Search

Summary Background The sepsis burden on acute care services in middle-income countries is a cause for concern. We estimated incidence, prevalence, and mortality of sepsis in adult Brazilian intensive care units (ICUs) and association of ICU organisational factors with outcome. Methods We did a 1-day point prevalence study with follow-up of patients in ICU with sepsis in a nationally representative pseudo-random sample. We produced a sampling frame initially stratified by geographical region. Each stratum was then stratified by hospitals' main source of income (serving general public vs privately insured individuals) and ICU size (ten or fewer beds vs more than ten beds), finally generating 40 strata. In each stratum we selected a random sample of ICUs so as to enrol the total required beds in 1690 Brazilian adult ICUs. We followed up patients until hospital discharge censored at 60 days, estimated incidence from prevalence and length of stay, and generated national estimates. We assessed mortality prognostic factors using random-effects logistic regression models. Findings On Feb 27, 2014, 227 (72%) of 317 ICUs that were randomly selected provided data on 2632 patients, of whom 794 had sepsis (30·2 septic patients per 100 ICU beds, 95% CI 28·4–31·9). The ICU sepsis incidence was 36·3 per 1000 patient-days (95% CI 29·8–44·0) and mortality was observed in 439 (55·7%) of 788 patients (95% CI 52·2–59·2). Low availability of resources (odds ratio [OR] 1·67, 95% CI 1·02–2·75, p=0·045) and adequacy of treatment (OR 0·56, 0·37–0·84, p=0·006) were independently associated with mortality. The projected incidence rate is 290 per 100 000 population (95% CI 237·9–351·2) of adult cases of ICU-treated sepsis per year, which yields about 420 000 cases annually, of whom 230 000 die in hospital. Interpretation The incidence, prevalence, and mortality of ICU-treated sepsis is high in Brazil. Outcome varies considerably, and is associated with access to adequate resources and treatment. Our results show the burden of sepsis in resource-limited settings, highlighting the need to establish programmes aiming for sepsis prevention, early diagnosis, and adequate treatment. Funding Fundacao de Apoio a Pesquisa do Estado de Sao Paulo (FAPESP).

Background The aim of this study was to develop a 48‐h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C‐statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48‐h mortality in the IMPROVE data was reasonable (C‐statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C‐statistic was estimated compared with using age alone. Conclusion The assessed risk scores did not have sufficient accuracy to enable potentially life‐saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non‐intervention rates, while respecting the wishes of the patient and family., Not much help

The objective of this study was to evaluate the effects of dried distillers grains with solubles (DDGS) on ram lamb feedlot performance, carcass characteristics, serum testosterone concentration, and semen quality. One hundred twenty ram lambs (40.4 ± 9.1 kg; Suffolk × western white face) were used in a completely randomized design to determine the effects of DDGS on feedlot performance and carcass characteristics. Rams were allotted into one of three dietary treatments (n = 4 pens/treatment; 10 rams/pen): 1) 0DDGS: 85% corn and 15% commercial market lamb pellet, 2) 15DDGS: 15% DDGS substituted for corn (DM basis), and 3) 30DDGS: 30% DDGS substituted for corn (DM basis). Rams were weighed on consecutive days at the beginning (d 0 and 1) and end (d 96 and 97 and d 116 and 117) of the trial. Scrotal circumference was measured on all rams on d 84, 96, and 116. Semen and blood samples were collected on a subset of 48 rams (4 rams/pen; 16 rams/treatment; n = 4) to evaluate semen quality. Blood samples were collected every 14 d throughout the study. Semen samples were collected on d 84, 98, and 112. Rams were fed to market weight, shipped to a commercial abattoir, and harvested for carcass data collection. Initial BW, final BW, change in scrotal circumference, days on feed, carcass characteristics, serum testosterone concentrations, and spermatozoa motility score were not different (P ≥ 0.23) due to dietary treatment. However, DMI increased linearly (P < 0.001) as DDGS increased in the ration, resulting in a linear increase (P = 0.02) in ADG. Additionally, spermatozoa concentration decreased linearly (P = 0.05) as DDGS concentration increased in the ration. Increasing DDGS in the diet did not have a negative impact on ram feedlot performance or carcass characteristics; however, spermatozoa production may have been negatively affected, necessitating the need for additional research on the impact of DDGS on ram development.

Thoracic endovascular repair (TEVR) has developed from endovascular treatment of infrarenal aortic aneurysms, and is now considered first-line treatment for a variety of thoracic aortic pathologies. In contrast to infrarenal repair, there are no large randomized controlled trials to underpin this change in practice, and most of the existing data are from smaller trials designed to evaluate the safety of a particular device. The aim of this review was to describe these studies with respect to perioperative adverse events, occurrence of device failure, mid-term aortic death, mid-term overall survival and freedom from aortic reintervention. The implications of these results are discussed in the context of their implications for clinical practice, taking into account the relative strengths and weakness of the available data. Where the individual trial design allows, direct comparison is made between TEVR and open surgical controls, and the results of TEVR applied to particular pathology groups is discussed.

