Primary aortoenteric fistulae: the challenges in diagnosis and review of treatment.

Primary aortoenteric fistula (PAEF) is a potentially fatal condition which poses a considerable diagnostic challenge because of its infrequency and the nonspecific presentation. We report the case of a 61-year old woman who presented to her general practitioner with nonspecific and intermittent rectal bleeding, hematemesis, and weight loss. Four days later, she presented to the emergency department with worsening symptoms. The investigations revealed a new small 3.8-cm abdominal aortic aneurysm on computed axial tomography (CT), however, no evidence of a fistula was observed either on CT scan or endoscopy. Two days later, she became unstable requiring an emergency laparotomy and was taken to the operation theater for an en bloc resection of a segment of the aorta and duodenum with exclusion of the duodenum with an inline reconstruction of the aorta using a Dacron graft for a PAEF. The published data were reviewed to address the issues of optimal diagnostic methods and management of PAEF.

Two Stage Complex Embolization of an Arteriovenous Fistula between the Right Common Iliac Artery and the Inferior Vena Cava.

We present an interesting case of a symptomatic high flow AV fistula between the right common iliac artery (CIA) and the inferior vena cava (IVC), successfully treated by endovascular coil embolization. The patient was found to have a right lower polar renal artery crossing the ipsilateral ureter arising from the CIA, causing pelvi-ureteric junction (PUJ) obstruction and recurrent pyelonephritis. It is hypothesized that this fistula arising from the lower polar renal artery and entering the IVC, may have occurred as a result of trauma during a previous pyeloplasty, or a pathologically induced process of angiogenesis stemming from recurrent pyelonephritis.

Annual review of fractured neck of femur mortality rates: is this a true picture?

BACKGROUND: Annual fractured neck of femur death rates within a region are used by the Department of Health (DoH) as a clinical performance indicator of hospital trusts. Presently trusts and DoH publish performance figures annually but there is significant variability year to year. OBJECTIVE: Does a 5-year mortality review reflect a truer picture? METHODS: Hospital information services were used to provide the details for all patients who died within 30 days of admission. These were analysed to determine the true fractured neck of femur mortality. RESULTS: The variations in fractured neck of femur mortality rates between years within the same and between different trusts shows that annual scrutiny is an inappropriate, often skewed, analysis of performance. CONCLUSIONS: A 5-year mortality review would seem more appropriate to visualise true trends and should be performed to remove anomalous results.