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Communication is key to any successful relationship with the patient-physician partnership being no different. Recent advances in technology have provided us with an array of new communication tools such as the mobile phone, computer, internet, and email. This new technology has revolutionized communications; however, limitations to their widespread use include access, literacy, and willingness for both the physician and patient to change. To gather international data, questionnaires were completed by patients attending vascular surgery outpatient clinics in hospitals in Ireland and Canada. Five hundred ninety-seven patients participated in the study. Of the participants, 83.2% were over 50 years old. The mean age was 63.1 years, with a range of 18–95 years. Overall, home phone call was the most preferred method of communication with 41.0% of patients selecting this option. Of the patients, 82.4% had a mobile phone but just 48.5% use text message. In those over the age of 70, 72.1% use a mobile phone and just 25.3% use text message. Of the participants, 64.1% had access to a computer, and 67.2% had access to the internet with a decline in the usage of both with increasing age. Within this patient population, the use of technologies decreases with increasing age of the patients. This demonstrates a large population of service users who are contented with conventional methods of communication. Change within healthcare ICT is inevitable, and therefore, these patients need to be guided and educated to allow a smooth transition from the old to the new.

Communication is key to any successful relationship with the patient-physician partnership being no different. Recent advances in technology have provided us with an array of new communication tools such as the mobile phone, computer, internet, and email. This new technology has revolutionized communications; however, limitations to their widespread use include access, literacy, and willingness for both the physician and patient to change.To gather international data, questionnaires were completed by patients attending vascular surgery outpatient clinics in hospitals in Ireland and Canada.Five hundred ninety-seven patients participated in the study. Of the participants, 83.2% were over 50 years old. The mean age was 63.1 years, with a range of 18-95 years. Overall, home phone call was the most preferred method of communication with 41.0% of patients selecting this option. Of the patients, 82.4% had a mobile phone but just 48.5% use text message. In those over the age of 70, 72.1% use a mobile phone and just 25.3% use text message. Of the participants, 64.1% had access to a computer, and 67.2% had access to the internet with a decline in the usage of both with increasing age.Within this patient population, the use of technologies decreases with increasing age of the patients. This demonstrates a large population of service users who are contented with conventional methods of communication. Change within healthcare ICT is inevitable, and therefore, these patients need to be guided and educated to allow a smooth transition from the old to the new.

Background Critical limb ischemia (CLI) is the most severe manifestation of peripheral vascular disease. Revascularization is the preferred therapy, but it is not achievable in 25%–40% of patients due to diffuse anatomic distribution of the disease or medical comorbidities. No-option CLI represents an unmet medical need. Mesenchymal stromal cells (MSCs) may provide salvage therapy through their angiogenic and tissue-trophic properties. This article reports a phase 1b clinical study examining the safety and feasibility of intramuscular transplantation of autologous bone-marrow MSCs for patients with no-option CLI. Methods Twelve patients were enrolled in the clinical trial, and nine proceeded to bone marrow aspiration and culture expansion of MSCs. Results A high rate of karyotype abnormality (>30%) was detected in the produced cell batches, resulting in failure of release for clinical administration. Four patients were treated with the investigational medicinal product (IMP), three with a low dose of 20 × 106 MSCs and one with a mid-dose of 40 × 106 MSCs. There were no serious adverse events related to trial interventions, including bone marrow aspiration, IMP injection or therapy. Conclusions The results of this trial conclude that an autologous cell therapy approach with MSCs for critical limb ischemia is limited by the high rate of karyotype abnormalities.

Background: ULHG first detected CPE in 2009. A decision was made at the outset to flag CPE contacts on the surveillance software system (ICNet) rather than write to discharged contacts. CPE was declared a national public health emergency, October 2017. In September 2018, the Irish CPE Expert Group mandated that all hospitals write to CPE contacts, as per open disclosure policy, to inform them of their status. Screening was also offered. An eligible contact was defined as one who did not have 4 negative screens since exposure. Methods: An ICNet search was conducted to detect all CPE contacts, cross-checking with the national death registry before delineating the number of CPE screens tested via the Laboratory Information System. Processes were put in place to address queries from patients; a generic helpline and a recorded telephone line for clinical concerns or complaints. Screening packs were developed. National template letters were posted to patients, their GPs and consultants. Results: 2016 CPE contacts were identified from Feb 2009 to Sept 2018. 422 patients contacted the generic helpline; 347 requested call-back from the CPE nursing expert. 115 requested testing packs with 103 delisted as contacts. Patients voiced many concerns including anger for the untimely notification, upset at the potential risk of CPE acquisition and criticism regarding the letter content. Conclusions: The decision to inform patients is appropriate but it must be timely with access to understandable information and support from a suitably trained professional. The communication programme continues prospectively in the setting of CPE endemicity.

BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody testing in community settings may help us better understand the immune response to this virus and, therefore, help guide public health efforts.AimTo conduct a seroprevalence study of immunoglobulin G (IgG) antibodies in Irish GP clinics.Design & settingParticipants were 172 staff and 799 patients from 15 general practices in the Midwest region of Ireland.MethodThis seroprevalence study utilised two manufacturers’ point-of-care (POC) SARS-CoV-2 immunoglobulin M (IgM)—IgG combined antibody tests, which were offered to patients and staff in general practice from 15 June to 10 July 2020.ResultsIgG seroprevalence was 12.6% in patients attending general practice and 11.1% in staff working in general practice, with administrative staff having the lowest seroprevalence at 2.5% and nursing staff having the highest at 17.6%. Previous symptoms suggestive of COVID-19 and history of a polymerase chain reaction (PCR) test were associated with higher seroprevalence. IgG antibodies were detected in approximately 80% of participants who had a previous PCR-confirmed infection. Average length of time between participants’ positive PCR test and positive IgG antibody test was 83 days.ConclusionPatients and healthcare staff in general practice in Ireland had relatively high rates of IgG to SARS-CoV-2 compared with the national average between 15 June and 10 July 2020 (1.7%). Four-fifths of participants with a history of confirmed COVID-19 disease still had detectable antibodies an average of 12 weeks post-infection. While not proof of immunity, SARS-CoV-2 POC testing can be used to estimate IgG seroprevalence in general practice settings.