Diabetes-related foot disease is a major health problem leading to significant morbidity and cost. If high-risk populations could be identified and treated before they develop complications, a significant reduction in the burden of foot disease and number of amputations might be expected. We examined the evidence to support population-based screening programs. MEDLINE and EMBASE databases were searched from January 1970 to February 2012 to identify studies assessing the impact of screening on lower limb complications in diabetes. Foot screening was defined as combined risk stratification and intervention to prevent foot complications in a population of people with diabetes mellitus. Articles reporting singularly on stratification of risk factors to predict subsequent complications but not reporting effect on minor, major and/or combined major and minor (total) amputation were excluded. Two randomized control trials were identified. These demonstrated patient benefit from screening in the setting of a general secondary care diabetes clinic and renal dialysis unit. Four before and after studies suggested benefit from primary care or regional screening. One study tried to address confounding from general improvements in the provision of diabetes foot care separately from screening. All the observational studies were prone to confounding. The evidence base for formal national primary care-based foot screening of all patients with diabetes is weak. Focused research is needed to confirm that general population-based screening in the community is effective and cost-effective. Limited evidence suggests that screening of high-risk populations of patients may be justified.

Background The UK Multicentre Aneurysm Screening Study (MASS) demonstrated reduced mortality from screening for abdominal aortic aneurysm (AAA). As a result, the National Health Service AAA Screening Programme was introduced in England. This study reports the results from an early-implementation screening centre. Methods Men aged 65 years were invited to attend an ultrasound assessment. Data were analysed for 15 months from the onset of the screening programme. Results A total of 6091 men aged 65 years were invited between April 2009 and June 2010, of whom 2037 (33·4 per cent) failed to attend. There were 162 self-referrals (median age 71·3 years) so that 4216 men were screened. Of those scanned, 4146 (98·3 per cent) had an aortic diameter of less than 3·0 cm, 65 (1·5 per cent) had an aneurysm measuring 3·0–5·4 cm, and five (0·1 per cent) had an aneurysm with a diameter of 5·5 cm and above. The presence of an aneurysm was more common in those who self-referred than in the invited group (P < 0·001). All 70 screen-detected aneurysms were found in white men. Conclusion The prevalence of AAA was lower than expected. This reflects the younger age of this cohort compared with those in published large multicentre studies and the diverse ethnic background of the local population. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Limited data are available regarding the influence of thiamine supplementation on the incidence of polioencephalomalacia (PEM) in lambs fed diets containing increased concentrations of S in the diet (>0.7%). Therefore, our objective was to evaluate the influence of thiamine supplementation on feedlot performance, carcass quality, ruminal hydrogen sulfide gas concentrations, and incidence of PEM in lambs fed a finishing diet containing 60% distillers dried grains with solubles (DDGS; DM basis). Two studies were conducted using completely randomized designs to evaluate the influence of concentration of thiamine supplementation. Study 1 used 240 lambs fed in 16 pens, whereas study 2 used 55 individually fed lambs. Lamb finishing diets contained 60% DDGS, which resulted in a dietary S concentration of 0.73% (DM basis). Treatments diets were based on the amount of supplemental thiamine provided: 1) no supplemental thiamine (CON), 2) 50 mg/animal per day (LO), 3) 100 mg/animal per day (MED), or 4) 150 mg/animal per day (HI). Additionally, in study 2, a fifth treatment was included, which contained 0.87% S (DM basis; increased S provided by addition of dilute sulfuric acid) and provided 150 mg of thiamine/animal per day (HI+S). In study 1, ADG decreased quadratically (P = 0.04), with lambs fed the CON, LO, and MED diets gaining BW at a greater rate than lambs fed the HI diet. In study 1, DMI responded quadratically (P or = 0.17) in lamb performance were observed in study 2. In both studies, most carcass characteristics were unaffected, with the exception of a tendency for decreased carcass conformation (study 1; P = 0.09) and greater flank streaking (study 2; P = 0.03). No differences in ruminal hydrogen sulfide concentration (P > 0.05) among treatments were apparent until d 10, at which point lambs fed the LO diet had less hydrogen sulfide concentrations than all other treatments. Lambs fed HI had the greatest concentrations of hydrogen sulfide on d 31 (1.07 g of hydrogen sulfide /m(3); P < 0.009). Ruminal pH did not differ (P = 0.13) and averaged 5.6 +/- 0.06. No clinical cases of PEM were observed during the course of either study. The use of thiamine as a dietary additive to aid in the prevention of PEM in finishing lambs does not appear to be necessary under the conditions of this study.

Radiocarbon dating has been used infrequently as a chronological tool for research in Anglo-Saxon archaeology. Primarily, this is because the uncertainty of calibrated dates provides little advantage over traditional archaeological dating in this period. Recent advances in Bayesian methodology in conjunction with high-precision 14C dating have, however, created the possibility of both testing and refining the established Anglo-Saxon chronologies based on typology of artifacts. The calibration process within such a confined age range, however, relies heavily on the structural accuracy of the calibration curve. We have previously reported decadal measurements on a section of the Irish oak chronology for the period AD 495–725 (McCormac et al. 2004). In this paper, we present decadal measurements for the periods AD 395–485 and AD 735–805, which extends the original calibration set.

Aortic dissection is the most common of the acute aortic syndromes, once initiated, intimal disruption can propagate in an anterograde or retrograde fashion, and the resulting false lumen may compress the ostia of aortic branches or cause aortic expansion and eventual rupture. Acute complicated type B dissection most often requires immediate interventional treatment, whereas uncomplicated dissection has classically been managed with medical therapy alone. The first line management of complicated acute and aneurysmal chronic type B dissections has shifted toward minimally invasive endovascular treatment. To give an overview of the contemporary management of acute type B dissection, clinical manifestations, aims of management, and therapeutic options are discussed in the context deciding which patients require intervention and when.

