Palaeoparasitology confirms Early Lapita evidence of pig and dog at Kamgot, Bismarck Archipelago.

Little is known about helminth parasites of the Bismarck Archipelago, in either archaeological or modern contexts. This study presents a parasitological analysis of soil samples from Early Lapita habitation layers at Kamgot (3300-3000 BP). Evidence for the presence of pigs and dogs and the timing of their arrival in Early Lapita contexts have been contested in the literature. The finding of parasite eggs in samples from Kamgot supports the presence of pigs and dogs at the site. Six types of helminth eggs were identified: pig nematode Trichuris suis, dog nematode Toxocara canis, and cestode Dipylidium caninum, as well as two unknown trematodes and a possible anoplocephalid cestode, thereby indicating the local presence of other mammals or birds. This study represents the first confirmed record of ancient helminth parasites in tropical Oceania.

The cestode Stringopotaenia psittacea (Fuhrmann, 1904) (Cestoda: Anoplocephalidae) from a critically endangered New Zealand bird: New evidence from ancient coprolites.

New Zealand's kakapo parrot, once widespread, is now critically endangered due to habitat loss and introduced mammalian predators. Prior to major population decline, a unique kakapo cestode, Stringopotaenia psittacea, was found in the 1880s and first described in 1904. Here we report the discovery of eggs of this cestode in kakapo coprolites of pre-human settlement age from the Honeycomb Hill cave system, north-west Nelson. Analysis of 52 samples, including coprolites of post-human settlement age, from nine sites within six South Island locations across a wide geographic range, yielded only eight infected samples in this single cave system. Results suggest that prior to human settlement, S.psittacea was not widespread within and between kakapo populations, in marked contrast to other parasite types of the extinct moa spp. Intense management of the last remaining kakapo has endangered or possibly caused the extinction of this cestode. This is the first confirmed record of S.psittacea since its discovery in 1884.

Aggregated α-synuclein and complex I deficiency: exploration of their relationship in differentiated neurons.

α-Synuclein becomes misfolded and aggregated upon damage by various factors, for example, by reactive oxygen species. These aggregated forms have been proposed to have differential toxicities and their interaction with mitochondria may cause dysfunction within this organelle that contributes to the pathogenesis of Parkinson's disease (PD). In particular, the association of α-synuclein with mitochondria occurs through interaction with mitochondrial complex I and importantly defects of this protein have been linked to the pathogenesis of PD. Therefore, we investigated the relationship between aggregated α-synuclein and mitochondrial dysfunction, and the consequences of this interaction on cell survival. To do this, we studied the effects of α-synuclein on cybrid cell lines harbouring mutations in either mitochondrial complex I or IV. We found that aggregated α-synuclein inhibited mitochondrial complex I in control and complex IV-deficient cells. However, when aggregated α-synuclein was applied to complex I-deficient cells, there was no additional inhibition of mitochondrial function or increase in cell death. This would suggest that as complex I-deficient cells have already adapted to their mitochondrial defect, the subsequent toxic effects of α-synuclein are reduced.

Current practice of carotid endarterectomy in the UK.

BACKGROUND: Carotid endarterectomy (CEA) reduces the risk of stroke in patients with internal carotid stenosis of 50-99 per cent. This study assessed national surgical practice through audit of CEA procedures and outcomes. METHODS: This was a prospective cohort study of UK surgeons performing CEA, using clinical audit data collected continuously and reported in two rounds, covering operations from December 2005 to December 2007, and January 2008 to September 2009. RESULTS: Some 352 (92·6 per cent) of 380 eligible surgeons contributed data. Of 19,935 CEAs recorded by Hospital Episode Statistics, 12,496 (62·7 per cent) were submitted to the audit. A total of 10,452 operations (83·6 per cent) were performed for symptomatic carotid stenosis; among these patients, the presenting symptoms were transient ischaemic attack in 4507 (43·1 per cent), stroke in 3572 (34·2 per cent) and amaurosis fugax in 1965 (18·8 per cent). The 30-day mortality rate was 1·0 per cent (48 of 4944) in round 1 and 0·8 per cent (50 of 6151) in round 2; the most common cause of death was stroke, followed by myocardial infarction. The rate of death or stroke within 30 days of surgery was 2·5 per cent (124 of 4918) in round 1 and 1·8 per cent (112 of 6135) in round 2. CONCLUSION: CEA is performed less commonly in the UK than in other European countries and probably remains underutilized in the prevention of stroke. Increasing the number of CEAs done in the UK, together with reducing surgical waiting times, could prevent more strokes.