Background To evaluate the association between inflammatory markers expressed as neutrophil–lymphocyte ratio (NLR) and process of arteriovenous fistula (AVF) maturation. Methods A retrospective review of patients with end-stage renal disease referred for formation of a new AVF in one center. Patients referred to the vascular service in the University Hospital of Limerick for creation of vascular access between 2009 and 2013. The association between NLR, calculated from preoperative blood tests, and functional fistula maturation, as determined by successful use of the AVF for 6 consecutive hemodialysis sessions, was investigated using univariate and logistic regression analyses. A logistic regression analysis was carried out to assess potential influence from other factors related to AVF maturation. Stepwise regression test was performed including the NLR. Results Overall AVF functional maturation rate in our study was 53.7% (66/123). Patients with matured AVFs had an NLR of 4.850 (1.8–15.7) compared with 3.554 (1.7–15.0); this difference was found to be significant ( P = 0.024). Female gender ( P = 0.008) and a history of kidney transplant ( P = 0.004) were the only independent factors of fistula maturation outcome in a logistic regression model. Conclusion Increased level of NLR was found to be associated with fistula maturation; however, more studies are needed to validate this finding.

COVID-19 is an unprecedent occurrence in modern times and individuals who work within healthcare settings, face a broad array of challenges in responding to this worldwide event. Key information on the psychosocial responses of such healthcare workers (HCWs) in the context of COVID-19 is limited and in particular there is a need for studies that utilise longitudinal methods, an overarching theoretical model, and use of a cohort of participants within a defined geographical area across acute and community settings. The work packages making up the current research project use quantitative and qualitative methods to examine the psychological sequelae for HCWs in the context of COVID-19 in geographically adjacent healthcare areas (South and Mid-West of Ireland) across four time points (induction, 3 months, 6 months, and 1 year follow-up). The quantitative arm of the project (WP 1) utilises the Common-Sense Model of Self-Regulation (CSM-SR) and examines a number of key psychological factors pertinent to this model including perceptions about COVID-19 and infection more generally, coping, formal and informal support and a number of impact variables including mood, sleep quality, and perceptions of stigma. The qualitative study (WP 2) will address HCWs experiences of working during the pandemic, ascertain any additional areas of psychological functioning, environmental and workplace factors and resources that may be utilised by HCWs and that are not assessed by the quantitative study protocol, focusing particularly on those staff groups typically underrepresented in previous studies.

A pilot randomized controlled trial that evaluated the effect of remote ischemic preconditioning (RIPC) on clinical outcomes following major vascular surgery was performed. Eligible patients were those scheduled to undergo open abdominal aortic aneurysm repair, endovascular aortic aneurysm repair, carotid endarterectomy, and lower limb revascularization procedures. Patients were randomized to RIPC or to control groups. The primary outcome was a composite clinical end point comprising any of cardiovascular death, myocardial infarction, new-onset arrhythmia, cardiac arrest, congestive cardiac failure, cerebrovascular accident, renal failure requiring renal replacement therapy, mesenteric ischemia, and urgent cardiac revascularization. Secondary outcomes were components of the primary outcome and myocardial injury as assessed by serum troponin values. The primary outcome occurred in 19 (19.2%) of 99 controls and 14 (14.1%) of 99 RIPC group patients ( P = .446). There were no significant differences in secondary outcomes. Our trial generated data that will guide future trials. Further trials are urgently needed.

Objectives A systematic review and meta-analysis was performed to determine the incidence of thrombotic events following great saphenous vein (GSV) endovenous thermal ablation (EVTA). Methods MEDLINE, Embase and conference abstracts were searched. Eligible studies were randomised controlled trials and case series that included at least 100 patients who underwent GSV EVTA (laser ablation or radiofrequency ablation [RFA]) with duplex ultrasound (DUS) within 30 days. The systematic review focused on the complications of endovenous heat induced thrombosis (EHIT), deep venous thrombosis (DVT), and pulmonary embolism (PE). The primary outcome for the meta-analysis was deep venous thrombotic events which were defined as DVT or EHIT Type 2, 3, or 4. Secondary outcomes for the meta-analysis were EHIT Type 2, 3, or 4, DVT and PE. Subgroup analyses were performed for both the RFA and EVLA groups. Pooled proportions were calculated using random effects modelling. Results Fifty-two studies (16,398 patients) were included. Thrombotic complications occurred infrequently. Deep venous thrombotic events occurred in 1.7% of cases (95% CI 0.9–2.7%) (25 studies; 10,012 patients; 274 events). EHIT Type 2, 3, or 4 occurred in 1.4% of cases (95% CI 0.8–2.3%) (26 studies; 10,225 patients; 249 events). DVT occurred in 0.3% of cases (95% CI = 0.2%–0.5%) (49 studies; 15,676 patients; 48 events). PE occurred in 0.1% of cases (95% CI = 0.1–0.2%) (29 studies; 8223 patients; 3 events). Similar results were found when the RFA and EVLA groups were analysed separately. Conclusion Thrombotic events occur infrequently following GSV EVTA. Given the large numbers of procedures worldwide and the potential for serious consequences, further research is needed on the burden of these complications and their management.

