Over view of major traumatic injury in Australia--Implications for trauma system design.

BACKGROUND: Trauma registries are known to drive improvements and optimise trauma systems worldwide. This is the first reported comparison of the epidemiology and outcomes at major centres across Australia. METHODS: The Australian Trauma Registry was a collaboration of 26 major trauma centres across Australia at the time of this study and currently collects information on patients admitted to these centres who die after injury and/or sustain major trauma (Injury Severity Score (ISS) > 12). Data from 1 July 2016 to 30 June 2017 were analysed. Primary endpoints were risk adjusted length of stay and mortality (adjusted for age, cause of injury, arrival Glasgow coma scale (GCS), shock-index grouped in quartiles and ISS). RESULTS: There were 8423 patients from 24 centres included. The median age (IQR) was 48 (28-68) years. Median (IQR) ISS was 17 (14-25). There was a predominance of males (72%) apart from the extremes of age. Transport-related cases accounted for 45% of major trauma, followed by falls (35.1%). Patients took 1.42 (1.03-2.12) h to reach hospital and spent 7.10 (3.64-15.00) days in hospital. Risk adjusted length of stay and mortality did not differ significantly across sites. Primary endpoints across sites were also similar in paediatric and older adult (>65) age groups. CONCLUSION: Australia has the capability to identify national injury trends to target prevention and reduce the burden of injury. Quality of care following injury can now be benchmarked across Australia and with the planned enhancements to data collection and reporting, this will enable improved management of trauma victims.

[Anemia, a new severity factor in young infants with acute viral bronchiolitis?] / L'anémie, un nouveau facteur de sévérité de la bronchiolite aiguë du nourrisson ?

INTRODUCTION: The role of anemia is raised as a risk of low respiratory infection of the child, but there are no data on anemia as a severity factor in acute viral bronchiolitis (AVB) in infants. METHODS: All infants less than 16 weeks old admitted to Montpellier University Hospital from 2015/10/01 to 2016/04/01 for AVB were included in a retrospective observational study. The primary objective was to determine whether the hemoglobin (Hb) concentration on admission was an independent factor of clinical severity, judged by the modified Wood's clinical asthma score (m-WCAS). The secondary objective was to assess the impact of Hb level on the characteristics of hospitalization, including the type and duration of respiratory support. RESULTS: The m-WCAS was used at least once during hospitalization in 180 out of 220 patients (82%), making it possible to distinguish patients with mild AVB (maximum m-WCAS<2, n=81) from patients with severe AVB (maximum m-WCAS>2, n=99). A logistic regression model indicated that the Hb concentration, for every 1g/dL decrement, was an independent factor of AVB severity (OR 1.16 [1.03-1.29], P=0.026). A level under 10g/dL on admission was associated with a higher use of continuous positive airway pressure (P<0.001), as well as a longer duration of respiratory support (P=0.01). CONCLUSION: This study suggested that anemia may influence the clinical expression of AVB in young infants.

HOSPEX in the antipodes.

The Australian Army recently adopted the British concept of hospital exercise (HOSPEX) as a means of evaluating the capabilities of its deployable NATO Role 2E hospital, the 2nd General Health Battalion. The Australian approach to HOSPEX differs from the original UK model. This article describes the reasons why the Australian Army needed to adopt the HOSPEX concept, how it was adapted to suit local circumstances and how the concept may evolve to meet the needs of the wider Australian Defence Force and our allies.

The effect of diabetes mellitus on costs and length of stay in patients with peripheral arterial disease undergoing vascular surgery.