Outcome and safety of Aorfix™ stent graft in highly angulated necks - a prospective observational study (arbiter 2).

OBJECTIVES: Severe neck angulation is associated with poor outcome following endovascular aneurysm repair. The aim was to study the safety and early outcome of patients with infrarenal aortic aneurysms with severe neck angulation (60-90°) treated with the Aorfix™ endovascular stent graft. DESIGN/METHODS: This was a non-randomized prospective observational study of 30 patients with infra-renal abdominal aortic aneurysms with highly angulated necks. Outcomes were primary technical success, 30 day and short term (30 days-6 months) clinical success and other patient morbidity at 30 days. RESULTS: Median neck angulation was 81.2°. Initial technical success was 93.3% (n = 28) with 2 stents deployed too low. Intra-operatively 3 patients initially had type I endoleaks, but all were resolved by ballooning. 30 day clinical success was 96.7%: there were no type I or type III endoleaks observed, and no reports of graft thrombosis or migration. Early clinical failure was accounted for by one perioperative death (3% mortality). No aneurysm-related interventions were required during follow-up. At 6 months two patients were reported as having type I endoleaks, although both sacs have reduced in size. Neither has required intervention. No patient has died due to aneurysm rupture or required removal of the endograft. CONCLUSION: The results of this study support the continued application of the Aorfix™ graft to the highly angulated neck.

Use of the AorfixTM stent graft in patients with tortuous iliac anatomy.

AIM: Iliac limb occlusion following endovascular repair (EVAR) may result in limb threatening acute ischemia. The incidence is reported at up to 10% and is known to be influenced by iliac angulation and kinking of the stent graft. The aim of this study was to evaluate the performance of the AorfixTM graft in tortuous iliac anatomy and examine the impact of the graft on the rate of iliac limb thrombosis following EVAR in a single UK centre METHODS: We performed a retrospective review of all EVAR performed from May 1998 to May 2010. From November 2007, patients with highly angulated iliac anatomy were treated with the AorfixTM(Lombard) stent graft, or when a ZenithTM(Cook) main body was chosen, the AorfixTM iliac limbs were used with the ZenithTM(Cook) device. We compared the rate of iliac limb occlusions before (group 1) and after (group 2) the adoption of this policy. RESULTS: Two hundred and sixty seven patients underwent EVAR (group 1 n=129; group 2 n=138). In group 1, eight patients had a unilateral iliac limb occlusion (6.2%). Six of the patients had >90 degrees iliac angulation, one had an unrecognised limb stenosis, and one patient had the stent landed in the external iliac. In group 2 there were no limb occlusions. Of the 138 patients, 25 had iliac angulation of >90 degrees . Of these 25, eighteen were treated with the AorfixTM stent graft system because of iliac angulation, and 7 were treated with AorfixTM legs and ZenithTM bodies. CONCLUSION: The rate of early iliac limb occlusion following EVAR in patients with angulated iliac anatomy can be substantially reduced by using the flexible Aorfix stent graft system.

The advantages of Aorfix for endovascular repair of abdominal aortic aneurysm.

AIM: The aim of this paper was to review the use of the Aorfix stent-graft in the endovascular repair of abdominal aortic aneurysms and to report the early results of a multicenter study conducted on patients receiving this endograft. METHODS: A retrospective review of 40 patients having the Aorfix stent-grafts for their aneurysm repair was undertaken at two centers. Patient notes and imaging findings were used to identify technical success, 30 day mortality, rupture rates during follow-up, postoperative complications including endoleaks, graft migration and any secondary interventions. RESULTS: All patients were treated successfully. Four patients required the use of proximal extensions due to severe neck angulation. There were neither deaths nor secondary interventions in the follow-up period. No incidence of graft migration or endoleaks was identified at 12 months after the procedure. CONCLUSIONS: Early data with the Aorfix stent-graft shows favorable results. The device's flexible design allows safe and accurate aneurysm sac exclusion in patients with highly challenging anatomy. This is likely to increase the number of patients considered suitable for endovascular aneurysm repair, who were previously excluded from this type of treatment and also reduce the levels of endoleaks.

