Predictors of outcome of ruptured aortic aneurysms in a metropolitan hospital.

The mortality in patients presenting with ruptured abdominal aortic aneurysm remains high. In this study we aimed to assess the outcome and factors predicting the mortality in patients admitted to a teaching hospital with the diagnosis of ruptured abdominal aortic aneurysm. During the study period (July 2001 to July 2007) all patients admitted with a diagnosis of a ruptured abdominal aortic aneurysm were included. There was a total of 62 patients with a mean age of 76 years. The hospital mortality was 32.3% (20 patients). Twelve patients (19.4%) were discharged home, 25 patients (40.3%) were discharged to rehabilitation and five patients (8%) were discharged to other hospitals for further care. There was a significant difference between survivors and non-survivors in age, loss of consciousness at presentation and duration of hospital stay. Logistic regression analysis of these variables suggests the presence of chronic obstructive pulmonary disease (P=0.04, odds ratio 6.7, 95% confidence interval 1.1 to 41.3) and age (P=0.02, odds ratio 1.2, 95% confidence intervals 1.0 to 1.3) to be independently associated with mortality. These results compare favourably with published Australian as well as the international data.

Transcranial Doppler microembolus detection in the identification of patients at high risk of perioperative stroke.

OBJECTIVES: Perioperative ischaemic stroke is the leading cause of morbidity and mortality associated with carotid endarterectomy (CEA). The aim was to test the hypotheses that the detection of microembolic ultrasonic signals (MES) with transcranial Doppler ultrasound (TCD) during and after the operation may be of value in identifying patients at increased perioperative stroke risk. DESIGN: Open prospective case series. PATIENTS AND METHODS: Eighty-one consecutive patients undergoing CEA with TCD monitoring. Preoperative, intraoperative and interval postoperative TCD monitoring of the middle cerebral artery (MCA) ipsilateral to the operated carotid artery. On-line pre- and intraoperative MES counting and blinded off-line analysis of postoperative MES counts. End-points were any focal neurological deficit and death at 30 days postoperatively. RESULTS: MES were detected in 94% of patients intraoperatively and 71% of cases during the first postoperative hour. MES counts ranged from 0 to 25 per operative phase (range of median counts 0-8) and from 0 to 212 per hour postoperatively (range of median counts 0-4). Eight cases (10%) developed postoperative MES counts greater than 50/h. Five of these eight cases evolved ischaemic neurological deficits in the territory of the insonated MCA, indicating a strong association between frequent postoperative microembolism and the development of early cerebral ischaemia (chi 2 = 34.2, p < 0.0001). Intraoperative MES were not associated with clinical outcome measures. CONCLUSIONS: MES counts of greater than 50/h in the early postoperative phase of carotid endarterectomy are predictive of the development of ipsilateral focal cerebral ischaemia.

Impact of the New Deal on vascular surgical training.

The rapid development and technological advances in vascular surgery have provided the impetus for the establishment of dedicated pure vascular surgical services. It remains unclear whether all vascular surgery will be provided by such units in the future or whether several district general hospitals will combine resources and provide dedicated vascular on-call rotas between surgeons on separate sites. Training in vascular surgery is also changing rapidly. A modular training scheme encompassing three levels of training has been recommended (1). Some of the training will only be performed in large training units, but there remains a requirement for general surgeons to be exposed to some vascular surgery during their training. The "New Deal' for junior doctors has imposed limits on the amount of hours worked during a week. Junior doctors should not on average be contracted for more than 72 hours a week or work more than 56 (2). The maximum on-call rota which fulfils these criteria is a 1 in 4 on-call with no early starts, late finishes and no prospective cover. Allowing for holidays, study leave, early starts and late finishes a 1 in 5 or 1 in 6 rota system is required. Implementation of the Calman report in higher specialist training would reduce the time spent in training at high specialist level to perhaps five years. In a modular training programme in vascular surgery there may be as little as one year Level II training spent in vascular surgery or perhaps two years if the candidate opted to have vascular surgery as their only sub-specialty. In an attempt to assess the impact of the New Deal and the Calman report on vascular surgical training we have assessed the exposure to vascular surgical procedure of hypothetical trainees on a 1 in 6 rota.