Appearance of the Nellix endoprosthesis on postoperative imaging: implications for patient and device surveillance.

The Nellix stent graft has novel features that influence interpretation of imaging follow-up, in particular, the use of endobags that seal the aneurysm sac. The polymer within the endobags contains a small amount of contrast medium, which causes a predictable temporal change in appearances. Understanding of these features allows correct image evaluation. In this article, we review the appearance of Nellix on computed tomography, ultrasound, magnetic resonance imaging, and plain radiography. We describe the special considerations that are important to consider when reviewing imaging, including endobag position and seal, endobag configuration, endobag and polymer maturation, and endobag gas. Detection of complications is discussed, with suggestion of a follow-up protocol based on the authors' experience.

Endovascular aneurysm repair (EVAR) follow-up imaging: the assessment and treatment of common postoperative complications.

Endovascular abdominal aortic aneurysm repair (EVAR) is a well-established procedure, which has long-term mortality rates similar to that of open repair. It has the additional benefit of being less invasive, making it the favoured method of treating abdominal aortic aneurysms in elderly and high-risk patients with multiple co-morbidities. The main disadvantage of EVAR is the higher rate of re-intervention, due to device-related complications, including endoleaks, limb occlusion, stent migration, kinking, and infection. As a result lifelong surveillance is required. In order to avoid missing these complications, intricate knowledge of stent graft design, good-quality diagnostic ultrasound skills, multiplanar reformatting of CT images, and reproducible investigations are important. Most of these complications can be treated via an endovascular approach using cuff extensions, uncovered stents, coils, and liquid embolic agents. Open surgery is reserved for complex complications, where an endovascular approach is not feasible.

Infectious aortitis in a liver transplant recipient.

The development of an abdominal aortic aneurysm secondary to infectious aortitis following solid organ transplantation is a rare event that in the absence of surgical intervention, can lead to uncontrolled sepsis, catastrophic hemorrhage and death. Arterial allografts have been a viable surgical option for the past 30 years, although operative modalities have undergone a paradigm shift in recent years. We describe the first case in the literature of a liver transplant recipient who developed an infrarenal aortic aneurysm secondary to Salmonella bacteraemia, which was treated successfully with aortic allograft transplantation.

Patient-led training on patient safety: a pilot study to test the feasibility and acceptability of an educational intervention.

BACKGROUND: Training in patient safety is an important element of medical education. Most educational interventions on patient safety training adopt a 'health-professional lens' with limited consideration on the impact of safety lapses on the patient and their families and little or no involvement of patients in the design or delivery of the training. AIMS: This paper describes a pilot study to test the feasibility and acceptability of implementing a patient-led educational intervention to facilitate safety training amongst newly qualified doctors. METHOD: Patients and/or carers who had experienced harm during their care shared narratives of their stories with trainees; this was followed by a focused discussion on patient safety issues exploring the causes and consequences of safety incidents and lessons to be learned from these. RESULTS: The intervention, which will be further tested in an NIHR-funded randomised controlled trial (RCT), was successfully implemented into an existing training programme and found acceptance amongst the patients and trainees. CONCLUSION: The pilot study proved to be a useful step in refining the intervention for the RCT including identifying appropriate outcome measures and highlighting organisational issues.

Acceptability of virtual unenhanced CT of the aorta as a replacement for the conventional unenhanced phase.

AIM: To evaluate whether virtual unenhanced (VU) computed tomography (CT) images generated of the aorta were of sufficient quality to replace the conventional unenhanced (CU) images. MATERIALS AND METHODS: Forty-nine patients undergoing examination of the thoracic or abdominal aorta were examined using a dual-energy protocol. VU images were generated from the arterial phase images and compared to the CU images. Objective analysis was performed by drawing paired regions of interest (ROIs) within the thoracic and abdominal aorta and measuring the radiodensity in Hounsfield units attenuation within the ROIs. Subjective analysis was performed by two experienced readers evaluating the VU images in terms of noise, quality, calcium loss, and overall acceptability. RESULTS: The attenuation was significantly higher in the VU images compared to the CU images within the thoracic aorta (p < 0.01) but not within the abdominal aorta (p = 0.15). Overall the VU images of the abdominal aorta were deemed acceptable as replacements for the CU images in 93% of cases. For the thoracic aorta, the VU images were deemed acceptable in only 12% of cases, primarily due to pulsation artefact. CONCLUSION: VU images of the abdominal aorta are acceptable as replacements for the CU images in the vast majority of cases; however, they are not suitable as replacements for the CU images of the thoracic aorta.