Purpose: The aim of this study was to assess the utilisation of carbon dioxide arteriography, performed with a simple injection system, as the imaging technique of choice in patients with chronic renal failure. Methods: Patients with chronic renal impairment who required arterial imaging or intervention were recruited for carbon dioxide angiography. Demographic data were prospectively recorded and pre- and post-arteriogram renal function was quantified. Radiographic images were graded by an independent radiologist. Results: Twenty-eight patients underwent renal or aorto-femoral studies with only one failure. There were no cases of contrast-induced nephropathy. Twenty-two of the films (79%) were graded as excellent or good, four as acceptable and two were considered to be poor (non-diagnostic). Conclusions: This study has demonstrated that carbon dioxide angiography is a safe and clinically effective procedure in patients with chronic renal failure.

The objective of this study was to evaluate the effects of dried distillers grains with solubles (DDGS) on ram lamb feedlot performance, carcass characteristics, serum testosterone concentration, and semen quality. One hundred twenty ram lambs (40.4 ± 9.1 kg; Suffolk × western white face) were used in a completely randomized design to determine the effects of DDGS on feedlot performance and carcass characteristics. Rams were allotted into one of three dietary treatments (n = 4 pens/treatment; 10 rams/pen): 1) 0DDGS: 85% corn and 15% commercial market lamb pellet, 2) 15DDGS: 15% DDGS substituted for corn (DM basis), and 3) 30DDGS: 30% DDGS substituted for corn (DM basis). Rams were weighed on consecutive days at the beginning (d 0 and 1) and end (d 96 and 97 and d 116 and 117) of the trial. Scrotal circumference was measured on all rams on d 84, 96, and 116. Semen and blood samples were collected on a subset of 48 rams (4 rams/pen; 16 rams/treatment; n = 4) to evaluate semen quality. Blood samples were collected every 14 d throughout the study. Semen samples were collected on d 84, 98, and 112. Rams were fed to market weight, shipped to a commercial abattoir, and harvested for carcass data collection. Initial BW, final BW, change in scrotal circumference, days on feed, carcass characteristics, serum testosterone concentrations, and spermatozoa motility score were not different (P ≥ 0.23) due to dietary treatment. However, DMI increased linearly (P0.001) as DDGS increased in the ration, resulting in a linear increase (P = 0.02) in ADG. Additionally, spermatozoa concentration decreased linearly (P = 0.05) as DDGS concentration increased in the ration. Increasing DDGS in the diet did not have a negative impact on ram feedlot performance or carcass characteristics; however, spermatozoa production may have been negatively affected, necessitating the need for additional research on the impact of DDGS on ram development.

Endovascular aneurysm repair (EVAR) is now universally adopted as first-line therapy for the management of large abdominal aortic aneurysms (AAA). The applicability has broadened such that up to 80% of patients are morphologically suitable for EVAR. In-spite of the evidence base demonstrating improved early outcomes following EVAR compared to open surgery, and informed patients' preference, EVAR-sceptics remain. The doubters voice anxieties regarding the durability of an endovascular repair and cite evidence of graft failures from the EVAR-1 trial results. Historically, graft migration and endoleak development have been the Achilles heel of EVAR. However, EVAR is an evolving technology that over the last 10 years has seen significant development from industry, and greater experience among clinicians. This has combined with centralisation of expertise in larger vascular units, with increased case-volume, leading to more appropriate periprocedural and long-term care. Current devices offer a durable repair for patients with infra-renal aortic aneurysms. The risk of graft migration is minimised by devices with secure fixation systems, potentially limiting de-novo type 1 and 3 endoleaks. Appropriate surveillance and timely endovascular re-interventions are perhaps the most important factors to ensure robust long-term outcomes from endovascular repair, even when native vessel morphology changes. Industry registry evidence and large single unit case series are now generating a healthy evidence base of EVAR durability in contemporary endovascular practice, that affirms its role as first-line therapy in the majority of morphologically suitable patients.

Background : The permeability of the alveolar-capillary barrier to an inhaled aerosol of technetium 99m labelled diethylenetriamine penta-acetate ( 99m Tc-DTPA) is used as an index of alveolar epithelial injury. Permeability is greatly increased in active smokers. Aims : To determine the effect of sidestream smoke inhalation on permeability as this has not been described previously. Methods : We measured lung clearance of inhaled 99m Tc-DTPA aerosol in 20 normal non-smoking subjects before and after exposure to one hour's sidestream smoke inhalation. Results : Measured carbon monoxide (CO) levels rose to a maximum of 23.5±6.2 ppm (mean ± SD) from baseline values of 0.6±1.3 (p

Background: Aortic aneurysm repair in the presence of a functioning renal transplant carries significant risks of renal ischaemia. We describe the management of patients undergoing this treatment by using a temporary, externally sited axillofemoral bypass and discuss other treatment options. Methods: Three patients underwent a temporary, externally sited axillary artery to common femoral artery bypass. The aneurysm was then dissected via a transperitoneal incision. When the aneurysm was clamped, the axillofemoral graft was opened allowing retrograde perfusion to the renal transplant. Results: All three patients made a good recovery without postoperative deterioration of renal function. Conclusion: Numerous methods of protecting the transplanted kidney have been described, including expeditious surgery with no renal protection or some form of temporary shunt to perfuse the donor iliac artery. Temporary insertion of an axillofemoral bypass adds 45−60 min of extra operating time if two surgeons are present. However, this technique should completely avoid transplant ischaemia and is an excellent technique for dealing with abdominal aneurysms in patients with functioning transplants.