General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial.

BACKGROUND: The effect of carotid endarterectomy in lowering the risk of stroke ipsilateral to severe atherosclerotic carotid-artery stenosis is offset by complications during or soon after surgery. We compared surgery under general anaesthesia with that under local anaesthesia because prediction and avoidance of perioperative strokes might be easier under local anaesthesia than under general anaesthesia. METHODS: We undertook a parallel group, multicentre, randomised controlled trial of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries. Participants were randomly assigned to surgery under general (n=1753) or local (n=1773) anaesthesia between June, 1999 and October, 2007. The primary outcome was the proportion of patients with stroke (including retinal infarction), myocardial infarction, or death between randomisation and 30 days after surgery. Analysis was by intention to treat. The trial is registered with Current Control Trials number ISRCTN00525237. FINDINGS: A primary outcome occurred in 84 (4.8%) patients assigned to surgery under general anaesthesia and 80 (4.5%) of those assigned to surgery under local anaesthesia; three events per 1000 treated were prevented with local anaesthesia (95% CI -11 to 17; risk ratio [RR] 0.94 [95% CI 0.70 to 1.27]). The two groups did not significantly differ for quality of life, length of hospital stay, or the primary outcome in the prespecified subgroups of age, contralateral carotid occlusion, and baseline surgical risk. INTERPRETATION: We have not shown a definite difference in outcomes between general and local anaesthesia for carotid surgery. The anaesthetist and surgeon, in consultation with the patient, should decide which anaesthetic technique to use on an individual basis. FUNDING: The Health Foundation (UK) and European Society of Vascular Surgery.

Uncomplicated varicose vein surgery in the UK--a postcode lottery?

INTRODUCTION: Recent research confirms that uncomplicated varicose vein surgery provides significant benefits in terms of quality of life compared to conservative treatment at a relatively small cost. There appear to be major variations in indications for treating varicose veins across the UK and this seems to be based mainly on financial restraint imposed by local Primary Care Trusts (PCTs). This survey was aimed at quantifying this variation. MATERIALS AND METHODS: An E-mail questionnaire was sent to 245 surgical members of the Vascular Society of Great Britain and Ireland across the UK. The main questions asked were aimed at finding out whether surgeons were having any restrictions imposed on them by their local PCTs with regard to treatment of varicose veins. RESULTS: A total of 109 surgeons replied (44% response rate). Of these, 64% of surgeons had restrictions set upon them by their local PCTs; however, 62% of surgeons under restrictions still offered surgery for symptomatic uncomplicated varicose veins. Restrictions varied from 100% to 0% across different regions in the UK. CONCLUSIONS: Many patients are denied surgical treatment for their symptomatic uncomplicated varicose veins according to where they live in the UK regardless of their symptoms.

Simulation and clinical practice: strengthening the relationship.

INTRODUCTION: This discussion paper argues for a creative synthesis between simulation and clinical practice, where an iterative process of continual interaction ensures that skills are learned and reinforced within the context of everyday professional life. BACKGROUND: Evidence is mounting that long-established approaches to surgical training are no longer acceptable in the current ethical and professional climate. This paper considers alternatives to the traditional approach of 'learning by doing' in a clinical context, focusing on recent developments in the technology of simulation and virtual reality. Clinical expertise is a complex phenomenon and no single theory can account for its acquisition. After a brief contextualising overview, Vygotsky's 'zone of proximal development' is proposed as a conceptual framework for task-based surgical learning that takes place within skills laboratories. The discussion is located within a wider context of educational theory, drawing on current thinking about situated learning and apprenticeship. The notion of 'legitimate peripheral participation' in a complex professional environment places technical skill alongside a range of other competencies that are necessary to safe practice. CONCLUSIONS: Simulation offers a safe environment within which learners can repeatedly practise a range of clinical skills without endangering patients. Comprehensive simulated environments allow a move away from isolated tasks to more complex clinical situations, recreating many of the challenges of real life. Such simulations, however, can operate in isolation from their clinical context, ignoring the learning needs of individuals within a real health care environment. To realise its full potential as a learning aid, simulation must be used alongside clinical practice and linked closely with it.

