atrial shunt flow and defect size after balloon mitral valvotomy. It is a quick, reliable, and fairly simple method that can be readily incorporated into routine clinical practice.

Cardiac troponins have emerged over recent years as the “gold standard” serum biochemical marker for the diagnosis and management for patients with acute myocardial infarction (MI). The relationship between old (creatine kinase; CK) and new (troponin T; TT) markers of myocardial injury were examined in this study of 392 consecutive patients admitted to a district hospital with a diagnosis of an acute MI. Significant correlation of serum TT and peak CK levels were seen (R = 0.58, p

Restoring blood flow to ischaemic tissue can cause lung damage with pulmonary oedema. Hydroxyethyl starch (HES) solution, when used for volume replacement, may modify and reduce the degree of ischaemia-reperfusion injury. We compared the effects of HES solution with those of Gelofusine solution on pulmonary function, microvascular permeability and neutrophil activation in patients undergoing elective infrarenal abdominal aortic aneurysm surgery.Forty patients were randomized into two groups. The anaesthetic technique was standardized. Lung function was assessed with the PO(2)/FI(O(2)) ratio, respiratory compliance, chest x-ray and a score for lung injury. Microvascular permeability was determined by measuring microalbuminuria. Neutrophil activation was determined by measurement of plasma elastase.Four hours after surgery, the median (quartile values) PO(2)/FI(O(2)) ratio was 40.3 (37.8, 53.1) kPa for the HES-treated patients compared with 33.9 (31.2, 40.9) kPa for the Gelofusine-treated patients (P0.01, Mann-Whitney test). The respiratory compliance was 80 (73.5, 80) ml cm(-1) H(2)O in the HES-treated patients compared with 60.1 (50.8, 73.3) ml cm(-1) H(2)O in the Gelofusine-treated patients (P0.01, Mann-Whitney test). The lung injury score 4 h after surgery was less for the patients treated with HES compared with the patients treated with Gelofusine (0.33 vs 0.71, P=0.01, Wilcoxon rank sum test). Mean (SD) plasma elastase was less in the HES-treated patients on the first postoperative day (1.96 (0.17) vs 2.08 (0.24), P0.05). The log mean microalbuminuria was less in the HES-treated patients (0.41 vs 0.91 mg mmol(-1), P0.05). This difference in microvascular permeability was associated with different volumes of colloid required to maintain stable cardiovascular measurements in the two groups of patients studied (3000 vs 3500 ml, P0.01, Mann-Whitney test).Compared with Gelofusine, the perioperative pulmonary function of patients treated with HES after abdominal aortic aneurysm surgery was better.

The central pulmonary arteries and any thrombus within them can be imaged by transoesophageal echocardiography. Its use is reported in the diagnosis and subsequent management of a patient with acute pulmonary embolism, whose response to thrombolytic treatment was monitored by further transoesophageal studies. Transoesophageal echocardiography may be a valuable primary diagnostic procedure in patients who seem to have sustained a significant pulmonary embolus and require urgent intervention.

To determine if uncontrolled hypercholesterolaemia predisposes to progression of carotid artery stenosis.Fasting blood samples were collected from 76 patients referred for carotid duplex ultrasound for investigation of transient ischaemic attacks or recent stroke. Patients were grouped depending on the severity of the stenosis found. Patients on lipid lowering agents were excluded. The data were analysed using one way analysis of variance and the c2 test as appropriate.There were more men in the 70-99% group (15 vs 6, c2 = 10.6, p0.001, Table I). The total cholesterol was raised in all three groups. Patients with carotid stenosis of 70-99% had significantly elevated triglycerides (2.4 mmol vs 1.47 mmol and 1.37 mmol, p0.003), low HDL (1.14 mmol vs 1.45 mmol and 1.18 mmol, p0.003) and a higher cholesterol/HDL ratio (5.56 vs 4.29 and 4.71, p0.014) compared with the other two groups. There was no difference in lipoprotein(a) in the three groups.Increased triglycerides and low HDL cholesterol seen in the 70-99% group suggest that a worsening lipid profile is associated with progression of carotid artery stenosis.

Anabolic steroids have been associated with a variety of adverse reactions, including myocardial infarction. We report two cases of myocardial infarction in young men on anabolic steroids. In both men, extensive intracoronary thrombosis was demonstrated at coronary angiography; this failed to resolve despite anticoagulation.

Until recently, surgery was the only effective treatment for patients with severe mitral stenosis. Mitral balloon valvotomy is a percutaneous technique which can achieve results comparable to surgery in selected patients.