In 2016 the HSE Clinical Strategy and Programmes Division and the Acute Hospital Division collaborated in co-sponsoring a proof of concept programme for Scientific Management Practices in Healthcare to tackle Patient Flow. It is a key work-stream of the Integrated Care Programme for Patient Flow and is closely aligned with the work of the Special Delivery Unit (SDU). To support planning and delivery of the programme, the HSE engaged[1] a technical partner, GE Healthcare Finnamore, with expertise and experience in application of operations management techniques such as lean, simulation and modelling, implementation of evidence based best practice and change management methodologies to improve patient flow. A key outcome is building capacity and capability within the HSE to enable national implementation. The 3 year programme combines hands on change management support, implementation of evidence based best practice in patient flow supported by state of the art data, simulation and analytical techniques and skills transfer to HSE staff at local and national levels to ensure sustainability. Techniques such as capacity and demand and workforce modelling are being applied to support changes in clinical models and processes to deliver improvements in patient flow in 2 demonstrator sites over an 18 month timeline, with subsequent national roll out over a further 18 month period. While the initial focus of this work is in the acute hospital systems in University Hospital Limerick and Galway University Hospitals, the importance of understanding whole system patient flow and interdependencies across acute, primary and community health and social care settings is acknowledged. Initial tests of change are underway in both proof of concept sites, covering such areas as ED flow, bed turnaround, improving flow in medical pathways, frail older persons services, bed management and emergency theatre and surgical assessment areas. Results are anticipated in the following 6-12 months. [1] through a competitive tender process

Summary Background Ultrasonography is increasingly used by clinicians to identify abdominal aortic aneurysms (AAA). We performed a systematic review and meta-analysis comparing the accuracy of non-radiologist performed ultrasound (NRPUS) for AAA disease to the ‘gold standard’ of radiologist performed aortic imaging (RPI), intra-operative findings or postmortem findings. Methods Cochrane Library, MEDLINE, EMBASE, SCOPUS-V.4, trial registries, conference proceedings, and article reference lists were searched to identify studies comparing NRPUS with RPI as the reference standard. Data abstracted from eligible studies was used to generate 2 × 2 contingency tables allowing calculation of pooled sensitivity and specificity values. Results 11 studies (944 patients) evaluated NRPUS for AAA detection. NRPUS had a pooled sensitivity of 0.975 [95% confidence interval (CI), 0.942–0.992] for AAA detection and a pooled specificity of 0.989 (95% CI, 0.979–0.995). Conclusions Non-radiologist performed ultrasound achieves acceptable sensitivity and specificity for both detection and measurement of AAA. There was no evidence of significant heterogeneity with respect to pooled sensitivity or specificity.

Introduction Controversy exists relating to carotid endarterectomy (CEA) versus carotid artery stenting (CAS). We aimed to assess the quality of online patient information relating to both. Methods The Google search engine was searched for "carotid endarterectomy" and "carotid stenting". The first 50 webpages returned were assessed. The Gunning Fog Index (GFI) and Flesch Reading Ease Score (FRES) were calculated to assess readability. The LIDA tool (Minervation Ltd., Oxford, U.K.) was used to assess accessibility, usability and reliability. Results 20% ( n = 10) of the webpages returned for CEA were from peer reviewed sources with 34% ( n = 17) posted by hospitals or health services. Comparatively, for CAS, 40% ( n = 20) were peer reviewed with 16% ( n = 8) posted by hospitals or health services. GFI and FRES scores indicated webpages for both CEA and CAS had poor general readability. Webpages for CEA were easier to read than those for CAS (mean FRES difference of 6.7 (95% CI 0.51 to 12.93, p = 0.03). Median LIDA scores demonstrated acceptable reliability, accessibility and usability of information for both CEA and CAS webpages. The more readable webpages were not associated with higher LIDA scores for either CEA or CAS webpages. Conclusion Webpages providing information on carotid disease management must be made more readable. Online information currently available to patients regarding CAS is more difficult to read and comprehend than CEA.

Reconfiguration of surgical services in the Mid-West in 2009 resulted in a large increase in numbers of patients undergoing emergency surgery for appendicitis in University Hospital Limerick (UHL). The aim of this study was to assess the impact of reconfiguration on the management of appendicitis in this area. Data on all patients who underwent appendicectomy between January and June 2007 were compared with the corresponding data from January to June 2011. The numbers of operations, types of operations, lengths of stay (LOS), operation start times, rates of negative histology specimens and readmissions within 30 days were compared. One hundred and twenty-five appendicectomies [48 laparoscopic (38.4 %)] were performed in the 2007 group of which 32 specimens (25.6 %) were histologically negative. Three hundred and nineteen appendicectomies [238 laparoscopic (74.6 %)] were performed in the 2011 group of which 62 specimens (19.4 %) were histologically negative. The increase in numbers of laparoscopic procedures was significant (p

Acute surgical patients are admitted to our regional hospital through the emergency department (ED) and through a new surgical assessment unit (SAU). The aim of this study was to compare the efficiency of the two units in seeing and assessing acute surgical patients, as well as patients' satisfaction with their experiences in both units.A patient satisfaction scoring questionnaire was distributed to 115 consecutive surgical patients attending the SAU and ED over an 8-week period. Patients' impressions of waiting times, pain management and interactions with staff were detailed. The actual times taken for assessment, admission and discharge were recorded and compared with those perceived by the patients.Patients' perceptions of care were very high within both the ED and the SAU, with 95 % of SAU patients reporting their care as excellent or very good compared with 86 % of ED patients (p = 0.014). Patients were assessed considerably faster in the SAU compared with the ED, with an average wait from registration to admission or discharge totalling 5 h in the SAU compared with 12 h in the ED.The SAU provides an effective and efficient mode of assessment of acute surgical patients. While patients were discharged faster from the SAU than the ED, patients rated both units highly in terms of satisfaction with the service provided.

