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ObjectivesInfection following major lower limb amputation is common but surgical influences on the rates of infection are not known. We aim to assess the influence of peri-operative surgical factors on outcome.Design and methodsReview of a prospective database included all patients undergoing a major lower limb amputation from March 2008 to July 2010. Infection was classified using Centre for Disease Control criteria and multivariate analysis performed to identify significant risk factors.Results127 patients, median age 78 yrs (31–98) were included. 34.6% of patients developed a wound infection following surgery; 47.7% of which were classed as superficial incisional surgical site infections, with 52.3% being deep incisional surgical site infections.There was a higher infection rate in below knee than above knee amputations (p

This is a case study of trademark infringement disputes. One of the authors (M. Cosgrove) incorporated The Econoclast, Inc. in 1979. The company provides capital market publications to financial and nonfinancial institutions, and owns the trademark Econoclast. Over the years, others have attempted to use the same name for similar services. This case study presents the practical steps that Cosgrove undertook to prevent infringement of his trademark in various cases that occurred since our prior paper was published in 2005 (Cosgrove, Marsh and Chester.) The paper also explains the basics of trademark law, the meaning of trademark infringement, and obligations of the trademark owner.

This is a case study of trademark infringement disputes. One of the authors (Cosgrove) incorporated The Econoclast, Inc. that owns a registered trademark (Econoclast®) that has provided capital market publications to financial and nonfinancial institutions since 1979. Over the years, others have used the same name for similar services. The case study explains the basics of trademark law and the meaning of trademark infringement. The authors describe the practical steps Cosgrove undertook to prevent infringement of his trademark in three different situations. There remains an on-going dispute involving possible international infringement in one of the illustrations.

The efficacy of regional thrombolysis for treating leg ischaemia is well established, but the duration of infusion and the frequent complications remain major disadvantages. By delivering recombinant human tissue type plasminogen activator (rt-PA) as pulsed intra-thrombus 5-mg aliquots combined with catheter manipulation to maintain an intra-thrombus location, the average time taken to achieve thrombolysis in 20 consecutive patients with infra-aortic occlusions was 109 min. Immediate thrombolysis was achieved in every case. Pulsed delivery of high dose rt-PA significantly accelerates thrombolysis, decreases dose and reduces costs.

We have conducted three in vitro experiments (using cadaver internal mammary artery as a model for crural artery), which establish the advantage of the Miller collar and Taylor patch over direct PTFE-artery anastomoses: (1) A new method of simultaneously measuring longitudinal and circumferential elasticity in human saphenous vein (n = 16) has demonstrated the latter to be anisotropic (i.e.: greater longitudinal than transverse compliance, P less than 0.002). This suggests that benefit may be gained by aligning the saphenous vein's longitudinal axis with that of the arteriotomy--a feature of both vein interposition anastomoses. (2) We have compared maximal pulsatile and constant flow across each type of anastomosis (n = 10 of each) using a flow model incorporating standard pressure, viscosity, graft and outflow vessel length, and anastomotic angle. This experiment has demonstrated loss of anastomotic reliability only in direct PTFE-artery anastomoses (i.e. no correlation between flow and vessel diameter, r = 0.04). (3) Casts of the internal anatomy of the anastomoses (n = 10 of each) have demonstrated a greater degree of oval distortion of the toe of the outflow vessel of direct PTFE-artery anastomoses than either of the other techniques (P less than 0.01). This experimental evidence suggests that both of these vein interposition techniques optimise the mechanical properties of saphenous vein and protect small arteries from anastomotic distortion. These benefits do not occur with direct PTFE-artery anastomoses.

A 48-year-old woman with severe juvenile-onset rheumatoid arthritis presented with a bleeding cutaneous sinus distal to her right total hip replacement scar. Methicillin resistant Staphylococcus aureus (MRSA) was isolated on culture. She had previously undergone bilateral total hip and knee replacements at aged 23 and six years later had the right knee prosthesis removed for infection, with subsequent osteomyelitis of the femoral shaft and right total hip prosthesis disruption. Peripheral arteriography was performed in view of persistent bleeding from the sinus, which revealed a 6 cm false aneurysm filling from and compressing the right external iliac artery (EIA). A PTFE-covered, balloon expandable JOSTENT was deployed in the right EIA, successfully excluding the false aneurysm and preventing further bleeding from the sinus. No graft infection was reported at 12 months. This case illustrates the potential use of endovascular stent-grafting in the treatment of an infected pseudoaneurysm.

Although the quality of the distal run-off has been considered as an important factor affecting the success of bypass grafting, reasonable results have nevertheless been reported for bypass grafts to a popliteal artery with no direct communication with the tibial or peroneal vessels (isolated popliteal segment, IPS). The use of autogenous vein has produced the best results in this situation with most authors finding polytetrafluoroethylene (PTFE) less satisfactory. Improved results have nevertheless been shown for femoro-popliteal and femorotibial PTFE grafts by the incorporation of vein patches into the anastomoses. In this paper, the influence of this technique on the patency of PTFE grafts to IPS is evaluated. Thirty-three PTFE grafts to an IPS and 67 to the below knee (BK) popliteal artery with one or more run-off vessels were studied. All IPS grafts were carried out for limb salvage and in the BK popliteal group, 46 (69%) were for limb salvage and 21 (31%) were for severe claudication. Groups were matched in terms of age, smoking history and prevalence of diabetes mellitus. Cumulative patency rates of 84% at 1 year and 76% at 3 years were achieved in the IPS group compared to 90 and 81% for the BK popliteal group with one or more run-off vessels. Using the Taylor patch technique, comparable 3 year patency rates can be expected for PTFE grafts to IPSs and to BK popliteal arteries with patent tibial or peroneal run-off.

Introduction Popliteal venous aneurysms are rare and can cause recurrent pulmonary emboli despite adequate anticoagulation. Report A 43-year old patient with known antiphospholipid syndrome developed an extensive pulmonary embolus and ischaemic stroke despite anticoagulation. Duplex ultrasound confirmed a right popliteal venous aneurysm containing non-adherent multi-layered thrombus. At operation an 8 cm × 5 cm true aneurysm of the popliteal vein was excised. A postoperative echocardiogram revealed a patent foramen ovale. Discussion This case is unusual as the patient suffered a paradoxical embolism due to his patent foramen ovale. Although antiphospholipid syndrome is associated with venous thrombosis, this is usually prevented by therapeutic anticoagulation.

Jejunostomy is an alternative method for feeding patients who cannot be fed orally.1 However, there may be an associated morbidity and potential mortality.2 In the case presented, overdistension of a jejunostomy catheter balloon led to intestinal obstruction and pressure necrosis (of the small bowel), with subsequent abscess formation leading to death from septicemia. (Journal of Parenteral and Enteral Nutrition12:410-411, 1988)

The Α-adrenergic blocker phenoxybenzamine has been shown to be useful in the treatment of prosta-tism. To assess the place of phenoxybenzamine in the management of acute retention, 43 patients presenting with acute urinary retention secondary to benign prostatic hyperplasia were catheterized suprapubically. They were then randomized to receive either oral phenoxybenzamine (10 mg b.i.d.; n = 21), or placebo tablets (n = 22). Forty-eight hours later, the bladder of each patient was filled through the catheter with 300 ml sterile saline, the catheter was clamped, and the patient encouraged to void. Only 2 of 21 (10%) patients receiving phenoxybenzamine and 3 of 22 (14%) receiving placebo were able to void satisfactorily (p = NS). In this study phenoxybenzamine had no place in the management of acute rentention of urine secondary to benign prostatic hyperplasia.