Imaging patients with myeloma.

Multiple myeloma (MM) is a neoplastic proliferation of plasma cells within the bone marrow. The disease is characterized by a plasma cell infiltrate of the bone marrow, osteolytic bone lesions, and the presence of monoclonal protein in the serum or urine with extraosseous involvement by disease less common. Although the skeletal survey has long been the standard investigation in these patients, there have been significant recent advances in computed tomography (CT), magnetic resonance imaging (MRI), and functional imaging. We present a comprehensive review of the evidence for the use of each of these studies in the diagnosis, prognosis, assessment of complications, and response evaluation in patients with MM.

Imaging appearances and endovascular management of uncommon pseudoaneurysms.

Pseudoaneurysms are uncommon and their aetiology is varied. They occur in numerous anatomical locations and present with a multitude of clinical presentations sometimes life-threatening. This review describes the causes, sites, and presentations of uncommon pseudoaneurysms, as well as illustrating their diagnostic appearances and endovascular management.

Illness action rediscovered: a case study of upper limb pain.

Theoretical frameworks provide generalised accounts of illness action although empirical studies of the process are still in short supply. This study of upper limb pain provided a case study of illness action; as it is a common condition, there is uncertainty about its treatment and management, orthodox and non-orthodox care are seen as legitimate sources of help and it is linked with a range of causes. Face-to-face informal interviews were carried out with 47 informants with upper limb pain and their practitioners (n= 19). The data were analysed in two different ways. The general stages of the illness action process were identified through a descriptive analysis of the upper limb pain sufferers' accounts and the policies and practices reported by their practitioners. Then, case studies were constructed to depict individual pathways through healthcare and consequences for sufferers. The illness action process was characterised by the normalisation and accommodation of pain informed by a discourse that predominantly invoked ageing and the wear and tear of the body. Practitioners also preferred to adopt a biomechanical approach and were reluctant to attribute psychosocial labels. The case studies illustrated the divergent, negotiated and opportunistic nature of the process and showed that the use of both orthodox and non-orthodox care formed only part of strategies used to manage upper limb pain. Sufferers evaluated the care they received in terms of pain alleviation, and were resigned to searching for the best way of living with their pain.

Upper limb pain in primary care: health beliefs, somatic distress, consulting and patient satisfaction.

BACKGROUND: Beliefs and mental well-being could influence decisions to consult about upper limb pain and satisfaction with care. OBJECTIVES: To describe beliefs about upper limb pain in the community and explore associations of beliefs and mental health with consulting and dissatisfaction. METHODS: Questionnaires were mailed to 4998 randomly chosen working-aged patients from general practices in Avon. We asked about upper limb pain, consulting, beliefs about symptoms, dissatisfaction with care, somatizing tendency (using elements of the Brief Symptom Inventory) and mental well-being (using the Short-Form 36). Associations were explored by logistic regression. RESULTS: Among 2632 responders, 1271 reported arm pain during the past 12 months, including 389 consulters. A third or more of responders felt that arm pain sufferers should avoid physical activity, that problems would persist beyond 3 months, that a doctor should be seen straightaway and that neglect could lead to permanent harm. Consulters were significantly more likely to agree with these statements than other upper limb pain sufferers. The proportion of consultations attributable to such beliefs was substantial. Dissatisfaction with care was commoner in those with poor mental health: the OR for being dissatisfied (worst versus best third of the distribution) was 3.2 (95% CI 1.2-8.5) for somatizing tendency and 2.4 (95% CI 1.3-4.7) for SF-36 score. Both factors were associated with dissatisfaction about doctors' sympathy, communication and care in examining. CONCLUSIONS: Negative beliefs about upper limb pain are common and associated with consulting. Somatizers and those in poorer mental health tend, subsequently, to feel dissatisfied with care.

The CT appearances of sclerosing mesenteritis and associated diseases.