The aim of this study was to determine the rate of venous ulcer recurrence and the level of compliance in patients wearing European class 1 or class 2 compression stockings. A total of 100 patients with healed venous leg ulcers were recruited, and were randomised to either class 1 (n = 50) or class 2 (n = 50) compression stockings. Follow‐up was at 1 week, 3, 6, 9 and 12 months to monitor ulcer recurrence and compliance. Patients had a duplex scan to identify the source of venous incompetence. The rate of ulcer recurrence after 12 months was 16·1%, and the difference in recurrence rate between classes was not statistically significant (P = 0·287) although greater numbers in class 1 developed a recurrence. Participants (88·9%) were compliant; non‐compliant patients were at a significantly greater risk of recurrence (P≤ 0·0001). Thirteen patients had both superficial and deep incompetence; those randomised to class 1 stockings (n = 4) developed ulcer recurrence. Patients with a history of multiple episodes of ulceration were more likely to develop a recurrence (P = 0·001). The lowest venous ulcer recurrence rates were seen in patients who were compliant with hosiery regardless of the compression level. Patients with both superficial and deep incompetence had a lower rate of recurrence with class 2 compression.

The use of radial augmentation index (rAI) as an indicator of vascular disease was investigated in the vascular imaging laboratory in a regional hospital.The aim of this study was to investigate whether a correlation exists between ankle-brachial pressure index (ABPI) and rAI in normal subjects, patients with peripheral obstructive arterial disease, and diabetic patients.A group of 46 patients and 14 controls had ABPI and rAI measured and factors affecting AI were assessed.rAI was found to have a negative correlation with ABPI (Spearman's ρ = -0.513, p0.01). There was significant increase in the rAI scores of diabetic patients compared to normal patients (normal median was 64% lower than diabetic median, p0.01) and in peripheral obstructive vascular disease patients compared to normal (normal median 69% lower, p0.001). Of the various affecting factors, age stood out with rAI having a positive correlation to age (Spearman's ρ = 0.68, p0.01).The augmentation index appears be a significant indicator of cardiovascular disease and may be a useful tool in the diagnosis of vascular pathology.

ObjectivesTo compare mobility in patients with venous leg ulcers to matched controls and determine the influence of mobility, age and ulcer size on ulcer healing.Methods25 leg ulcer patients, and 25 matched controls wore a mobility monitor (ActivPAL™, PAL Technologies Ltd, Glasgow, Scotland)) which recorded the number of steps and amount of time spent walking, standing, sitting or lying for a one-week period. A walking index was calculated. The ulcer group were treated with compression bandaging and ulcer healing recorded over 12 weeks.ResultsThere were 13 female subjects in each group. The median age was 70.5 (range 30–89) years. There was no difference in the amount of time either group spent standing, walking and resting. There was a significant reduction in the number of steps taken and in the walking index in the ulcer group compared to controls (ulcer group, median 6,685 steps/day, range 2074–17,999; control group median 8750, range 4917–16,043, p

This best evidence topic was investigated according to a described protocol. We asked the question: what is the minimal vein diameter that can successfully predict maturation of an arteriovenous fistula (AVF) in patients undergoing dialysis. Using the reported search 804 papers were found, of which five represented the best evidence to answer the clinical question. All studies assessed the association between successful AVF maturation and the size of vein used. The strongest evidence came from a nonrandomised controlled follow-up study in which 76% of fistulas created using >2 mm cephalic vein successfully matured compared to 16% when the vein measured ≤2 mm. Another prospective, multicentre study showed 65% successful maturation using veins >4 mm compared to 45% with veins

Poor long-term survival and significant co-morbidity among diabetic patients with limb ischaemia makes the shortest, simplest revascularisation procedure desirable.Evaluate limb salvage, primary graft patency and peri-operative morbidity rates in diabetic patients undergoing popliteal-to-distal artery bypass for limb salvage.Patients undergoing popliteal-to-distal artery bypass for critical limb ischaemia over a seven-year period were retrospectively identified. Patients operative and follow-up data were entered into a database and limb salvage and patient survival determined using Kaplan Meier survival analysis.During the study period 21 popliteal-to-distal artery bypasses were performed on 19 diabetic patients. Mortality rate after one year was 11%. Primary graft patency rates among surviving patients was 81%, 67% and 48% at 1, 2 and 6 years respectively. Amputation was required in three patients.Popliteal-to-distal artery bypass produces favourable results in high-risk diabetic patients with critical limb ischaemia.

The development of regional dialysis units and the expanding indications for dialysis has led to increased demand for vascular access surgery. Consequently, the provision and maintenance of access, and the management of related complications has created a considerable burden on vascular surgical units in hospitals providing renal replacement therapy (RRT).The objectives of our study were to review our experience with a variety of vascular access modalities for haemodialysis and to quantify the associated surgical workload.We reviewed our experience in a consecutive group of dialysis patients who had access surgery for RRT in a regional hospital setting.Between January 1995 and January 2000, 69 patients entered the long-term dialysis programme in the Mid-Western region (population = 320,000). Of the 158 procedures performed, 138 (87%) were for access creation, and 20 (13%) related to access revision procedures. Twenty patients (29%) developed a total of 30 access related complications. Vascular access procedures accounted for 10% of the vascular surgical workload (1598 procedures) in the five-year period.Vascular access is an important part of the haemodialysis services and surgical expertise should be available at local level to cope with likely demand.