OBJECTIVE: To determine the impact of diabetes mellitus (DM) and other comorbidities on length of stay (LOS) and costs in patients with peripheral arterial disease (PAD) admitted to a vascular surgical unit. METHODS: A retrospective study was conducted between January 2011 and July 2012 at a tertiary referral hospital in Sydney. Demographic, laboratory, and operative data were obtained from the Australasian Vascular Audit database and hospital diagnostic-related group (DRG) reports. Patients with confirmed PAD with or without DM requiring hospital admission for a diagnosis of claudication, rest pain, ulcer/gangrene, and infection that required lower limb surgical intervention were included. Associations between LOS, surgical procedure, and DRG were explored. RESULTS: Five hundred and sixty-eight admissions (492 patients) were identified: 292 admissions with PAD and 276 admissions with PAD in conjunction with DM (PADDM). Mean LOS for patients with PAD was 10 ± 13.7 days compared with 15 ± 18.2 days for PADDM (p < .01; 95% confidence interval 2.7-8.0). LOS and costs were greatest in patients with PADDM undergoing major amputation (37 ± 13.7 days; US$42,236; p < .01). Analysis of variance indicated that the best predictors of LOS were the presence of DM, bypass surgery, amputation, chronic kidney disease (CKD) stage V, infection, and emergency admission. Over 18 months, the estimated total inpatient costs associated with lower limb intervention for PAD with and without DM amounted to US$7,598,597. People with DM incurred greater inpatient costs, averaging US$1,912 more per episode of admission and a total of US$528,029 over 18 months. CONCLUSION: The impact of diabetes as a comorbid condition in patients with PAD is significant, both clinically and economically. Factors that predict increased LOS in patients with PAD are DM, bypass surgery, amputation, CKD stage V, infection, and emergency admission.

Early carotid endarterectomy following thrombolysis in the hyperacute treatment of stroke.

BACKGROUND: Thrombolysis with intravenous recombinant tissue plasminogen activator improves the probability of complete neurological recovery if given promptly following the onset of acute ischaemic stroke. Carotid endarterectomy (CEA) can reduce the risk of further embolic stroke in selected patients and is most effective within 14 days of the incident event. The safety of surgery so soon after thrombolysis is unknown. The aim of this study was to report the immediate outcomes of this management strategy early in the unit experience and to encourage pooling of data, recognizing that this will be an uncommon procedure even in busy stoke units with an active lysis programme. METHODS: Data were extracted from two prospectively collected databases, and included patient demographics, type of stroke, type and timing of surgical procedure, and immediate outcome. On presentation with a stroke, all patients underwent urgent computed tomography (CT) of the brain. Those eligible received thrombolysis according to the unit protocol. They underwent CT angiography 24 h after thrombolysis and patients with a severe carotid stenosis had surgery. RESULTS: Ten of a cohort of 450 patients who had received lysis underwent CEA. Seven of these were women and eight of the procedures were carried out under local anaesthetic. Surgery was performed a median of 8 (range 2-23) days after the index event; there were no major complications. CONCLUSION: Few patients with acute stroke are eligible, but CEA performed soon after thrombolytic therapy for stroke appears to be safe.

Comparison of tumour-based (Petersen Index) and inflammation-based (Glasgow Prognostic Score) scoring systems in patients undergoing curative resection for colon cancer.

After resection, it is important to identify colon cancer patients, who are at a high risk of recurrence and who may benefit from adjuvant treatment. The Petersen Index (PI), a prognostic model based on pathological criteria is validated in Dukes' B and C disease. Similarly, the modified Glasgow Prognostic Score (mGPS) based on biochemical criteria has also been validated. This study compares both the scores in patients undergoing curative resection of colon cancer. A total of 244 patients underwent elective resection between 1997 and 2005. The PI was constructed from pathological reports; the mGPS was measured pre-operatively. The median follow-up was 67 months (minimum 36 months) during which 109 patients died; 68 of them from cancer. On multivariate analysis of age, Dukes' stage, PI and mGPS, age (hazard ratio, HR, 1.74, P=0.001), Dukes' stage (HR, 3.63, P<0.001), PI (HR, 2.05, P=0.010) and mGPS (HR, 2.34, P<0.001) were associated independently with cancer-specific survival. Three-year cancer-specific survival rates for Dukes' B patients with the low-risk PI were 98, 92 and 82% for the mGPS of 0, 1 and 2, respectively (P<0.05). The high-risk PI population is small, in particular for Dukes' B disease (9%). The mGPS further stratifies those patients classified as low risk by the PI. Combining both the scoring systems could identify patients who have undergone curative surgery but are at high-risk of cancer-related death, therefore guiding management and trial stratification.

