The use of clopidogrel in carotid endarterectomy: an audit of current practice.

Clopidogrel is commonly encountered in patients presenting for carotid endarterectomy (CEA). Its use around this time is controversial and there is no randomized control trial data to determine best practice. Questionnaires were posted to all members of the Vascular Society investigating clopidogrel use at the time of CEA. 52% discontinue clopidogrel preoperatively, with 51% of those using no alternative and 49% replacing it with aspirin. Clopidogrel use is not related to the number of endarterectomies performed by each surgeon. There is no consensus on clopidogrel use during CEA. This highlights the need for quality prospective data on this subject.

Helicobacter pylori in renal transplant recipients.

An unselected group of 33 renal transplant recipients were examined by upper gastrointestinal endoscopy at between two and four months after transplantation. All abnormal lesions were documented and biopsied and, in addition, random biopsies were obtained from the gastric antrum and from the first part of the duodenum. The biopsies were examined and graded for gastritis and duodenitis and the presence of Helicobacter pylori was noted. Duodenitis was identified in 16 patients and gastritis in 10; four patients had a gastric ulcer. Helicobacter was identified in the gastric antrum of 16 patients (48%) and was strongly associated with symptomatic dyspepsia, with gastritis, and with peptic ulceration. There was no relationship between H pylori and prednisolone dose, serum cyclosporine levels, or renal function. H pylori was found to be common in the upper GI tract of renal transplant recipients and may explain the high prevalence of upper GI pathology in these patients. It is interesting to speculate that immunosuppression may contribute to this, although there is no direct evidence from this study to support this theory.

Peripheral arterial thrombosis related to commercial airline flights: another manifestation of the economy class syndrome.

Venous thromboembolism is a well recognised complication of air travel, particularly on long haul flights. This has been attributed to relative immobility in cramped surroundings and to dehydration secondary to alcohol consumption and low cabin humidity. Under these conditions thrombosis at other sites would be expected, and indeed myocardial ischaemia is the commonest emergency in commercial flights. Peripheral arterial thrombosis, however, is not reported, even in comprehensive reviews of flying related medical emergencies. We report on three patients who developed acute lower limb ischaemia following long haul air flights.

Late outcome of undersewing alone for gastric ulcer haemorrhage.

Between 1977 and 1988 22 patients requiring urgent surgery for bleeding gastric ulceration were managed by simple undersewing of the ulcer. Long-term follow-up of these patients was undertaken to determine the risk of recurrent gastric ulceration and further gastric ulcer haemorrhage. Two patients died in the immediate perioperative period leaving 20 patients available for long-term follow-up (mean 43.3 months). Three recurrent gastric ulcers were diagnosed, two of these presenting with haemorrhage. No patient presented with further gastric ulceration while on histamine (H2) receptor antagonist therapy. The long-term outcome of undersewing alone, when combined with maintenance H2-receptor antagonist therapy, is satisfactory in terms of low mortality and low risk of ulcer recurrence.

Percutaneous nephrostomy in the management of malignant ureteric obstruction.

A study was made of 16 patients who developed renal failure secondary to ureteric obstruction by tumour. All were managed by percutaneous nephrostomy inserted under local anaesthesia. The results in terms of recovery of renal function, subsequent management and long-term outcome are described.