Introduction A brachiobasilic arteriovenous fistula (BB-AVF) can provide access for haemodialysis in patients who are not eligible for a more superficial fistula. However, it is unclear whether one- or two-stage BB-AVF is the best option for patients. Aim To systematically assess the difference between both procedures in terms of access maturation, patency and postoperative complications. Methods Online search for randomised controlled trials (RCTs) and observational studies that compared the one-stage versus the two-stage technique for creating a BB-AVF. Results Eight studies were included (849 patients with 859 fistulas), 366 created using a one-stage technique, while 493 in a two-stage approach. There was no statistically significant difference between the two groups in the rate of successful maturation (Pooled risk ratio = 0.95 [0.82, 1.11], P = 0.53). Similarly, the incidence of postoperative haematoma (Pooled risk ratio = 0.73 [0.34, 1.58], P = 0.43), wound infection (Pooled risk ratio = 0.77 [0.35, 1.68], P = 0.51) and steal syndrome (Pooled risk ratio = 0.65 [0.27, 1.53], P = 0.32) were statistically comparable. Conclusion Although more studies seem to favour the two-stage BVT approach, evidence in the literature is not sufficient to draw a final conclusion as the difference between the one-stage and the two-stage approaches for creation of a BB-AVF is not statistically significant in terms of the overall maturation rate and postoperative complications. Patency rates (primary, assisted primary and secondary) were comparable in the majority of studies. Large randomised properly conducted trials with superior methodology and adequate sub-group analysis are needed before making a final recommendation.

Objective: To review the management and the cost of leg ulcers. Design: Cross-sectional survey based on a questionnaire completed by healthcare workers caring for patients with leg ulcers in a defined population. Setting: The Mid-Western Health Board area in Ireland with a population of 317069. Patients: All patients receiving healthcare for active leg ulceration. Results: Leg ulcers were recorded for 389 individuals and public health nurses primarily provided care (n = 283). Patients had open ulcers for a median period of 8 months (interquartile range: 3 months — 2 years) with almost half (n = 181) reporting previous episodes of ulceration. Fifty different dressing products were used to treat leg ulcers in the region. Only 52.2% (203/389) of patients had the aetiology of their leg ulcers properly investigated and evidence-based care was generally apparent in this group. Otherwise, care appeared haphazard and at times inappropriate. The estimated annual direct cost of dressing leg ulcers was £585 660. Conclusion: A regional strategy for managing leg ulcers needs to be clarified and implemented if practitioners are to incorporate evidence-based care into routine work.

Introduction Radiation arteritis following neck irradiation as a treatment for head and neck malignancy has been well documented. The long-term sequelae of radiation exposure of the carotid arteries may take years to manifest clinically, and extra-cranial carotid artery (ECCA) stenosis is a well-recognised vascular complication. These carotid lesions should not be regarded as benign and should be treated in the same manner as standard carotid stenosis. Previous studies have noted increased cerebrovascular events such as stroke in this cohort of patients because of high-grade symptomatic carotid stenosis resulting in emboli. Aim To evaluate the effect of radiation therapy on ECCA atherosclerosis progression. Methods Online search for case-control studies and randomised clinical trials that reported on stenosis in extra-cranial carotid arteries in patients with neck malignancies who received radiation therapy (RT) comparing them to patients with neck malignancies who did not receive RT. Results Eight studies were included in the final analysis with total of 1070 patients – 596 received RT compared to 474 in the control group. There was statistically significant difference in overall stenosis rate (Pooled risk ratio = 4.38 [2.98, 6.45], P = 0.00001) and severe stenosis (Pooled risk ratio = 7.51 [2.78, 20.32], P

Background: The success of day case varicose vein surgery (DCWS) is traditionally denned clinically. However, the patient's perception of his or her own health prior to and following DCWS has not been established. This study prospectively measured the health status of patients with varicose veins, compared this with established population norms and assessed the impact of DCWS on both general health perception and varicose vein symptoms. Method: Fifty-three consecutive patients undergoing DCWS over a 9 month period were enrolled in this study. The SF-36 health assessment questionnaire and a vein-symptom-specific questionnaire were administered on the morning of surgery, 7 weeks postoperatively and 1 year following surgery. All patients in this study underwent a standard varicose vein operation and followed a standard protocol of postoperative management. Results: DCWS population health scores were lower than general population norms preoperatively. There was a significant improvement in the 7 week postoperative group in physical function and health perception (pConclusion: Varicose veins are associated with diminished well-being. Day case varicose vein surgery improves patient health perception and symptoms and is the treatment of choice for suitable patients with varicose veins.

Nurse led clinics in joint hospital and community settings are now being advocated as the most effective and economic way of dealing with leg ulcers. However, little information exists on the profile and outcome of patients with venous ulcers treated either in the community or in the hospital setting. Over a 2 yr period we assessed 134 patients with leg ulcers of whom 122 were deemed suitable for compression bandaging therapy. Thirty-four patients (28 per cent) were treated by the newly developed community service and 88 (72 per cent) were treated at the hospital clinic. Our overall healing rate for venous ulcers was 50 per cent @ 40 weeks. This probably reflects the long duration (48 per cent >2 yr) and large size (0.5–600 cm2) of ulcer prior to treatment. There were no differences in outcome between hospital (50 per cent @ 40 weeks) and community (35 per cent @ 40 weeks) based treatment (p>0.05). We conclude that most venous ulcers can be effectively treated in the community and resources should be provided to achieve this goal.