Effect of intraoperative fluid optimisation on renal function in patients undergoing emergency abdominal surgery: a randomised controlled pilot study (ISRCTN 11799696).

BACKGROUND: Emergency abdominal surgery carries a high risk of postoperative morbidity and mortality. Goal directed therapy has been advocated to improve outcome in high-risk surgery. The aim of the present pilot study was to examine the effect of goal directed therapy using fluid alone on postoperative renal function and organ failure score in patients undergoing emergency abdominal surgery. METHODS: This prospective randomised pilot study included patients over the age of 50 undergoing emergency abdominal surgery. In the intervention group pulse pressure variation measurements were used to guide fluid boluses of 6% Hydroxyethylstarch 130/0.4. The control group received standard care. Serum urea, creatinine and cystatin C levels were measured prior to and at the end of surgery and postoperatively on day 1, day 3 and day 5. RESULTS: Thirty patients were recruited. One patient died prior to surgery and was excluded from the analysis. The intervention group received a median of 750 ml of hydroxyethylstarch. The peak values of postoperative urea were 6.9 (2.7-31.8) vs. 6.4 (3.5-11.5)mmol/l (p=0.425), creatinine 100 (60-300) vs. 85 (65-150) micromol/l (p=0.085) and cystatin C 1.09 (0.66-4.94) vs. 1.01 (0.33-2.29)mg/dl (p=0.352) in the control and intervention group, respectively. CONCLUSIONS: In the present pilot study replacing the identified fluid deficit was not associated with a change in renal function. These results do not preclude that goal directed therapy using fluid alone may have an effect on renal function but they would suggest that the effect size of fluid optimisation alone on renal function is small.

Assessment of the 16S-23S rDNA intergenic spacer region in Enterococcus spp. for microbial source tracking.

A new library-based microbial source tracking (MST) approach intended for initial application in the coastal waters of Virginia was evaluated. Host-origin isolates of Enterococcus spp. were collected from beaches and the surrounding tidewater region of Virginia and used to construct a library based on the pattern of DNA band lengths produced by the amplification of the 16S-23S rDNA intergenic spacer (IGS) region, and subsequent digestion with MboI. Initial results from small host-origin libraries (64 and 200 total isolates) with discriminant analysis (DA) and logistic regression (LR) yielded high average rates of correct classification (ARCC) for a four-source classification split (birds, dogs, sewage, and wildlife), with ARCCs ranging from 83 to 100%. However, the poor results obtained when classification was attempted on a non-library validation set (VS, ARCCs of 47 and 48%, respectively, using DA and LR) demonstrated that a library of 200 isolates was insufficient to adequately represent the diversity of the enterococci in the sampled region. An increase in the library size to 1029 total isolates was accompanied by a reduction in the ARCC of the library to 42.7% with DA and 45.7% with LR, plus similarly poor results obtained from the VS. The low correct classification rates generated by the larger known-source library were unsuitable for field application. Many reported MST methods have been based on results obtained using small host-origin libraries without external validation. Our results indicate that such an approach can be very misleading, and that larger libraries and external validation is essential for the confirmation of preliminary results.

Comparison of the prognostic value of selected markers of the systemic inflammatory response in patients with colorectal cancer.