Thoracic endovascular repair (TEVR) has developed from endovascular treatment of infrarenal aortic aneurysms, and is now considered first-line treatment for a variety of thoracic aortic pathologies. In contrast to infrarenal repair, there are no large randomized controlled trials to underpin this change in practice, and most of the existing data are from smaller trials designed to evaluate the safety of a particular device. The aim of this review was to describe these studies with respect to perioperative adverse events, occurrence of device failure, mid-term aortic death, mid-term overall survival and freedom from aortic reintervention. The implications of these results are discussed in the context of their implications for clinical practice, taking into account the relative strengths and weakness of the available data. Where the individual trial design allows, direct comparison is made between TEVR and open surgical controls, and the results of TEVR applied to particular pathology groups is discussed.

The objective of this research was to compare the growth performance, incidence of prolapse and mortality, carcass characteristics, blood hormone concentration, and N balance of lambs implanted with increasing dosages of zeranol. One hundred forty-four crossbred lambs (29.6 ± 4.9 kg) were used in a completely random design and placed into 16 feedlot pens (4 pens/treatment) for a 116 d finishing study. Lambs were fed an 84.7% corn and 15.3% market lamb pellet (DM basis) diet ad libitum. Treatments were 0, 12, 24, and 36 mg zeranol (Ralgro; Schering-Plough), and lambs were implanted in the ear according to treatment on d 0. Lambs were weighed. Thirty lambs (67.6 ± 3.4 kg) and 96 lambs (65.8 ± 5.1 kg) were harvested on d 84 and d 118, respectively. Carcass data were collected 24 h after chill. Blood samples were collected on d 0, 28, 56, 70, 82, 99, and 116 from 64 lambs (29.6 ± 2.1 kg) in the feedlot study (subsample of 4 lambs per pen) and analyzed for thyroxine, triiodothyronine, and IGF-I. A second study was conducted to compare effects of 0, 12, 24, or 36 mg zeranol on N balance in 16 crossbred lambs (34.8 ± 2.1 kg). There were no differences among treatments for BW, ADG, DMI, and G:F (P0.05) in the feedlot study. However, there was a linear increase for incidence of prolapse (P = 0.006; 2.78, 5.55, 24.98, and 27.75%, respectively) and mortality (P = 0.005; 0.00, 5.55, 11.10, and 13.88%, respectively) as zeranol dosage increased. Carcass characteristics, blood hormone concentrations, and N balance were not affected by treatment (P0.05). These results indicate zeranol increases incidence of prolapse and mortality without increasing growth performance.

Diabetes-related foot disease is a major health problem leading to significant morbidity and cost. If high-risk populations could be identified and treated before they develop complications, a significant reduction in the burden of foot disease and number of amputations might be expected. We examined the evidence to support population-based screening programs. MEDLINE and EMBASE databases were searched from January 1970 to February 2012 to identify studies assessing the impact of screening on lower limb complications in diabetes. Foot screening was defined as combined risk stratification and intervention to prevent foot complications in a population of people with diabetes mellitus. Articles reporting singularly on stratification of risk factors to predict subsequent complications but not reporting effect on minor, major and/or combined major and minor (total) amputation were excluded. Two randomized control trials were identified. These demonstrated patient benefit from screening in the setting of a general secondary care diabetes clinic and renal dialysis unit. Four before and after studies suggested benefit from primary care or regional screening. One study tried to address confounding from general improvements in the provision of diabetes foot care separately from screening. All the observational studies were prone to confounding. The evidence base for formal national primary care-based foot screening of all patients with diabetes is weak. Focused research is needed to confirm that general population-based screening in the community is effective and cost-effective. Limited evidence suggests that screening of high-risk populations of patients may be justified.

EVAR-1 published its 10 year results in 2010. The principal finding of the study was that the endovascular group (EVR) had a significant reduction in early aneurysm related mortality compared to open surgery (OR), but the benefit was lost by the end of the study (adjusted hazard ratio [HR], 0.92; 95% confidence interval [CI] 0.57-1.49; P=0.73). By the end of follow-up, there was no significant difference between the OR and EVR group in terms of death from any cause (HR 1.03; 95% CI 0.86-1.23; P=0.72). Despite these findings the uptake of EVR continues to increase. EVR is driving improved surgical outcomes in elective abdominal aortic aneurysm (AAA) surgery, and may yet establish itself as an essential tool in the emergency setting. Elective AAA mortality may be reducing in the U.K. as a consequence of broader application of EVR. This article presents and examines the EVAR-1 data and reports the additional wealth of evidence supporting EVR from prospective registries. It proposes that EVR should be re-evaluated, but not as a consequence of the long-term EVAR-1 results. Clinicians' expertise, understanding and the technology of EVR have progressed significantly since the establishment of the EVAR-1 trial, such that the results, though valuable, may not translate to modern practice. It is essential to maintain excellence in vascular surgery and the evidence-base now demonstrates that best practice in AAA management is in specialist vascular centres, performing high volume surgery offering EVR to all patients who are morphologically suitable.

To quantify global variation in the incidence of lower extremity amputations in light of the rising prevalence of diabetes mellitus.An electronic search was performed using the EMBASE and MEDLINE databases from 1989 until 2010 for incidence of lower extremity amputation. The literature review conformed to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards.Incidence of all forms of lower extremity amputation ranges from 46.1 to 9600 per 10(5) in the population with diabetes compared with 5.8-31 per 10(5) in the total population. Major amputation ranges from 5.6 to 600 per 10(5) in the population with diabetes and from 3.6 to 68.4 per 10(5) in the total population. Significant reductions in incidence of lower extremity amputation have been shown in specific at-risk populations after the introduction of specialist diabetic foot clinics.Significant global variation exists in the incidence of lower extremity amputation. Ethnicity and social deprivation play a significant role but it is the role of diabetes and its complications that is most profound. Lower extremity amputation reporting methods demonstrate significant variation with no single standard upon which to benchmark care. Effective standardized reporting methods of major, minor and at-risk populations are needed in order to quantify and monitor the growing multidisciplinary team effect on lower extremity amputation rates globally.