Human recombinant growth hormone (rhGH) has been shown to increase skeletal muscle protein synthesis and improve nitrogen balance in critically ill patients and those undergoing surgery. rhGH effects on hepatic protein turnover in critically ill patients are less clearly understood.To examine rhGH effects on hepatic acute phase protein responses and inflammatory cytokine release in patients undergoing major surgery.Prospective double blind randomised trial.Tertiary referral university teaching hospital.Patients undergoing elective abdominal aortic aneurysm repair.Patients received rhGH (Genotropin, 0.3 IU/kg per day, n = 8) or placebo (n = 10) for 6 days prior to surgery.Blood levels of growth hormone (GH) and insulin-like growth factor (IGF-1) were measured following rhGH treatment and C-reactive protein (CRP), serum amyloid A (SAA) and the cytokines interleukin-6 (IL-6) and the IL-1 receptor antagonist (IL-1ra) were measured for up to 24 h following surgery. Significant increases in plasma rhGH (0.84 +/- 0.3, mean (sem) versus 52 +/- 20 mU/l, p0.0008) and IGF-1 levels (119 +/- 13 versus 644 +/- 110 ng/ml, p0.0001) were seen prior to surgery following rhGH administration. No differences in acute phase protein or cytokine levels were seen following surgery in patients receiving rhGH.These results indicate that pre-operative administration of rhGH does not alter acute phase protein or inflammatory cytokine release in response to major surgery.

Background The aims of this study were to evaluate the effects of aortic clamping and unclamping on neutrophil and monocyte activation and release of plasma mediators in 2() patients undergoing elective aortic aneurysm surgery, and to correlate these findings with pulmonary haemodynamics and gas exchange. Methods Simultaneous arterial and mixed venous samples were obtained during and after aortic damping and unclamping. Results Neutrophil respiratory burst activity in mixed venous samples increased significantly during the period of aortic clamping. An initial increase in neutrophil CD11b expression in venous blood 5 min after clamp removal was followed by a significant decrease in level of expression. Plasma tumour necrosis factor levels increased at the end of the cross-clamp period and reached a maximum 60 min following reperfusion. There was a significant and sustained rise in plasma thromboxane B 2 levels following clamp removal. This increase correlated with the development of increased pulmonary vascular resistance. Conclusion This study confirms the central role played by activated neutrophils in the early stages of reperfusion injury and also suggests a role for plasma mediators in mediating cardiopulmonary dysfunction during major vascular surgery.

Objective: To validate the usefulness of written information for patients with venous leg ulcers and test the hypothesis that patients who receive written information retain more knowledge than those who receive verbal information alone. Method: Twenty patients newly diagnosed with venous leg ulcers were recruited into this prospective trial. Patients were randomised either to the control group (given verbal information on their condition) or the intervention group (same verbal information and an information leaflet). The verbal information was in the same format as in the leaflet. Patients’ knowledge of the condition was ascertained at an initial interview and at follow-up four to six weeks later. Results: At follow-up both groups showed an overall improvement in knowledge, with no statistical difference between them. Conclusion: The results indicate there is limited value in providing information leaflets to this patient group, who were predominantly older patients with low levels of education. The relatively small sample size may explain the disappointing results. Further research may reveal a benefit of providing these leaflets to carers. Declaration of interest: None.

An 18-year-old man presented to the emergency department with an acutely swollen right upper limb having spent the previous day canoeing. Venography confirmed right subclavian venous thrombosis at middle one-third of right clavicle with no evidence of cervical rib or other structural abnormalities. Following heparinisation, catheter directed thrombolysis was performed which restored luminal flow. Postprocedure the patient developed spontaneous small-volume haemoperitoneum and acute renal failure. The patient was admitted to the intensive care unit for haemodialysis and supportive management. The patients’ renal function improved and he was discharged well following his 28th day of admission. Paget-Schroetter syndrome or effort thrombosis involves subclavian venous thrombosis associated with strenuous activity of upper extremities. In these cases, catheter directed thrombolysis with first rib resection provides greater patency rate than anticoagulation therapy alone. Acute kidney injury following mechanical thrombolysis is rarely reported in the literature.

The aim of this study was to determine whether glyceryl trinitrate (GTN) has a protective effect on neutrophil- mediated lung injury in a model of aortic occlusion (30 min) and reperfusion (120 min). Sprague-Dawley rats were randomized into control (n = 11), ischaemia-reperfusion (IR) (n = 12), and IR treated with GTN (2 μg kg−1 min−1) during reperfusion (n = 10). Myeloperoxidase (MPO) activity measured pulmonary neutrophil influx. Pulmonary endothelial permeability was measured by wet:dry weight ratio, bronchoalveolar lavage (BAL) protein and neutrophil counts. Neutrophil superoxide release was measured by flow cytometry in a further IR versus GTN experiment (n = 6 in each group). The significant increase in MPO activity produced by IR to a level of 7·99 units g−1 was prevented by GTN which reduced the level to 4·73 units g−1. The increase in pulmonary microvascular leakage after reperfusion was also prevented by GTN: BAL protein without GTN was 992 μg ml−1 and with GTN 579 μg ml−1; BAL neutrophil count without GTN was 3219 cells mm−3 and with GTN 820 cells mm−3; the wet:dry lung weight ratio without GTN was 3·8 and with GTN 3·3. Neutrophil superoxide release increased significantly after 40 min of reperfusion in the untreated IR group (P < 0·05). This increase was prevented in the GTN-treated group. GTN administration had no effect on plasma thromboxane production during revascularization. These data suggest that GTN administration during the reperfusion phase has the potential to decrease pulmonary microvascular injury.