Background Subclavian vein access using anatomical landmarks for guidance is widely used and is known to carry risks of serious complications. While the use of ultrasound imaging in cannulating the internal jugular vein is well established, there is currently no similar recommendation for subclavian vein puncture. This study evaluates the use of real-time ultrasound imaging for cannulating the subclavian vein over the first rib during pacemaker implantation. Methods Over a 2-year period, 112 consecutive patients were studied prospectively using the ultrasound technique. They were compared with 100 consecutive patients in whom the anatomical landmark technique had been used. The same standard equipment for venous cannulation and pacemaker implantation was used by a single operator in both groups. The subclavian vein and artery were imaged in cross-section over the first rib using a portable ultrasound machine (sonosite MicroMaxx) equipped with a vascular transducer. The vein was identified by its medical location and its deformation to digital compression. Its diameter (d) and distance (s) from the skin surface were measured. The puncture technique is as shown. Results There were no significant differences between the two groups (ultrasound vs anatomical landmark) with respect to age (77±10 vs 78±9 years,) sex (61% vs 65% male), body mass index (26±5 vs 26±4 kg/m 2 ) or history of hypertension (46% vs 49%), ischaemic heart disease (37% vs 41%), heart failure (21% vs 26%), diabetes (15% vs 17%) or dual chamber pacemakers (59% vs 47%). Median d was 0.9 cm (range 0.4–1.5) and s 1.8 cm (range 0.9–3.2). The subclavian vein was successfully punctured with ultrasound guidance in all patients and there was no pneumothorax. In contrast subclavian vein access failed in seven patients (p=0.004) and pneumothorax occurred in four patients (p=0.03) in the anatomical landmark group. Further advantages of the ultrasound technique were speed of access, minimal discomfort to patients, smooth passage of introducer and multiple leads under the clavicle and identification of patients at risk of air embolism. There was no death, haematoma or wound infection in either group. Conclusions Puncture of the subclavian vein using ultrasound guidance is superior to the anatomical landmark technique. It eliminates the risk of pneumothorax and failure of access. It should be used routinely in patients undergoing implantation of pacemakers and other rhythm devices.

Background Previous investigations have suggested that neutrophil derived proteinases play a significant role in the development of ischaemia–reperfusion (I–R) related lung injury. Hydroxyethyl starch solution has been shown to protect against the I–R induced injury in animal models.1 Aims To investigate the effects of volume expansion with hydroxyethyl starch (eloHAES) on pulmonary function and neutrophil elastase release (NER). Patients and methods Twenty patients undergoing infra-renal elective aneurysm surgery were randomly allocated to receive either gelofusine or eloHAES solution. Urinary albumin excretion and plasma elastase were measured pre-operatively (T0), before cross clamp of the aorta (T1), after reperfusion (T2), subsequently four hourly for 12 h (T3,4,5), and on the first postoperative day (T6). The albumin excretion was expressed as albumin creatinine ratio (ACR) in mg mmol−1, and the plasma elastase in μg litre−1. These were correlated with the lung injury score (LIS) determined by PaO2/FIO2, chest X-ray and lung compliance. Results The ACR increased in all patients following reperfusion and was lower in the eloHaes group indicative of less systemic capillary leaks (Table 31). The LIS was significantly lower in the eloHAES treated patients for up to 8 h following reperfusion. There was no difference in neutrophil elastase during the study period. Conclusions EloHAES reduces systemic protein extravasation and limits pulmonary dysfunction. This effect appears to be independent of elastase release.

Echocardiography including Doppler examination has been used to assess left ventricular hypertrophy and diastolic function in 24 patients: 12 black Negro patients and 12 white patients who were matched with respect to age, heart rate and systolic and diastolic blood pressure. Significant left ventricular hypertrophy was present with normal systolic function but impaired diastolic function with a decrease in peak E velocity, an increase in peak A velocity and reversal of the E/A ratio. In the combined groups LV mass and LVPW correlated with systolic blood pressure (P less than 0.05). In the blacks systolic and diastolic blood pressure correlated with LV mass and LVPW thickness (P less than 0.05). Septal thickness correlated only with systolic blood pressure (P less than 0.01). In contrast the indices of diastolic function did not correlate with blood pressure or with left ventricular hypertrophy. No morphological differences in the left ventricle have been shown between the two groups but both had significant left ventricular hypertrophy. Whilst diastolic function is abnormal, this appeared to be independent of either blood pressure or degree of left ventricular hypertrophy. A neurohumeral mechanism has not been discounted.

Objective To study the relation between serum cardiac troponin T (cTnT) and mortality in patients presenting with acute limb ischaemia secondary to an embolism. Material and methods A two years prospective study of all patients admitted to the vascular unit with a diagnosis of acute limb ischaemia secondary to an embolism. On admission all patients had an ECG. A blood sample was taken for measurement of cTnT, CRP, serum biochemistry, full blood count and clotting. All embolectomies were performed under local anaesthesia. Patients were followed until discharge from hospital and up to twelve months after surgery. Results There were 37 patients with lower limb and 2 patients with upper limb ischaemia. Twenty four patients were female and fifteen were male, with the mean age of 76 years (50–95) for women and 84 years (77–90) for men. Seventeen patients (44%) had a raised cTnT. The patients with raised cTnT were older than those with normal cTnT [86y (77–92) vs 77y (51–95), p = 0.01, t test]. The mean cTnT was 0.20 μg/L (range: 0.11–0.27). Only two patients with raised cTnT gave a history of chest pains. All of the patients with an elevated cTnT had also raised CRP. There was no significant difference in the serum creatinine in the group of patients with elevated cTnT compared to those with normal cTnT [112 μmol/L (range 98–159) vs 119 μmol/L (range: 47–177), p = ns]. The cumulative survival for cTnT+ patients at 7 days was 53% and that of cTnT− patients was 100%. The cumulative survival for cTnT+ and cTnT− patients was statistically different (p = 0.0000, χ 2 = 13.1, Log Rank test). Using regression analysis, an elevated cTnT was found to be an independent predictor of outcome. Conclusion A significant proportion of patients presenting with an acutely ischaemic limb have an elevated cTnT. An elevated cTnT may be an early marker of overall disease severity and a predictor of outcome.