There is increasing evidence that the presence of a systemic inflammatory response plays an important role in predicting survival in patients with colorectal cancer. However, it is not clear what components of the systemic inflammatory response best predict survival. The aim of the present study was to compare the prognostic value of an inflammation-based prognostic score (modified Glasgow Prognostic Score (Mgps) 0=C-reactive protein <10 mg l(-1), 1=C-reactive protein >10 mg l(-1), and 2=C-reactive protein >10 mg l(-1) and albumin<35 g l(-1)) with that of components of the white cell count (neutrophils, lymphocytes, monocytes and platelets using standard thresholds) in patients with colorectal cancer. Two patient groups were studied: 149 patients who underwent potentially curative resection for colorectal cancer and 84 patients who had synchronous unresectable liver metastases. In those patients who underwent potentially curative resection the minimum follow-up was 36 months and 20 patients died of their cancer. On multivariate survival analysis only TNM stage (HR 3.75, 95% CI 1.54-9.17, P=0.004), monocyte count (HR 3.79, 95% CI 1.29-11.12, P=0.015) and mGPS (HR 2.21, 95% CI 1.11-4.41, P=0.024) were independently associated with cancer-specific survival. In patients with synchronous unresectable liver metastases the minimum follow-up was 6 months and 71 patients died of their cancer. On multivariate survival analysis only single liver metastasis >5 cm (HR 1.78, 95% CI 0.99-3.21, P=0.054), extra-hepatic disease (HR 2.09, 95% CI 1.05-4.17, P=0.036), chemotherapy treatment (HR 2.40, 95% CI 1.82-3.17, P<0.001) and mGPS (HR 1.44, 95% CI 1.01-2.04, P=0.043) were independently associated with cancer-specific survival. In summary, markers of the systemic inflammatory response are associated with poor outcome in patients with either primary operable or synchronous unresectable colorectal cancer. An acute-phase protein-based prognostic score, the mGPS, appears to be a superior predictor of survival compared with the cellular components of the systemic inflammatory response.

Chyle leakage and early enteral feeding following pancreatico-duodenectomy: management options.

BACKGROUND: Chyle leaks are a rare complication following abdominal surgery. The aim of this study is to describe the management of chyle leaks following surgery for pancreatico-duodenal malignancy. METHODS: Data were collated from a consecutive series of 105 patients who had undergone a pancreatico-duodenectomy for malignancy. From this cohort, patients who developed significant chyle leaks, defined as drainage of more than 600 ml of amylase-poor chylous fluid per day, were identified and their management reviewed. RESULTS: A total of 7 (6.7%) patients with significant chyle leaks were identified. All but one of the chyle leaks were identified between the 5th and 9th post-operative day. Early restoration of enteral feeding appeared to increase the incidence of chyle leak. Six of the 7 patients were successfully treated conservatively with total parenteral nutrition and after a median of 7.5 days the chyle leak had resolved. One patient required a peritoneovenous shunt for chylous ascites. CONCLUSION: This study has described a high incidence of chyle leak among patients undergoing surgery for pancreatico-duodenal malignancy. Early introduction of enteral feed may encourage development. However, patients who develop an abdominal chyle leak remain clinically well and the leak can be managed relatively easily with parenteral nutrition.

Preoperative but not postoperative systemic inflammatory response correlates with survival in colorectal cancer.

BACKGROUND: The aim of the present study was to evaluate the relationship between the preoperative and postoperative systemic inflammatory response and survival in patients undergoing potentially curative resection for colorectal cancer. METHODS: One hundred and eighty patients with colorectal cancer were studied. Circulating concentrations of C-reactive protein (CRP) were measured before surgery and in the immediate postoperative period. RESULTS: The peak in CRP concentration occurred on day 2 (P < 0.001). During the course of the study 59 patients died, 30 from cancer and 29 from intercurrent disease. Day 2 CRP concentrations were dichotomized. In univariable analysis, advanced tumour node metastasis stage (P = 0.002), a raised preoperative CRP level (P < 0.001) and the presence of hypoalbuminaemia (P = 0.043) were associated with poorer cancer-specific survival. CONCLUSION: Preoperative but not postoperative CRP concentrations are associated with poor tumour-specific survival in patients undergoing potentially curative resection for colorectal cancer.

Urinary proteomic profiles distinguish between active and inactive lupus nephritis.

