Modified stent-assisted coil embolization technique to treat an internal iliac artery aneurysm.

Stent-assisted coil embolization is a well-described technique for the treatment of wide-necked intracranial aneurysms. We describe a modification of this technique used successfully to occlude a wide-necked internal iliac artery aneurysm.

Three-year audit and cost assessment of open abdominal aortic aneurysm repair in a district general hospital.

INTRODUCTION: The aims of this study were to audit the outcome of elective open abdominal aortic aneurysm (AAA) repair in a district general hospital, as well as investigate the true costs for this procedure in relation to the national tariff. PATIENTS AND METHODS: A database is maintained on AAA surgery in the trust. Data were supplemented by drawing information from blood bank and clinical notes. Patients with symptomatic or emergency aneurysms were excluded. Data from January 2005 to December 2007 were obtained on demographics, morbidity, 30-day mortality and blood usage. Costs were obtained from the trust finance department. RESULTS: Between January 2005 and December 2007, 79 elective AAA procedures were undertaken. Median age was 75 years (range, 52-85 years), median aneurysm size was 63 mm (range, 42-105 mm) and median ITU stay was 3 days (range, 1-41 days). Major morbidity rate was 20.3% (16 of 79 patients) and 30-day mortality overall was 5.1% (4 of 79 patients). Average cost per case was pound15,012.91 (range, pound4,040.03- pound82,158.00), when National Tariff is pound6,722.00 ( pound5,649.00 x local Market Forces Factor of 1.19). Loss per case for our trust was pound8,290.91 with a total annual loss of pound218,299.56. CONCLUSIONS: Morbidity and mortality in this district general hospital compare well with national studies; however, the total cost is far in excess of the national tariff.

Deep vein thrombosis prophylaxis protocol--needs active enforcement.

Each hospital department tends to have its own DVT prophylaxis protocol generally based on the recommendations of the THRIFT consensus group. This is developed to help the junior medical staff to prescribe the appropriate prophylaxis according to risk assessment. However, adherence to the protocol tends to be haphazard unless actively enforced. This study is aimed at determining whether active enforcement of the protocol improves the uptake of prophylaxis.

Tissue plasminogen activator production by monocytes in venous thrombolysis.

Laminated occlusive thrombus was induced in the rat inferior vena cava (IVC) by a distal stenosis and injection of thrombin. Immunocytochemistry was performed on serial cryostat sections of the thrombus for tissue plasminogen activator (tPA) and a variety of phenotype markers for mononuclear cells. There was little tPA in 2-day-old thrombus. However, tPA was present in significant quantities in 1- and 2-week-old thrombus. Most of the staining for tPA was associated with monocytes, which had infiltrated the thrombus in large numbers. No caval endothelium was seen in these sections. By 4 weeks, the IVC had re-canalized and new endothelium had formed; tPA staining was weakly positive in the endothelium and smooth muscle. In situ hybridization with a digoxigenin-labelled RNA probe confirmed the monocytes as the main source of tPA. This study shows that large numbers of infiltrating monocytes are present in venous thrombosis and that they are the main source of tPA.

The tissue plasminogen activator and urokinase response in vivo during natural resolution of venous thrombus.

PURPOSE: The aim of this study was to measure the distribution of endogenous plasminogen activators during thrombolysis with an endothelial-conserving model of laminated thrombosis. METHODS: Thrombi were raised in the inferior vena cava of rats with thrombin and flow reduction. The thrombi, adjacent vein wall, and distant veins (the superior vena cava) were removed at intervals from 1 hour to 21 days from formation and then cryohomogenized and assayed with specific bioimmunoassays for tissue-type (t-PA) and urokinase-type plasminogen activators (u-PA). RESULTS: The measured t-PA activity of the vein wall around the thrombus was reduced compared with the control inferior vena cava at 4 days. Both the u-PA and t-PA content of the thrombus increased progressively during thrombolysis. The t-PA activity increased significantly in the distant vein walls in the animals with thrombi. Immunocytochemistry and in situ hybridization localized the t-PA to a mononuclear cell infiltrate and showed up-regulation of mRNA for rat t-PA in these monocytes. CONCLUSIONS: The local plasminogen activator response was predominantly within the thrombus itself. Increased t-PA activity was additionally found in distant veins but was reduced in the vessel wall adjacent to the thrombus. This is the first report to show that u-PA activity is increased within organizing thrombus in vivo and that most of the t-PA activity is localized to a monocyte infiltrate.

The use of recombinant factor VIIa in a patient with acquired haemophilia A undergoing surgery.

An elderly woman with acquired haemophilia A secondary to a monoclonal gammopathy, required elective surgery for a parotid tumour but was unable to tolerate conventional treatment. Recombinant activated factor VII (rVIIa) was used successfully to cover a biopsy and then subsequent resection of the tumour. The use of rVIIa in the management of acquired inhibitors is discussed.

