A case of primary cutaneous B-cell lymphoma of the knee.

We report the case of a gentleman with a primary cutaneous B cell lymphoma of the leg who underwent an amputation and later died. This is an uncommon type of cutaneous lymphoma with poor prognosis and the case demonstrates how aggressive the tumor can become.

The effect of acute normovolaemic haemodilution on the inflammatory response and clinical outcome in abdominal aortic aneurysm repair--results of a pilot trial.

OBJECTIVES: To determine the effect of acute normovolaemic haemodilution (ANH) on the inflammatory response and clinical outcome in elective open abdominal aortic aneurysm (AAA) repair. DESIGN: Randomised controlled clinical trial. METHODS: Thirty-six patients were randomised to undergo ANH or act as controls. Cell salvage was permitted in both groups. Heterologous blood was transfused according to pre-determined triggers. Outcome measures were markers of the systemic inflammatory response in serum and urine observed at multiple time points, and clinical recovery. RESULTS: Median 890 (range 670-1620) ml of blood was removed at ANH in 16 patients. There were no differences in peri-operative changes in neutrophil count ( P = 0.13), serum C-reactive protein ( P = 0.38), interleukin-6 ( P = 0.50), total antioxidant capacity ( P = 0.73), urinary secretion of albumin ( P = 0.97) or retinol binding protein ( P = 0.41). There were no differences in the mortality and morbidity rates, systemic inflammatory response syndrome, ITU or hospital stay. CONCLUSIONS: ANH, when used in combination with cell salvage, made no impact on systemic inflammatory response and clinical outcome when compared to cell salvage alone after AAA repair. ANH cannot be recommended for routine use in patients undergoing abdominal aortic aneurysm surgery when cell salvage is available.

Haemodilutional effect of standard fluid management limits the effectiveness of acute normovolaemic haemodilution in AAA surgery--results of a pilot trial.

OBJECTIVE: To evaluate the impact of standard fluid management on the effectiveness of ANH as a blood conservation method in elective open AAA repair. DESIGN: Prospective randomised controlled study. METHODS: Thirty-four patients undergoing elective AAA repair were randomised to have ANH (16) or act as controls (18). Intra-operative cell salvage was permitted in both groups. Haemoglobin (Hb) concentrations were determined at variable intervals peri-operatively. Blood loss and the use of heterologous blood were recorded. RESULTS: The pre- and post-operative Hb concentrations, surgical blood loss and the use of cell salvage were similar in both groups. Hb concentration (median, range) decreased significantly from pre-operative to aortic clamping (with blood loss <100 ml) in ANH patients from 8.8 (7.5-10.2) to 5.7 (4.2-6.6)mmol/l following ANH but also in controls from 8.6 (7.5-9.7) to 7.0 (4.5-9.0)mmol/l due to fluid infusion (P<0.01 for every comparison). Bank blood requirements were similar: median 2 units in ANH and 2.5 units in control patients (P=0.68). CONCLUSIONS: Large volumes of fluids infused during AAA repair already conserve blood by the mechanism of hypervolaemic haemodilution. When cell salvage is used with standard fluid management during AAA repair, additional ANH is ineffective in saving blood.

The effect of acute normovolaemic haemodilution on blood transfusion requirements in abdominal aortic aneurysm repair.

OBJECTIVE: to evaluate the impact of acute normovolaemic haemodilution (ANH) on the blood transfusion requirements in elective abdominal aortic aneurysm (AAA) repair in a single vascular unit. METHODS: thirty-two patients underwent ANH during elective AAA repair between 1992 and 1997. The operation was performed by the same surgeon/anaesthetist team in 75% of cases. Their demographic details, type of aneurysm (infra-renal or supra-renal), preoperative blood cross match, use of intra-operative red cell salvage, blood loss, peri-operative bank blood requirements, pre-op and on-discharge haemoglobin levels and post-operative outcome were recorded. The results were compared to a group of 40 randomly selected patients (to represent the unit average) who underwent elective AAA repair by variable surgeon/anaesthetist teams without ANH in the same time period. RESULTS: there were more supra-renal AAA repairs in the ANH group (8/32) than in the non-ANH group (0/40, p<0.01). ANH patients required significantly less blood transfusion peri-operatively (median 2 units) than the non-ANH patients (median 3 units, p=0.02). There were no other significant differences between the variables measured. CONCLUSION: these results suggest that a dedicated team can achieve significant reductions in the use of heterologous blood transfusion compared to the vascular unit average experience by the effective use of ANH.

The snuffbox arteriovenous fistula for vascular access.

OBJECTIVES: to determine the applicability, patency rates and factors influencing patency of snuffbox arteriovenous fistulae for haemodialysis access. DESIGN: retrospective non-randomised study. MATERIALS AND METHODS: patency was determined by reference to an ongoing database and dialysis records of 645 vascular access procedures between 1985 and 1997, including 210 snuffbox fistulae in 201 patients. RESULTS: snuffbox fistulae comprised 189/376 (50%) primary procedures. Records of 208 snuffbox fistulae were available for patency analysis by the life-table method. Twenty-two (11%) thrombosed within 24 hours of operation. After six weeks 80% were used for dialysis. Cumulative patency was 65% at 1 year and 45% at 5 years. After thrombosis of snuffbox fistulae, ipsilateral wrist fistulae could be constructed in 45%. Fistula patency was significantly better in men than women (p<0.001) and for left- than right-sided fistulae (p<0.001). Diabetes, age >70 years, and the prior commencement of haemodialysis did not significantly affect fistula survival. CONCLUSIONS: the snuffbox AV fistula gives a long segment of arterialised vein for needling and preserves proximal vessels. It is feasible in 50% of patients requiring primary access and has good long-term patency, especially in men. A more proximal fistula may be preferable in women with smaller vessels.