Background Deep vein thromboses (DVTs) are a significant cause of morbidity and mortality. Valvular destruction leads to the spectrum of disease called the post-thrombotic syndrome (PTS) with the sequelae of chronic venous ulceration and a reduced quality of life. Catheter-directed thrombolysis (CDT) may reduce the incidence of PTS following an acute proximal DVT and increases quality of life thereafter, but it is uncertain what proportion of patients diagnosed with a DVT would be suitable for CDT. Methods This study quantified the proportion of patients investigated for DVT that would have been suitable for CDT. A retrospective review was performed of all upper and lower limb duplex ultrasound scans for suspected DVTs in a contemporary one-year period in a major regional vascular institute. All positive scans for acute proximal lower limb DVTs were compared against strict inclusion and exclusion criteria for CDT, based on national guidelines and international randomized trials. Results A total of 2368 duplex ultrasound venous investigations were performed in a one-year period and 252 scans demonstrated DVT. Of these, 158 were acute proximal lower limb DVTs. Application of the inclusion and exclusion criteria for CDT suggested that 47/158 (30%) were potentially suitable for CDT using current criteria. The median age of the 158 patients was 58 years, meaning that more than half were of working age and 54% were men. Conclusion Using current eligibility criteria, only about 30% of patients with DVT appear to be suitable for CDT.

Foot ulcers are a common and important complication of diabetes. Variation in the clinical presentation of this disease has resulted in a paucity of evidence from comparable studies to guide optimal clinical management. A validated scoring system might help clinicians and researchers in everyday assessment and management of patients or the development and assessment of new therapies. The aim of the present review was to critically appraise the published literature of wound scoring systems for diabetic foot ulcers.An electronic search was performed using the EMBASE and MEDLINE databases from 1966 until 2009 for scoring systems for diabetic foot ulcers. The literature review conformed to PRISMA statement standards.The literature search identified 197 articles, of which 180 were excluded. Eleven scoring systems and six validation or comparative studies are described.Many scoring systems exist for classification of the diabetic foot, few of which have been validated. Detailed scoring systems offer a valuable method for the comparison of data from different diabetic foot centres. Simplistic scoring systems may be used in clinical practice and the choice of scoring system should be determined by the population under study.

Limited data are available regarding the influence of thiamine supplementation on the incidence of polioencephalomalacia (PEM) in lambs fed diets containing increased concentrations of S in the diet (0.7%). Therefore, our objective was to evaluate the influence of thiamine supplementation on feedlot performance, carcass quality, ruminal hydrogen sulfide gas concentrations, and incidence of PEM in lambs fed a finishing diet containing 60% distillers dried grains with solubles (DDGS; DM basis). Two studies were conducted using completely randomized designs to evaluate the influence of concentration of thiamine supplementation. Study 1 used 240 lambs fed in 16 pens, whereas study 2 used 55 individually fed lambs. Lamb finishing diets contained 60% DDGS, which resulted in a dietary S concentration of 0.73% (DM basis). Treatments diets were based on the amount of supplemental thiamine provided: 1) no supplemental thiamine (CON), 2) 50 mg/animal per day (LO), 3) 100 mg/animal per day (MED), or 4) 150 mg/animal per day (HI). Additionally, in study 2, a fifth treatment was included, which contained 0.87% S (DM basis; increased S provided by addition of dilute sulfuric acid) and provided 150 mg of thiamine/animal per day (HI+S). In study 1, ADG decreased quadratically (P = 0.04), with lambs fed the CON, LO, and MED diets gaining BW at a greater rate than lambs fed the HI diet. In study 1, DMI responded quadratically (P0.01), whereas G:F tended to differ linearly (P = 0.08) to concentration of thiamine supplementation, with MED lambs having greater DMI and decreased G:F. No differences (Por = 0.17) in lamb performance were observed in study 2. In both studies, most carcass characteristics were unaffected, with the exception of a tendency for decreased carcass conformation (study 1; P = 0.09) and greater flank streaking (study 2; P = 0.03). No differences in ruminal hydrogen sulfide concentration (P0.05) among treatments were apparent until d 10, at which point lambs fed the LO diet had less hydrogen sulfide concentrations than all other treatments. Lambs fed HI had the greatest concentrations of hydrogen sulfide on d 31 (1.07 g of hydrogen sulfide /m(3); P0.009). Ruminal pH did not differ (P = 0.13) and averaged 5.6 +/- 0.06. No clinical cases of PEM were observed during the course of either study. The use of thiamine as a dietary additive to aid in the prevention of PEM in finishing lambs does not appear to be necessary under the conditions of this study.

Endovascular abdominal aortic aneurysm (EVAR) repair has an established role in elective management of abdominal aortic aneurysms (AAA). The application of EVAR to ruptured AAAs (rAAA) is evolving and developing a strong evidence base in selected patients. Although EVAR has been utilized to manage rAAA for greater than ten years, to-date no randomized study has been completed to confirm superiority over traditional open surgical repair. Randomized controlled trials (RCTs) allow unbiased objective comparison of two techniques and are the most powerful scientific instrument available for clinical assessment; they form the corner-stone of surgical evidence-based practice. In light of current understanding, the role of a RCT to compare emergency EVAR (eEVAR) with open surgery has been challenged. Whether an RCT is necessary, is ethical or can mimic routine clinical practice are questions open to debate. This review presents the current best evidence for eEVAR, the arguments for and against an RCT, and details current and prospective clinical trials designed to identify the optimal management of rAAA.