Sclerosing mesenteritis is characterized by non-specific inflammation of the mesenteric fat associated with variable amount of fibrosis. The aetiology is unclear; the pathogenesis is obscure, and even its nomenclature remains variable. It is a rare condition with imaging features that can be mistaken either for a mesenteric neoplasm or for a wide variety of non-neoplastic inflammatory conditions. Knowledge of the imaging features of this condition may prevent unwarranted aggressive therapy. This review discusses the pathogenesis, clinical manifestations of this condition, as well as illustrating the characteristic computed tomography (CT) features of sclerosing mesenteritis. A rational approach to the differential diagnosis is discussed.

Making sense of aches and pains.

BACKGROUND: The uncertainty about the status of upper limb disorders (ULDs), particularly the non-specific conditions, is believed to have consequences for clinical management and patient care. OBJECTIVE: This paper presents evidence about how sufferers with ULDs respond to their pain, how their pain is managed, when and who they go to for formal help and how sufferers evaluate the care they receive. METHODS: The data analysis is derived from face-to-face, informal interviews with sufferers with a broad spectrum of upper limb disorders (n = 47). These informants were selected according to strict criteria from a 'screening' postal survey of the working population (25-64 years) in south-west England (n = 2781). RESULTS: Ideas about causation were crucial to understanding patterns of illness action and help seeking behaviour. The common strategy was to wait and see what happens as the pain was believed to be a natural part of the ageing process. Explanations invoking psychosocial and work related causes were less common and tended to be used when biomechanical explanations were no longer appropriate. Self-management was the preferred strategy but orthodox practitioners were usually the first choice for formal care. Complementary and alternative medicines (CAM) were popular but were used to complement orthodox care. Practitioners were evaluated mainly in terms of their ability to alleviate pain. CONCLUSION: There is a need for orthodox and non-orthodox care to be closely integrated in primary care and GPs should not depend on orthodox medications alone when caring for patients with upper limb pain.

Psychosocial difficulties, deprivation and cancer: three questionnaire studies involving 609 cancer patients.

The aim of the study is to investigate associations between deprivation and self-reported social difficulties and psychological distress in cancer patients. A total of 304 men and 305 women (age range 18-88 years) with a range of cancer diagnoses and living in a socially diverse region (Carstairs and Morris index) completed the Hospital Anxiety and Depression Scale and the Social Difficulties Inventory. Univariate analyses of variance revealed statistically significant differences in reported social difficulties between groups (F (67, 576)=2.4, P<0.0001) with stage of disease (F (5, 576)=7.6, P<0.0001), age (F (2, 576)=4.8, P=0.009) and to a lesser extent deprivation (F (1, 576)=4.0, P=0.048) making significant contributions. Significantly more social difficulties were reported by less affluent patients with locally recurrent disease or 'survivors'. No other interactions were found. Significant differences in levels of reported psychological distress were found between groups (F (67, 575)=1.723, P=0.001) for stage of disease, sex and deprivation but no interactions observed. In conclusion, deprivation is associated with reported psychological distress and, to a lesser extent, social difficulties. Patients at particular risk cannot be identified with confidence by socio-demographic and clinical means supporting the recommendation from National Institute for Clinical Excellence for provision of psychosocial assessment for individual cancer patients.

Evaluating health-care: the perspectives of sufferers with upper limb pain.

BACKGROUND AND AIMS: There is considerable uncertainty over the diagnosis, treatment and management of upper limb pain, which has implications for patient care. Research into patient experiences and evaluation of health-care has been neglected and the study presented here aims to fill this gap. METHODS: A two-staged, mixed methodology was adopted. Phase 1 involved a postal survey of a random sample (n = 2781) of the working age population (25-64) of an area in south-west England. Phase 2 consisted of follow-up, informal face-to-face interviews with a purposive sample of 47 informants identified, according to pre-defined criteria, from the survey sample. RESULTS: Our data showed that concerns about the effectiveness of treatments for alleviating pain were fundamental to users' evaluations of both orthodox and non-orthodox health-care. This took priority over the need for a diagnosis and other information. There was a general recognition that the treatments available were, at least, only partially effective and the pragmatic approach led some to eventually withdraw from both orthodox care and complementary and alternative medicines (CAM). CONCLUSION: Patients' priorities for health-care, in this context, were perceived to involve the provision of treatments which alleviated pain and were safe and painless. Orthodox and non-orthodox care needed to be more closely integrated into primary care services.