Motivated by a renewed interest in homeownership, the U.S. Department of Housing and Urban Development developed techniques to study patterns of ownership. A baseline model is used to forecast homeownership in 2000 and then extended to illustrate how policy initiatives designed to overcome race‐and income‐based barriers to ownership could affect the national homeownership rate and the rates of ownership by specific subgroups. Another technique uses American Housing Survey data to estimate how these initiatives could affect household location and the choice of housing type. This article clearly demonstrates that even limited success in reducing race‐and income‐based disparities will result in a significant increase in the national homeownership rate and dramatic increases for subgroups, such as minorities, young households, and low‐income households, that have low rates of homeownership. Thus, these techniques affirm the importance of focusing on access and affordability.

Introduction With increasing numbers of patients diagnosed with ESRD, arteriovenous fistula (AVF) maturation has become a major factor in improving both dialysis related outcomes and quality of life of those patients. Compared to other types of access it has been established that a functional AVF access is the least likely to be associated with thrombosis, infection, hospital admissions, secondary interventions to maintain patency and death. Aim Study of demographic factors implicated in the functional maturation of arteriovenous fistulas. Also, to explore any possible association between preoperative haematological investigations and functional maturation. Methods We performed a retrospective chart review of all patients with ESRD who were referred to the vascular service in the University Hospital of Limerick for creation of vascular access for HD. We included patients with primary AVFs; and excluded those who underwent secondary procedures. Results Overall AVF functional maturation rate in our study was 53.7% (52/97). Female gender showed significant association with nonmaturation (P = 0.004) and was the only predictor for non-maturation in a logistic regression model (P = 0.011). Patients who had history of renal transplant (P = 0.036), had relatively lower haemoglobin levels (P = 0.01) and were on calcium channel blockers (P = 0.001) showed better functional maturation rates. Conclusion Female gender was found to be associated with functional non-maturation, while a history kidney transplant, calcium channel-blocker agents and low haemoglobin levels were all associated with successful functional maturation. In view of the conflicting evidence in the literature, large prospective multi-centre registry-based studies with well-defined outcomes are needed.

This study evaluated the effect of varying the synthesis of nitric oxide with sodium nitroprusside or N-nitro-L-arginine methyl ester (L-NAME) in a pancreatitis-lung injury model. Rats (n = 45) were randomized to control or caerulein-induced pancreatitis groups, treated with saline, sodium nitroprusside (0·4 μg/kg) or l-NAME (10 mg/kg). Myeloperoxidase activity was used as a measure of neutrophil infiltration. Wet to dry (W:D) lung weight and bronchoalveolar lavage (BAL) protein concentrations were used to assess vascular leakage. Pancreatitis was shown to induce pulmonary neutrophil influx: mean(s.e.m.) myeloperoxidase activity 6·79(0·5) units/g in caerulein-treated animals versus 2·08(0·5) units/g in controls (P < 0·001). Animals with pancreatitis showed increased microvascular leakage compared with controls (mean(s.e.m.) W:D lung weight 7·01(0·5) versus 2·85(0·2), P < 0·001; BAL protein concentration 2539(222) versus 347(32) μg/ml, P < 0·001). Compared with the saline-treated pancreatitis group, these changes were reduced by sodium nitroprusside (mean(s.e.m.) myeloperoxidase activity to 2·5(0·4) units/g, P < 0·001; W:D lung weight to 3·8(0·37), P < 0·001; BAL protein concentration 1389(182) μg/ml, P < 0·05). L-NAME exacerbated the pancreatitis-induced pulmonary oedema (W:D lung weight increased to 11·96(0·6), P < 0·001), protein leakage (BAL protein concentration rose to 3707(309) μg/ml, P < 0·05) and neutrophil infiltration (myeloperoxidase activity increased to 9·01(0·3) units/g, P < 0·05). These data suggest that, in vivo, nitric oxide inhibits pancreatitis-induced lung injury, possibly in part by inhibiting pulmonary neutrophil influx.

Purpose: This study was conducted to investigate the distribution of reflux in the veins adjacent to or within the venous ulcer (local) and to correlate it with the pattern of disease of the axial veins (all veins away from the ulcer area) of the affected limb. Methods: Forty-three ulcers in 34 legs of 33 patients were examined with color-flow duplex imaging. The veins in the area of the ulcer were scanned with a sterile technique. Results: In 17 legs (50%) there was documented past deep venous thrombosis. All of the 34 limbs had reflux in the superficial or deep axial veins either alone or in combination. Fifteen of these limbs (44%) also had perforating vein incompetence, but none had perforator incompetence alone. Six ulcers showed no evidence of reflux in the local veins when scanned through the ulcer bed despite the presence of reflux in the axial veins of the limb. In 13 limbs with 17 ulcers, either the superficial axial veins alone or the deep axial veins alone were affected (with or without associated perforator incompetence). Examination of the local veins associated with these 17 ulcers revealed a similar pattern of reflux to that seen in the axial veins in 13 cases, with the remaining 4 ulcers showing no local venous abnormality. The pattern of reflux was less predictable at the local ulcer level in limbs where both superficial and deep venous incompetence coexisted in the axial veins. Only 7 of the 26 ulcers (27%) in these limbs had similar evidence of combined superficial and deep reflux in the local ulcer veins, whereas 10 ulcers (39%) were associated with local reflux in the superficial or deep veins alone. Conclusions: These data show that 86% (37/43) of the ulcers had some degree of reflux in the local area, the pattern of which may differ from the axial vein disease. Treatment of the local hemodynamic abnormalities may be an important factor in the healing of the ulcers and in the prevention of their recurrence. (J VASC SURG 1995;22:45-50.)