Patient satisfaction for carotid endarterectomy performed under local anaesthesia.

OBJECTIVES: To develop, validate and use a procedure specific questionnaire to evaluate patient experience and satisfaction following carotid endarterectomy (CEA) under either general (GA) or local anaesthesia (LA). METHODS: Twenty post-CEA patients were interviewed. Data were content analysed and recurrent themes used to generate the specific carotid endarterectomy experience questionnaire (CEA-EQ). The CEA-EQ consists of 15 pre-op and 13 postoperative questions. Validity was established by correlation with the FRS Patient Satisfaction with Surgical Services (SSSQ) and State form of the State Trait Anxiety Inventory (STAI-S) in 69 patients (35 LA, 34 GA). Subsequently 88 patients randomised to GA CEA and 88 to LA CEA received the CEA-EQ. A local anaesthetic intraoperative experience questionnaire (LA-EQ) was also developed and given to LA patients only. RESULTS: Validity was confirmed through significant correlations with the STAI-S (r=0.67, p<0.001) and the SSSQ (r=0.44, p<0.001). In the randomised prospective study response rates were greater than 90%. Overall experience and satisfaction with CEA was high. There was no statistically significant difference in anxiety, satisfaction or overall experience between anaesthetic techniques. LA CEA was associated with a significantly better perception of recovery. The majority of LA patients found the procedure acceptable. CONCLUSIONS: The CEA-EQ is a valid tool to assess qualitative aspects of CEA patient care. Overall satisfaction and experience with CEA is good and not related to anaesthetic technique. LA CEA is not associated with any increased anxiety, is tolerated by the majority of patients and is associated with a better perception of recovery.

Infrainguinal bypass graft patency and limb salvage rates in critical limb ischemia: influence of the mode of presentation.

Rest pain, ulceration, and gangrene are often considered together in studies describing outcomes in patients with critical limb ischemia. A retrospective analysis of prospectively collected data of 152 infrainguinal bypass grafts performed on 128 patients with chronic critical limb ischemia over a 6-year period was carried out. Grafts were classified according to the mode of presentation and were followed up by regular clinical and duplex examinations. Mean follow-up period was 29 months (range 12 to 60 months). Patients' demographics, risk factors, and graft characteristics were not statistically different between the groups. The 5-year cumulative primary patency rates were 33%, 52%, and 51% for gangrene, ulceration, and rest pain, respectively (p = 0.04). The 5-year cumulative primary assisted patency rates were 46%, 70%, and 72% for gangrene, ulceration, and rest pain, respectively (p = 0.01). The 5-year cumulative secondary patency rates were 48%, 76%, and 75% for gangrene, ulceration, and rest pain, respectively (p = 0.003). The 5-year cumulative limb salvage rates were 59%, 87%, and 83%, for gangrene, ulceration, and rest pain, respectively (p = 0.01). Gangrene is a distinct subcategory of critical limb ischemia with a worse prognosis than ulceration and rest pain and should be classified as such when reporting results of infrainguinal bypass grafts.

Vascular training in the U.K.: femorodistal bypass, an index procedure?

OBJECTIVES: femorodistal bypass operation is one of three index procedures for vascular training in the U.K. Our aim is to determine the suitability of femorodistal bypass to be considered as an index procedure in the era of increasing utilisation of percutaneous transluminal angioplasty (PTA). DESIGN: a retrospective analysis of prospectively collected data. PATIENTS AND METHODS: a total of 526 patients with 608 chronic critically ischaemic limbs admitted to the vascular unit, at the Royal United Hospital, Bath, between January 1994 and December 1999 was included in the study. RESULTS: revascularisation either by PTA, bypass surgery or a combination of both was attempted in 524 limbs (86%). Crural procedures were carried out on 71 limbs (14% of revascularised limbs). Primary crural procedures included 34 PTAs as a sole treatment (48%), and 37 femorodistal bypass operations (52%). CONCLUSIONS: during a 6-year period only 37 primary femorodistal bypass operations were performed in a unit which aggressively treats CLI. PTA is the initial step and increasingly the sole treatment for critical limb ischaemia (CLI), including distal lesions. We question the rationale of including an uncommon operation as a vascular training index procedure.