OBJECTIVES: Key aims of the treatment of lupus nephritis (LN) are to induce and maintain remission with minimal side effects. However, assessing ongoing renal inflammatory activity is poorly served by current diagnostic tests apart from renal biopsy, but frequent biopsies cannot be justified. Our long-term aim is to identify novel biomarkers from urinary protein profiles to improve diagnosis and monitoring of activity and response to therapy in LN. METHODS: We used surface enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF MS) to identify biomarkers able to discriminate between urine samples from patients with inactive (n= 49) and active (n= 26) LN. Discriminant function analysis was used to define the minimum number of proteins whose levels best distinguished between the two patient groups. Serial urines of six biopsied patients were studied prospectively, and multiple regression (MR) scores calculated. RESULTS: Proteins with masses of 3340 and 3980 distinguished active from inactive LN with 92% sensitivity and specificity of 92% each. The prospective study of the biopsied patients demonstrated that MR scores could predict both relapse and remission earlier than traditional clinical markers. CONCLUSIONS: SELDI-TOF MS identified potential biomarker profiles strongly associated with activity in LN. Identification of these proteins will allow us to devise specific assays to routinely monitor disease progression, and alter immunosuppressive drug regimens accordingly. These proteins may also play a critical role in the pathogenesis of glomerulonephritis, and could therefore provide targets for therapeutic intervention.

Fungal and plant gene expression during the colonization of cacao seedlings by endophytic isolates of four Trichoderma species.

Endophytic isolates of Trichoderma species are being considered as biocontrol agents for diseases of Theobroma cacao (cacao). Gene expression was studied during the interaction between cacao seedlings and four endophytic Trichoderma isolates, T. ovalisporum-DIS 70a, T. hamatum-DIS 219b, T. harzianum-DIS 219f, and Trichoderma sp.-DIS 172ai. Isolates DIS 70a, DIS 219b, and DIS 219f were mycoparasitic on the pathogen Moniliophthora roreri, and DIS 172ai produced metabolites that inhibited growth of M. roreri in culture. ESTs (116) responsive to endophytic colonization of cacao were identified using differential display and their expression analyzed using macroarrays. Nineteen cacao ESTs and 17 Trichoderma ESTs were chosen for real-time quantitative PCR analysis. Seven cacao ESTs were induced during colonization by the Trichoderma isolates. These included putative genes for ornithine decarboxylase (P1), GST-like proteins (P4), zinc finger protein (P13), wound-induced protein (P26), EF-calcium-binding protein (P29), carbohydrate oxidase (P59), and an unknown protein (U4). Two plant ESTs, extensin-like protein (P12) and major intrinsic protein (P31), were repressed due to colonization. The plant gene expression profile was dependent on the Trichoderma isolate colonizing the cacao seedling. The fungal ESTs induced in colonized cacao seedlings also varied with the Trichoderma isolate used. The most highly induced fungal ESTs were putative glucosyl hydrolase family 2 (F3), glucosyl hydrolase family 7 (F7), serine protease (F11), and alcohol oxidase (F19). The pattern of altered gene expression suggests a complex system of genetic cross talk occurs between the cacao tree and Trichoderma isolates during the establishment of the endophytic association.

The presence of a systemic inflammatory response predicts poorer survival in patients receiving adjuvant 5-FU chemotherapy following potentially curative resection for colorectal cancer.

There is increasing evidence that the presence of a systemic inflammatory response plays an important role in survival following curative resection for colorectal cancer. The present study evaluated the relationship between C-reactive protein concentrations and survival in a cohort of patients receiving adjuvant 5-fluorouracil (5-FU) chemotherapy following potentially curative resection for colorectal cancer. In all, 222 patients undergoing potentially curative resection for colorectal cancer were studied. Of these, 50 patients received adjuvant 5-FU-based chemotherapy. Circulating concentrations of C-reactive protein were measured prior to surgery. The minimum follow-up was 15 months; the median follow-up of the survivors was 38 months. During this period 61 patients died, 32 patients of their cancer and 29 of intercurrent disease. In those patients who did not receive adjuvant chemotherapy, age (P < 0.001), Dukes stage (P < 0.05) and an elevated C-reactive protein (P < 0.01) were significantly associated with survival. In those patients who did receive adjuvant chemotherapy, an elevated C-reactive protein concentration (P < 0.01) was significantly associated with survival. The presence of a systemic inflammatory response is an independent predictor of poor outcome in patients receiving adjuvant 5-FU-based chemotherapy following potentially curative resection for colorectal cancer.