Venous ulceration in males with sex chromosome abnormalities.

Two patients with Klinefelter's syndrome and three with 47,XYY who had venous ulcers, and one patient with 47,XYY and a post thrombotic limb are described. Sex chromosome abnormalities should be suspected in tall males with leg ulcers, especially those who have no progeny and are relatively young. Venous ulcers may be more common in males with 47,XYY.

The response of the vessel wall to thrombosis: the in vivo study of venous thrombolysis.

The vessel wall is the site of synthesis and regulation of the fibrinolytic system, and this delicate process is overwhelmed by occlusive thrombosis in veins. The endothelium may or may not survive thrombus formation, but has strong powers of regeneration, and is subsequently vital to the process of recanalizing the vessel. The endogenous fibrinolytic response to venous thrombosis is not well delineated but appears to involve both the newly formed endothelium within and beneath the organizing thrombus, together with an increase in tissue plasminogen activator synthesis or storage in distant uninvolved veins. The further use of thrombus models in which the endothelium is not definitely damaged should enable greater understanding of its role. Immunocytochemistry and in situ hybridization may be helpful in defining some of the unanswered questions.

Epithelial markers in pancreatic carcinoma: immunoperoxidase localisation of DD9, CEA, EMA and CAM 5.2.

Paraffin wax embedded, formalin fixed sections of 22 adenocarcinomas of the exocrine pancreas were stained with four mouse monoclonal antibodies: DD9-E7, an antibody raised against a human pancreatic tumour xenograft; carcino-embryonic antigen (CEA); epithelial membrane antigen (EMA); and cytokeratin (CAM 5.2). An indirect immunoperoxidase technique without enzyme pre-digestion and an affinity-purified sheep anti-mouse peroxidase conjugate were used. All of the tumours were positive for DD9-E7, EMA, and CAM 5.2. Twenty out of 22 were focally positive for CEA and the staining was often weak. As all of these adenocarcinomas were DD9-E7 positive, absence of staining for DD9-E7 in a tumour makes the diagnosis of adenocarcinoma of the exocrine pancreas very unlikely, and this is of value in distinction from endocrine carcinomas with a marked acinar pattern. The weak CEA staining distinguished pancreatic carcinomas from colorectal tumours. Because the distribution of staining for EMA and CAM 5.2 was no different from that previously seen in adenocarcinomas from other sites, these markers are likely to be of limited value in the differential diagnosis of abdominal adenocarcinomas of uncertain origin.

Sutures for inguinal herniorrhaphy--a comparison of monofilaments with PTFE.

Polybutester (Novafil, Davis & Geck) and expanded polytetrafluoroethylene PTFE (Gore-tex, W L Gore) were compared with nylon (Ethilon, Ethicon UK) for elective inguinal herniorrhaphy. PTFE had the best handling characteristics, but is expensive, and increased wound sepsis attended its use. Polybutester had significantly better handling characteristics, and is an attractive alternative to nylon for hernia repair.

Late strut fracture in a Björk-Shiley valve prosthesis (current series).

Fracture of the short strut of the latest series of Björk-Shiley mitral valve prostheses occurred 12 months after implantation. The patient died despite emergency surgery to excise and replace the prosthesis. Björk-Shiley 29-33 mm valves with a 60 degree opening angle manufactured between February 1981 and March 1982 have a predicted strut fracture rate of 0.3% (three times greater than that of valves produced outside these dates). Unimplanted valves from this batch have now been recalled by the manufacturers.

Sigmoid volvulus: new thoughts on the epidemiology.

Sigmoid volvulus usually affects the elderly, but it is being increasingly described in a younger age group. In these patients the diagnosis is often delayed, due to a prolonged and intermittent history. Three patients, of 31,36, and 67 years, are described here, and they demonstrate an increased incidence within families, which has not been previously recognized. Awareness of this possibility may allow earlier diagnosis when investigating young patients with intermittent abdominal symptoms, whose relatives are known to be affected.

Periurethral enterobacterial carriage in pathogenesis of recurrent urinary infection.

Periurethral carriage rates of enterobacteria have been studied in 20 normal women, 34 patients between episodes of bacteriuria, 34 patients with the "urethral syndrome," and 15 asymptomatic abacteriuric patients with a previous history of frequency and dysuria.Over a six-week period no difference in the Escherichia coli carriage rate was shown between these four groups. The carriage of all enterobacteria was slightly but significantly (P <0.05) lower in normal women compared with the patient groups but no difference was observed between the latter. There was no difference in the recovery rate and carriage of individual E. coli serotypes between the four groups.It is concluded that the presence of enterobacteria or E. coli on the periurethral area is not the principal determinant factor in the pathogenesis of recurrent urinary tract infection or the urethral syndrome and that definition of carriage status is of little practical value in management.