Aortic dissection is the commonest life-threatening event involving the aorta, affecting 5-10 per million people per year. Without treatment, half of patients with acute proximal aortic dissections die within 24 hours, and 60% of patients with acute distal aortic dissections die within 1 month. Only 10% of patients with proximal dissections and 40% of those with distal dissections will be alive at 1 year. Patients with chronic distal dissections are at risk of aortic rupture with nearly 20% requiring intervention. The aim of management of aortic dissection is to reduce propagation of the dissection plane and prevent the fatal complications of this condition. A paradigm shift in the surgical management of these patients began in the late 1990s with the reporting of two small series of patients being treated with custom-designed covered stents delivered through a unilateral arteriotomy. Both studies demonstrated the feasibility and technical success in endovascular sealing of the proximal intimal entry tear in patients with type B thoracic dissections.

Background The TUR syndrome is well described after transurethral resection of the prostate. Endoscopic transanal resection (ETAR) is increasingly used to remove rectal lesions. Methods A prospective study of 38 ETARs in 21 patients was carried out over 2 years. Each patient was observed for symptoms and signs of TUR syndrome, and each had serial venous blood sampling and subsequent biochemical and haematological analysis during the perioperative period. Results No symptoms or signs typical of TUR syndrome were recorded. However, analysis of the biochemical variables using the Kruskal-Wallis one-way analysis of variance showed that there were statistically significant (P

Traditional open surgical repair for mycotic aneurysms of the thoracic aorta is associated with significant morbidity and mortality. Endovascular repair has been reported as an alternative treatment in patients with mycotic thoracic aneurysms. This article reports our experience of endovascular stent graft placement in three patients with mycotic aneurysms of the thoracic aorta and compares the results with similar reports on the literature.

Endotension is a late complication following endovascular treatment of abdominal aortic aneurysm (AAA). A 83-year-old male had a successful endovascular repair of a 5.6 cm diameter AAA. During the follow-up period it was marked that the aneurysm continued to increase in size, became 6.6 cm maximal diameter and pulsatile with no evidence of endoleak. On laparotomy no endoleak was identified and the graft was left in situ. Postoperatively and on follow-up the patient remains asymptomatic while the aneurysm continued to appear shrunk.

We present a case of abdominal aortic aneurysm repair using a new technique of aortic stenting and discuss the anaesthetic technique used and the perioperative advantages of the technique.

Thromboembolic complications are relatively uncommon after conventional aneurysm surgery but have been reported in many early series of endovascular aneurysm repair. This article reviews the clinical evidence for embolization during endoluminal procedures and presents an ultrasound-based method to detect lower limb embolization during aneurysm repair. The results of a comparative clinical trial are presented that demonstrated a higher incidence of particulate embolization during endovascular as compared with conventional aneurysm surgery. The implications of this finding for clinical practice are discussed.

To use intraoperative aneurysmal sac pressure measurement and flow monitoring of the superficial femoral artery (SFA) to ensure complete exclusion of the aneurysm from the circulation.A 5F catheter was positioned in the aneurysmal sac of 15 consecutive patients undergoing endovascular aortomonoiliac aneurysm repair between February and September 1997. The catheter was connected to an external pressure transducer allowing pressure monitoring throughout the operation and for 24 hours postprocedurally. Flow velocity was monitored in the contralateral SFA by insonation with a 2-MHz Doppler ultrasound probe.No technical defect was observed in the deployment of 10 endografts, which demonstrated marked reduction in sac pressure and good flow in the lower limb. The mean aneurysm pressure dropped from 123 to 57 mmHg after graft insertion. In 5 cases, monitoring detected problems during the endograft procedure. In 3, incomplete stent deployment was detected by a failure of sac pressure to fall following stent inflation and by the presence of flow in the contralateral femoral artery. In the other 2 cases, a distal endoleak was detected by direct injection of contrast into the sac.Measuring aneurysm pressure in combination with SFA Doppler flow monitoring can detect complications of endovascular aneurysm repair.

Aim: This study was undertaken to determine the haemodynamic effect of incompetent calf perforating veins in patients with uncomplicated varicose veins and long saphenous incompetence. Methods: Thirty-eight limbs from 35 patients were studied. All patients had uncomplicated varicose veins with both long saphenous and calf perforator incompetence on duplex ultrasonography. Patients were randomized to have incompetent calf perforators ligated or left intact, in addition to saphenofemoral junction ligation, strip of long saphenous vein to knee and stab avulsion of any visible varicosities in the leg. Patients were assessed with air plethysmography pre-operatively and 3 months postoperatively. Results: Superficial venous surgery improved venous volume, venous filling index and ejection fraction in the patient cohort. No significant haemodynamic difference was demonstrated between the two groups of patients who were randomized. Conclusions: At present, the results of this study do not support the use of routine perforator ligation during superficial surgery for uncomplicated varicose veins.