Physiological advantages of cerebral blood flow during carotid endarterectomy under local anaesthesia. A randomised clinical trial.

OBJECTIVE: to examine the effects of type of anaesthesia on cerebral blood flow during carotid endarterectomy (CEA). DESIGN: prospective randomised study. METHODS: thirty-four CEA procedures under local anaesthesia (LA) are compared to 33 procedures under general anaesthesia (GA). Mean middle cerebral artery velocity (MCAV(mean)) was monitored using Transcranial Doppler (TCD) and mean arterial pressure (MAP) assessed by continuous intra-arterial blood pressure transducer. RESULTS: pre-op MCAV(mean) and MAP were similar in both groups. Pre-clamp MCAV(mean) was similar in both groups and did not differ from pre-op values. With carotid clamping the MCAV(mean) significantly dropped in both groups. The post-clamp MCAV(mean) was significantly less in the GA group (p < 0.05), and the percentage reduction in MCAV(mean) significantly more for GA procedures (p < 0.05). Pre-clamp MAP was significantly elevated in LA procedures and significantly lowered in GA procedures. Pre-clamp MAP was significant less for GA procedures (p < 0.001). Post clamp MAP did not differ from pre-clamp levels in either group. There was no correlation between MCAV(mean) and MAP. Complication rate, combined death/stroke rates were similar in each group. CONCLUSION: LA CEA is associated with better preservation of the ipsilateral cerebral circulation and increased tolerance of the effects of carotid clamping. Changes in MCAV(mean) cannot be explained by variations in blood pressure between the two techniques.

The role of pedometers in the assessment of intermittent claudication.

OBJECTIVES: to evaluate the role of pedometers in the assessment of patients with intermittent claudication by comparing them with treadmill testing, post-exercise ankle brachial pressure index (ABPI) and physical function questionnaires. PATIENTS AND METHODS: fifty patients with intermittent claudication were prospectively assessed by treadmill examination measuring maximum walking distance (MWD) and post-exercise ABPI. Three physical function questionnaires: (1) Medical Outcome Study Short Form-36 (MOS SF-36), Physical Function (PF). (2) MOS SF-36 Role limitation due to Physical Problems (RP). (3) Walking Impairment Questionnaire (WIQ) were completed. Pedometers were used for one week and the daily average number of steps taken by each patient recorded. Pedometers scores were compared with MWD, post-exercise ABPI and physical function questionnaires scores using Spearman correlation test. RESULTS: pedometers estimation of daily physical activity moderately correlated with MWD (Rho=0.35, p=0.01), post-exercise ABPI (Rho=0.35, p=0.01), MOS-SF 36 PF (Rho=0.31, p=0.02), MOS-SF RP (Rho=0.28, p=0.05) and with WIQ (Rho=0.42, p=0.003). CONCLUSIONS: they moderately correlate with treadmill testing, post-exercise ABPI, and with physical function questionnaires. Pedometers may provide a simple and cheap alternative for the assessment of physical and functional disability in intermittent claudication.

The increasing role of percutaneous transluminal angioplasty in the primary management of critical limb ischaemia.

OBJECTIVE: to review the current role and results of angioplasty in the management of critical limb ischaemia (CLI) in a single institution. METHODS: data on 526 patients with 608 ischaemic limbs, treated between January 1994 and December 1999 was collected prospectively and analysed retrospectively. Patients were divided into 3 groups according to the date of presentation: group 1 (1994-95), group 2 (1996-97) and group 3 (1998-99). The groups were comparable in terms of demographics, mode of presentation and level of disease. RESULTS: Revascularisation was attempted in 87%, 81% and 91% for groups 1, 2 and 3 respectively (NS). Primary percutaneous transluminal angioplasty (PTA) rates increased from 44% (1994-95) to 69% (1998-99) (p < 0.001), and surgical revascularisation rates decreased correspondingly (p<0.01). Overall cumulative patient survival and limb salvage rates were 82% and 89% for 1 year and 45% and 87% for 5 years, respectively. No statistically significant difference existed between the three groups regarding patient survival, limb salvage rates and mean hospital stay (19, 12 and 12 days, respectively). CONCLUSION: PTA is increasingly replacing bypass surgery in the treatment of CLI, without compromising patient survival or limb salvage rates.