Iliac arteriovenous (AV) fistula is rare after lumbar disk surgery. Traditionally, open repair through the arterial lumen was performed. We report endovascular exclusion of an iliac AV fistula in a 41-year-old woman 8 years after lumbar diskectomy. An angiogram showed an AV fistula connecting the right common iliac artery and vein. This was repaired with placement of two covered wall stents in the right common artery and external iliac artery, and embolization of the right internal iliac artery. Contrast medium-enhanced computed tomography scan at 5 months confirmed elimination of the AV fistula and right iliac artery patency. This technique should be considered in management of iliac AV fistulas. (J Vasc Surg 2003;37:1091-3.)

Abdominal aortic aneurysm (AAA) is a common disease of the elderly exhibiting a complex aetiology. In a survey of 82 Irish aneurysm patients, compared to 79 age- and sex-matched control subjects, we have investigated a number of potential biochemical and molecular genetic markers which are amenable to analysis from blood specimens and which might have predictive value for AAA. No significant differences were observed between patients and control subjects in relation to serum lipids, leucocyte elastase activity or serum alpha 1-antitrypsin concentration. We have used the polymerase chain reaction to screen the patient and control groups in search of disease-associated genetic variation on chromosome 16, particularly in the region of the Cholesteryl Ester Transfer Protein (CETP) gene. Although variation in allele frequencies was detected between patients and controls at the four marker loci studied, no significant gene-disease associations were detected. The absence of gene-disease associations in our study may indicate that the genetic component in the aetiology of AAA in Ireland differs from that in the UK. Alternatively, it may indicate that the high degree of polymorphism at microsatellite loci may make them unsuitable as markers for the study of gene-disease associations in moderately sized populations. We therefore conclude that the biochemical and molecular genetic markers which we have examined are of no predictive value, and that ultrasonography remains the screening modality of choice for abdominal aortic aneurysm.

To determine whether mechanical bowel preparation influences the incidence of anastomotic dehiscence following colorectal surgery, 186 patients undergoing elective left colonic or rectal resection were randomized before surgery to bowel preparation (n = 89) or no bowel preparation (n = 97). Surgical technique was standardized and no patient had a defunctioning colostomy. Seventeen patients were excluded (seven with preparation, ten without). Indications for surgery in the remaining 169 patients were carcinoma (133 patients), diverticular disease (26), inflammatory bowel disease (six) and miscellaneous conditions (four). Operations performed were left colonic resection or reversal of Hartmann's procedure (26 with preparation, 28 without) and anterior resection (56 versus 59). The overall morbidity rate (18 per cent) was similar in the two groups. All seven clinical anastomotic leaks occurred after low anterior resection, in three of the 39 patients who had undergone bowel preparation and four of the 36 who had not (P > 0·9). Two deaths occurred, both of patients who had received bowel preparation, one being secondary to anastomotic leakage. Bowel preparation does not influence outcome after elective colorectal surgery.

Equal access to the abdominal aorta can be attained through midline and transverse abdominal incisions. The surgical literature suggests that transverse incisions cause less postoperative pain and morbidity. Fifty patients (10 females and 40 males, mean age 67 years) undergoing abdominal aortic surgery were randomised to a midline (n = 25) or transverse (n = 25) incision. All patients were evaluated preoperatively and postoperatively for seven days. Changes in pulmonary function (FVC and FEV1), time to open and close the incision, analgesia used (morphine mg/kg/h), clinical or X-ray evidence of chest infection, and the duration of ICU stay were recorded. In the transverse group there was a reduction in the incidence of chest complications (20% vs. 28%, p = ns) and these incisions took longer to open (13.9 +/- 4.6 vs. 9.9 +/- 5.1, p0.05), but overall there was no significant difference between any other parameter in the two groups. Our results show no statistically significant difference in morbidity or analgesia consumption following transverse or midline abdominal incisions and we conclude that the type of incision used can be left to the surgeon's preference.

Maintaining vascular access (VA) patency continues to be the greatest challenge for dialysis patients. VA dysfunction, primarily due to venous neointimal hyperplasia development and stenotic lesion formation, is mainly attributed to complex hemodynamics within the arteriovenous fistula (AVF). The effect of VA creation and the subsequent geometrical remodeling on the hemodynamics and shear forces within a mature patient-specific AVF is investigated. A 3D reconstructed geometry of a healthy vein and a fully mature patient-specific AVF was developed from a series of 2D magnetic resonance image scans. A previously validated thresholding technique for region segmentation and lumen cross section contour creation was conducted in MIMICS 10.01, allowing for the creation of a 3D reconstructed geometry. The healthy vein and AVF computational models were built, subdivided, and meshed in GAMBIT 2.3. The computational fluid dynamic (CFD) code FLUENT 6.3.2 (Fluent Inc., Lebanon, NH) was employed as the finite volume solver to determine the hemodynamics and shear forces within the healthy vein and patient-specific AVF. Geometrical alterations were evaluated and a CFD analysis was conducted. Substantial geometrical remodeling was observed, following VA creation with an increase in cross-sectional area, out of plane curvature (maximum angle of curvature in AVF=30 deg), and angle of blood flow entry. The mean flow velocity entering the vein of the AVF is dramatically increased. These factors result in complex three-dimensional hemodynamics within VA junction (VAJ) and efferent vein of the AVF. Complex flow patterns were observed and the maximum and mean wall shear stress (WSS) magnitudes are significantly elevated. Flow reversal was found within the VAJ and efferent vein. Extensive geometrical remodeling during AVF maturation does not restore physiological hemodynamics to the VAJ and venous conduit of the AVF, and high WSS and WSS gradients, and flow reversal persist. It is theorized that the vessel remodelling and the continued non-physiological hemodynamics within the AVF compound to result in stenotic lesion development.