To determine the change in referral practice following establishment of an endovascular abdominal aortic aneurysm (AAA) program.A prospective audit of all elective admissions for AAA was established in January 1994 at the initiation of an endovascular AAA program. A comparison was made between this cohort and the elective AAA repairs performed between 1981 and 1993.Since January 1994, 213 AAA patients (177 men; median age 73 years, range 54 to 88) have been referred for potential endovascular aneurysm repair. To date, 142 patients have undergone elective surgery (41 endovascular and 101 conventional). Between 1981 and 1993, 304 patients (255 men; median age 69 years, range 45 to 86) had elective aneurysm repair. Comparison of the two time periods has revealed significant increases in the number of tertiary referrals (41.8% versus 9.5%, p0.01), annual operations (50 versus 23, p0.05), and overall mortality (12% versus 6.7%, p0.05), the latter attended by a significant increase in cardiorespiratory comorbidity.The higher elective AAA mortality rate since the establishment of an endovascular program reflects a change in referral practice and may be directly attributable to an increase in the number of high-risk patients. An endovascular AAA program has clinical and financial implications for the hospital concerned.

To report two cases of endovascular aortic aneurysm exclusion in patients with a horseshoe kidney.Two male patients, one with a known horseshoe kidney and history of multiple previous laparotomies, presented with abdominal aortic aneurysms of approximately 6-cm diameter. Each was treated with a tapered aortomonoiliac polytetrafluoroethylene graft secured proximally with a Palmaz balloon-expandable stent. The endograft was sutured distally to a Dacron femorofemoral crossover graft. An anomalous renal vessel was sacrificed in one case. The aneurysms were successfully excluded, and the patients recovered without sequelae.Endovascular repair should be considered as a treatment option in patients with aortic aneurysm in the presence of a horseshoe kidney, particularly if the renal vasculature can be wholly preserved.

To describe the management strategies used to deal with twisted aortic endografts.Two patients with successfully excluded aortic aneurysms developed symptoms referable to previously undetected twists in their endografts (one EndoVascular Technologies [EVT] and one customized aortomonoiliac device). The limb graft occlusion in the EVT graft was treated surgically with a femorofemoral bypass, but the aortomonoiliac endograft was salvaged with percutaneous implantation of a Wallstent. During another aortomonoiliac procedure, suboptimal flow through the endograft was traced to contortion of the endograft as it passed over an angulated proximal aneurysm neck. An X-large Palmaz stent was deployed to support the graft at this point.Unsupported aortic endografts may develop twists and kinks during deployment that can lead to low outflow and graft occlusion. Endovascular techniques are available to repair these defects postoperatively, although more precise intraoperative assessment tools may identify these problems so that they can be corrected at the initial intervention.

The TUR syndrome is well described after transurethral resection of the prostate. Endoscopic transanal resection (ETAR) is increasingly used to remove rectal lesions.A prospective study of 38 ETARs in 21 patients was carried out over 2 years. Each patient was observed for symptoms and signs of TUR syndrome, and each had serial venous blood sampling and subsequent biochemical and haematological analysis during the perioperative period.No symptoms or signs typical of TUR syndrome were recorded. However, analysis of the biochemical variables using the Kruskal-Wallis one-way analysis of variance showed that there were statistically significant (P0.05) subclinical changes during the 24 h following the procedure affecting levels of serum sodium, potassium, total protein, albumin, lactate dehydrogenase, glycine, ammonia and serum osmolality.The changes in the electrolyte concentrations, although statistically significant, were not of the same magnitude as described previously in the TUR syndrome. The risk of a TUR-type syndrome in ETAR is small and serial blood tests, as detailed above, may safely be omitted.

To describe a refined technique for aortomonoiliac endograft exclusion of abdominal aortic aneurysms (AAAs).A tapered aortomonoiliac graft was prepared from an 8-mm thin-walled expanded polytetrafluoroethylene tube graft predilated proximally to 35 mm and tapered distally to 15 mm. The proximal graft was sutured to a 5-cm-long, predilated Palmaz stent, which was mounted on a 30-mm balloon and backloaded into a 21F packaging sheath. With the patient under general anesthesia and both common femoral arteries exposed, the endograft was anchored in the infrarenal aorta and subsequently passed into one iliac system, where it was anastomosed to the iliac or femoral vessels. The contralateral common iliac artery was occluded, and an extra-anatomic, femorofemoral, or iliofemoral bypass grafting was performed.Twenty of the 25 AAAs treated to date with this technique have been successful, with aneurysm exclusion achieved in 18 (2 minor distal endoleaks are scheduled for endovascular repair). The technical failures were analyzed, resulting in enhancements to the technique. Complications included 2 early (30 days) deaths, 1 case of minor embolization, 1 transient renal failure, 1 pulmonary embolus, and 1 wound infection. The only late complication was a graft infection localized to the groin.Aortomonoiliac endovascular aneurysm repair is effective in patients with AAAs involving the iliac arteries. Short-term results are acceptable, but long-term efficacy must be addressed before this procedure is widely adopted. Technical changes made in response to early learning curve problems have led to a safer, more reliable procedure.

To differentiate and quantify the type and number of lower limb emboli occurring during endovascular aneurysm repair, as compared to conventional surgery.Thirty-eight patients underwent elective infrarenal aneurysm repair using a conventional surgical approach in 18 and an endovascular procedure in 20. Emboli were detected using a Doppler ultrasound system with a 2-MHz transducer interrogating the mid superficial femoral artery. Lower limb emboli were differentiated as particulate or gaseous based on the physical distance traversed by the embolic signal.Significantly more particulate (median 108 versus 59, p = 0.015) and gaseous (134 versus 46, p = 0.008) emboli were detected during endovascular aneurysm repair as compared to conventional surgery. Clinically, no case of massive microembolization occurred in either group, but one patient in the conventional group required a femoral embolectomy, and three patients undergoing endovascular repair developed self-limiting trash feet postoperatively. In patients undergoing endovascular aortomonoiliac aneurysm repair, there was only a poor correlation between the number of particulate emboli and either procedural duration or operator experience.The apparent lack of a relationship between particulate embolization and operative time or technical experience suggests that manipulation of endoluminal devices within the aneurysm sac may not be the sole determinant of intraprocedural embolization. Other as yet undetermined factors may predict patients at high risk for massive embolization.