Reintervention as a clinical trial endpoint after peripheral arterial bypass surgery.

BACKGROUND: Graft patency is usually the primary endpoint in studies of peripheral arterial bypass surgery, but gives only a limited indication of clinical outcome. The aim of this study was to evaluate reintervention as a study endpoint after femorodistal bypass surgery. METHODS: The database from a multicentre, prospectively planned study of 517 patients undergoing femorodistal bypass for severe ischaemia was used to investigate the predictive value of technical endpoints. Clinical symptoms, graft patency, vascular interventions and clinical outcomes were recorded for 12 months after operation. RESULTS: Complete follow-up data were obtained on 498 patients (96 per cent). Success in terms of patients' need for reintervention agreed with clinical outcome in 90 (95 per cent confidence interval (c.i.) 87-93) per cent of cases. Primary and secondary patency agreed with the clinical outcome in 80 (95 per cent c.i. 77-84) and 81 (95 per cent c.i. 78-85) per cent of patients respectively. However, the best agreement with clinical outcome was obtained from the composite endpoint of 'patient alive without reintervention': 92 (95 per cent c.i. 90-94) per cent. CONCLUSION: Recording the number of patients who did not need reintervention for 12 months after femorodistal bypass gave a more accurate assessment of the number with clinical improvement than was obtained by recording bypass graft patency. Inclusion of patient survival in a composite endpoint increased the clinical relevance of this endpoint in patients with severe ischaemia who had femorodistal bypass surgery.

Distortion of teatree stems by twine as a means to determine the number of years that the stems have been used to support cannabis plants.

In New Zealand, stems of teatree (Kunzea/Leptospermum) growing around illicit cannabis plots have been used to anchor lengths of twine running through the plots to hold cannabis plants upright. Forensic examinations of distortions of teatree stems caused by the twine have been carried out to determine when the twine had been first tied around the stems, in order to estimate the number of years that plots have been in operation. In this experiment, baling twine was tied around stems of a teatree (Kunzea ericoides) and the effect monitored for a period of three years. Varying degrees of stem distortion occurred during the first year, caused initially by expansion of callus (a wound tissue) rather than constriction of the growth (annual) rings of the xylem. Although this callus has a type of growth ring, these are not annual, therefore cannot be used to determine the number of years that stems have had twine attached. Xylem growth rings of the teatree in this experiment were not restricted until the third year. Distortion of teatree stems allows the determination of a minimum (not absolute) number of years that twine has been attached.

Pollen on grass clippings: putting the suspect at the scene of the crime.

In a case of alleged sexual assault, the pollen content of samples of grass clippings and soil from the suspect's clothing and shoes was compared to that of a sample of grass clippings from the alleged crime scene (a grassy area) to determine whether or not the suspect had been at the scene. The clothing and shoe samples showed a very strong correlation with each other and with the sample from the alleged crime scene in the combination of the different types of pollen present, very strongly supporting the contention that the suspect had been at the scene.

Patient and hospital benefits of local anaesthesia for carotid endarterectomy.

OBJECTIVES: this study reviews and compares carotid endarterectomy (CEA) performed under local anaesthesia (LA) with CEA performed under general anaesthesia (GA) in a single institution. METHODS: data were collected prospectively from 240 CEA procedures. 140 GA CEA procedures are compared to 100 LA CEA procedures in terms of outcome, operative techniques, complications, and length of stay. RESULTS: the groups were similar for age, gender distribution and preoperative risk factors. There were more asymptomatic patients in the LA group. There were no significant differences in death, stroke or death/stroke rate between the two techniques. LA CEA was associated with lower shunt rate (LA 13%, GA 50%, p < 0.001), lower incidence of intraoperative hypotension (LA 8%, GA 40%, p < 0.001), decreased hospital stay (median (IQ); LA 2 (1-2), GA 3 (1-4), and a cost saving of pound235 per CEA procedure. CONCLUSIONS: carotid endarterectomy can be performed safely under local anaesthesia with the advantage that LA CEA enables the surgeon to monitor and selectively shunt patients more accurately. In addition LA CEA is associated with a shorter hospital stay and important cost savings.