Is the landmark technique safe for the insertion of subclavian venous lines?

BACKGROUND: The complications of central venous line insertion have been highlighted by the recent NICE report advising that ultrasound guidance should be used for central line insertion. METHODS: We report a prospective audit of the complications of subclavian vein central venous line insertion for parenteral nutrition over a five-year period when ultrasound guidance was not used. RESULTS: In total, 201 lines were inserted for parenteral nutrition into a subclavian vein. A single consultant surgeon inserted 120 of the lines and year five or six surgical registrars performed the other line insertions. Five pneumothoraces occurred in four patients who had subclavian lines inserted and a chest drain was required in three cases. Four line tips were found to be going upwards rather than into the superior vena cava. Misplacement was more common with right subclavian insertion. Inability to site the line at that attempt was associated with previous line insertion in four of six patients. CONCLUSION: A low complication rate can be achieved for central line insertion for parenteral nutrition. It is likely that this is due to the small number of experienced operators.

Carbon source utilization profiles as a method to identify sources of faecal pollution in water.

AIMS: Carbon source utilization profiles as a phenotypic fingerprinting methodology for determining sources of faecal pollution in water were evaluated. METHODS AND RESULTS: Three hundred and sixty-five Enterococcus isolates were collected from known faecal sources in four different geographical regions and were identified to species with the commercial Biolog system. Discriminant analysis (DA) was used to identify the substrate-containing wells that best classified the 365 isolates by source. By using 30 of the 95 wells for the analysis, the average rate of correct classification (ARCC) by source was 92.7% for a human vs non-human two-way classification when isolates from all regions were combined into one library. Corresponding ARCCs for other classification schemes were 81.9% for a four-way classification of human vs livestock vs wildlife vs domestic pets, and 85.7% for a three-way classification without human isolates. When three individual libraries were made based on classification of sources within Enterococcus species, the ARCC was 95.3% for the Ent. faecalis library, 95.8% for the Ent. gallinarum library and 94.7% for the Ent. mundtii library. Thirty Enterococcus isolates (unknown sources) were obtained from each of three stream sites where a specific source of pollution was apparent; 90.0% of the isolates from a human-suspected source were classified as human, 86.6% were classified as livestock from a livestock-suspected site, and 93.3% were classified as wildlife from a wildlife-suspected site. CONCLUSIONS: Phenotypic fingerprinting with carbon source utilization profiles provided levels of correct classification by sources from an Enterococcus library that were in the upper range of those reported in the literature. ARCCs for three Enterococcus species-specific libraries were very high and may be the best approach for further developing this concept and methodology. SIGNIFICANCE ANC IMPACT OF THE STUDY: The results, based on a modest Enterococcus library and a preliminary field validation test, demonstrated the potential for carbon source utilization profiles to be employed as a phenotypic method for determining sources of faecal pollution in water.

Military surgery in Rwanda.

BACKGROUND: In April of 1994, a vicious civil was erupted in Rwanda, with more than 500,000 people massacred by extremist militias. The second United Nations Assistance Mission in Rwanda (UNAMIR II) deployed in August 1994 to monitor the ceasefire, with an Australian Defence Force Contingent of Health Service Support consisting of staff for the UNAMIR Head-quarters, and the Australian Medical Support Force (AS MSF). METHODS: A retrospective audit was conducted of all operative surgery performed during the year-long deployment, in the AS MSF operating theatres. RESULTS: Twenty surgeons rotated through in 6-week intervals. A total of 750 operations were performed on 547 patients, of which 636 (84.8%) involved civilians. A total of 558 (74.4%) cases were the result of trauma both accidental (38.4%) and war related (36%). The mean age of patients was 21.7 years. The age distribution was skewed, with 289 (38.5%) cases being performed on children. General surgeons performed a wide range of surgery, covering the majority of surgical specialties. These included cardiothoracic, neurosurgical, vascular and paediatric cases. Orthopaedic surgeons dealt with amputations, debridements and skin grafting in addition to bony injuries and infections. Children formed a substantial number of those treated, and required surgery for war-related injuries significantly more often than adults. CONCLUSIONS: Surgeons involved in future peacekeeping missions should be aware of the broad variety of clinical problems encountered, and undertake refresher training in the sub-specialties. Children are at great risk of violence in war, and if a civilization can be judged by the protection it affords its helpless, the Rwandan genocide and ensuing civil war represents a horrific example of the opposite extreme.