Endovascular abdominal aortic aneurysm (AAA) repair has been proposed as a minimally invasive alternative to conventional surgery and may offer significant advantages in respiratory function and analgesic requirements due to the absence of an abdominal incision.Respiratory function and analgesic requirements were quantified in 22 age-matched patients undergoing aneurysm repair under general anesthesia. Twelve patients underwent endovascular aneurysm repair, while 10 AAA patients had conventional surgery. One endovascular patient required conversion to conventional repair.The endovascular group required postoperative artificial ventilation for a shorter time (6 versus 21 hours, p0.05) and had lower PCA (patient-controlled analgesia) morphine consumption (41 versus 133 mg, p0.05) than the conventional group. The endovascular group also had significantly better forced expiratory volume and forced vital capacity at both 3 and 5 days when expressed as percentages of the preoperative values (p0.05).Endovascular AAA repair attenuates respiratory dysfunction associated with conventional surgery and reduces perioperative analgesia requirements.

To describe a technique to enhance stent visibility on the fluoroscopic monitor during aortic endograft deployment.To assist in accurate positioning and deployment of the proximal stent in a Parodi-type aortic endograft, the stent is affixed to the balloon so that the radiopaque marker sits at the stent's distal end. When the device is in position and the sheath is retracted, the stent and the radiopaque balloon markers are clearly seen on the fluoroscopic image. Using normal saline only to inflate the balloon allows the stent to remain visible throughout deployment.The use of saline rather than contrast medium for balloon inflation provides continuous visualization of the stent during expansion, thus facilitating accurate deployment and early recognition of balloon migration within the stent.

A specific method for quantification of methylmalonic acid (MMA) from urine samples dried onto filter paper is described. The method involves stable isotope dilution gas chromatography-mass spectrometry with [methyl-2H3]-MMA as the internal standard. MMA is stable in dry paper samples stored at room temperature for at least 2 weeks. The extraction efficiency of MMA from paper was 56-58%. The concentration of urinary MMA in dried filter paper specimens from 190 normal controls was 1.21 +/- 1.34 (mean +/- SD) mmol/mol of urinary creatinine. Age-related reference values are also reported. The concentrations, normalized to the urinary creatinine concentration, decrease with age. The applicability of this method to rapid screening for cobalamin (vitamin B12)-related disorders and methylmalonic aciduria is demonstrated.

Intratracheal administration of plasmid DNA resulted in gene expression in mouse airways in the absence of any enhancing agent. Administration of plasmid DNA encoding the chloramphenicol acetyltransferase gene (CAT) in sterile water lead to CAT transgene expression that peaked between 1 and 3 days and was detected up to 28 days after DNA administration. Transgene expression was independent of mouse gender, age and strain. Levels of expression from DNA in various isotonic solutions did not differ from levels obtained with DNA administered in water, suggesting that transfection is not dependent on damage to airway cells caused by a hypo-osmotic delivery vehicle. Pharmacokinetic studies using radiolabeled plasmid DNA showed that DNA was rapidly degraded, while higher levels of radioactivity were retained for longer duration following administration of cationic liposome-DNA complexes in the airway. Southern blot and PCR analysis confirmed that DNA complexed with DOTMA-DOPE was retained in the airways for a longer period. However, cationic liposomes DOTMA-DOPE (1:1) or DOTAP complexed with DNA, did not enhance expression over DNA alone. These results suggest that 'naked' plasmid DNA should be included as a control in all studies on intratracheal gene delivery using nonviral systems.

A rapid, sensitive, and specific method for quantification of orotic acid from dried filter-paper urine samples is described. The method involves stable isotope dilution with 1,3-[15N2]orotic acid analysis by gas chromatography-mass spectrometry. The assay is sufficiently sensitive to be used with solvent extraction techniques commonly used for urinary organic acid analysis. Extraction efficiencies of both native and isotopic orotic acid from dried filter paper and from water were 31% and 28%, respectively. The concentration of orotic acid in dried filter-paper urine specimens from 50 healthy controls was 1.1 +/- 0.67 (mean +/- SD) mmol/mol of urinary creatinine. The same 50 urine samples, analyzed directly from a 5-mL aliquot of liquid urine, gave values of 0.93 +/- 0.51. The correlation coefficient between the results obtained by the two different collection methods was 0.87. Age-related reference values in filter-paper samples are also reported. The concentrations, which are normalized to urinary creatinine, decrease with age. This method is applicable to rapid screening for urea cycle disorders and may also be used for carrier testing of ornithine transcarbamylase deficiency.

The management of patients with carotid artery disease who require coronary artery bypass grafting (CABG) remains controversial. Several published series from the USA (including one with prospective randomization) advocate a combined approach of carotid endarterectomy (CEA) followed immediately by coronary artery bypass surgery. However, experience of combined carotid endarterectomy and coronary bypass grafting has not been previously reported by a centre from the United Kingdom. Between 1986 and 1991 we performed this combined procedure on 18 patients who required myocardial revascularization and had co-existing severe (70%) carotid stenosis. Sixteen patients (89%) had angina and 11 patients (61%) had symptomatic carotid artery disease. The perioperative mortality was 5.5% and the ipsilateral perioperative stroke rate was 5.5%. These early results are encouraging and suggest that further evaluation of combined carotid endarterectomy and coronary artery bypass surgery is warranted.