Digestibility, apparent mineral absorption, and voluntary intake by horses fed alfalfa, tall fescue, and caucasian bluestem.

Alfalfa (Medicago sativa L.), low-endophyte (< 5%) tall fescue (Festuca arundinacea Schreb.), and caucasian bluestem (Bothriochloa caucasica [Trin.] C.E. Hubbard) were fed as chopped hay to six Arabian geldings (BW 441 kg; SE 2) in intake and digestibility experiments to determine nutritional value for horses at maintenance. Each experimental design was a replicated Latin square. Alfalfa was higher in DM and CP digestibility, IVDMD, apparent absorption of Ca, K, and S, and voluntary intake than the grasses (P < .05). Caucasian bluestem was higher in Zn but was lower in CP, TNC, Mg, P, K, S, and Cu concentrations than tall fescue. Crude protein digestibility and apparent absorption of Mg, K, and S were higher (P < .05) for tall fescue than for caucasian bluestem. Geldings fed alfalfa for ad libitum intake had higher serum concentrations of vitamin A, blood urea nitrogen, P, S, and Cu than geldings fed grass hays. Serum Zn was higher (P < .05), whole blood Se tended to be higher (P < .06), and BUN was lower (P < .05) in geldings fed caucasian bluestem than in those fed tall fescue. All forages met requirements for CP, Ca, Mg, K, and Fe when fed for ad libitum intake but were deficient in Cu for horses at maintenance. Caucasian bluestem was borderline in CP and was deficient in P but was the only forage that met the Zn requirement for the horses. Based on these results, caucasian bluestem could be a useful hay for horses but may require supplementation of CP and P.

No additional benefit from laser in balloon angioplasty of the superficial femoral artery.

OBJECTIVES: To evaluate the efficacy of the addition of plaque ablation by hot-tip laser to balloon angioplasty. DESIGN: Prospective randomised clinical trial. MATERIALS AND METHODS: Patients with either occlusion orf > 50% diameter stenosis less than 3 cm in length in the superficial femoral artery, and with two or three calf vessel run-off were eligible and randomised to receive either balloon angioplasty alone or with laser assistance. Treatment failure in follow-up was defined as reocclusion or recurrence of greater that 50% stenosis at the site of angioplasty. RESULTS: Ninety limbs (82 patients) were entered into the study. Forty-four patients had mild claudication, 32 more severe symptoms and 6 rest pain or ulceration. More patients with diabetes (5 of 5, p = 0.04, Fisher's exact test) and occlusions (16 of 22, p < 0.05, chi(2)) were randomised to the laser group. Initial technical success was obtained in all lesions. The median duration of follow-up was 1 year. Failure occurred in 40 limbs during follow-up. Three segments, all with initial occlusions and undergoing laser angioplasty re-occluded within 2 days, one requiring immediate thrombectomy. Another 20 limbs underwent further intervention. Overall success (+/- S.D.) (Kaplan-Meier) at 1 year was 67% (+/- 5%) and at 2 years 43% (+/- 7%). Only increased age, initial occlusion, female sex, and not smoking were significantly (p < 0.05, Cox's proportional hazards) associated with failure; on multivariate analysis, age and occlusion were the best independent predictors. There was no significant difference (p > 0.05) in outcome between limbs undergoing laser assisted balloon angioplasty and balloon alone either overall of within the stenosis or occlusion subgroups. CONCLUSIONS: This study found no significant benefit was gained by the addition of laser to balloon angioplasty and that the long term success was modest for lesions considered to be suitable for angioplasty.