Co-morbidity in patients with abdominal aortic aneurysm.

OBJECTIVES: Selection for surgery of patients with abdominal aortic aneurysm (AAA) depends on an assessment of risk from operation compared with risk from aneurysm rupture. A study was performed to assess the levels of co-morbidity and to see whether co-morbidity was different in people with a normal aorta after ultrasonographic examination than in those with an aneurysmal aorta. SETTING AND METHODS: Over a two year period 5392 people (2341 men, 3051 women) aged 65-80 were screened using B-mode linear ultrasound, with maximum measurements taken of transverse, anteroposterior diameters, or both. All subjects were given a questionnaire seeking a history of angina, stroke, claudication, myocardial infarct, respiratory problems, and diabetes. RESULTS: 218 men and women were found to have an AAA of 3 cm or greater. The results of the questionnaire were analysed using logistic regression whereby all the co-morbid conditions were adjusted for each other and for smoking, sex, and age. The only conditions which were significantly associated with AAA in both sexes were myocardial infarction with an odds ratio (OR) of 1.66 (95% confidence interval (CI) 1.06 to 2.60) and claudication with an OR of 1.68 (95% CI 1.17 to 2.42). The association between angina and AAA was of borderline significance (OR = 1.52, 95% CI 1.00 to 2.30). Stroke was significantly associated only in women, with an OR of 3.71 (95% CI 1.42 to 9.69). Rates of diabetes and respiratory disease were not significantly different between people with AAA and normal aortas. CONCLUSIONS: These findings show there is significantly higher co-morbidity in people with ultrasound detected AAA, which might influence outcome from surgery and long term survival.

Recent advances in the diagnosis and treatment of acute appendicitis.

Unnecessary appendicectomy carries long-term risks to the patient. The decision for surgical intervention is often made based on the patient's history and the findings of clinical examination. This article reviews recent papers published on the various methods of reducing the incorrect diagnosis of acute appendicitis, and the advances in its treatment.

Coronary artery disease in patients with peripheral vascular disease.

For patients requiring peripheral vascular surgery, coronary artery disease is the major determinant of perioperative mortality and long-term survival. The management of coronary artery disease in these patients is controversial as no randomized blinded prospective studies have been conducted. Data on the prevalence, diagnosis and management are reviewed.

Adrenal incidentaloma.

Improvements in ultrasonography and computed tomography have led to the problem of 'adrenal incidentaloma', an asymptomatic adrenal mass discovered during investigation of some other problem. In the light of current knowledge a management rationale for patients with such an adrenal abnormality is proposed.

The value of technetium-99M renography for the detection of renal artery stenosis in patients with aortic and lower limb vascular disease.

The results of technetium renography were compared with arteriography to determine whether this is a satisfactory screening test for renal artery stenosis (RAS). Sixty-three patients were studied before aortic surgery. All were investigated by aortography and isotope renography. These tests were assessed blind and all arteriograms were graded by a single independent radiologist. Renal artery stenosis was detected by arteriography in 34 (54%) patients. Twenty-three (37%) had mild (less than 50%) stenosis, seven (11%) had moderate (50-80%) stenosis and four (6%) had severe (greater than 80%) stenosis. Of these 34 patients, only 6 (18%) were correctly diagnosed by isotope renography. None of the four with severe stenosis were identified. Isotope renography resulted in six true positives, six false positives, 23 true negatives and 28 false negatives. It was concluded that isotope renography did not fulfil the criteria for a screening test for the detection of RAS and appeared to be of no value in those patients undergoing aortic surgery in whom arteriography was not indicated.

Fibrinolytic activity and calf pump failure.

The interstitial fibrinolytic activity of the upper and lower limbs was investigated in subjects with abnormal calf pump function by measuring the lysis rate of experimentally produced subcutaneous 125I-fibrin clots. Thirty-three subjects with healed venous ulcers, five with varicose veins and 11 controls were studied. 125I-fibrin clots were produced in the subcutaneous tissue of the forearms and legs and clearance half-life was calculated. Calf pump function was assessed by foot volumetry and the 'gaiter' skin nutritive circulation by measuring the transcutaneous oxygen tension (PtcO2). Fibrin clearance was prolonged from the subcutaneous tissues of the legs of subjects with varicose veins and healed ulcers compared with controls. Negative correlations were found between fibrin clearance half-life and the half-volume refilling time (P less than 0.01) and the PtcO2 (P less than 0.01).

Fibrinolytic activity of the arms and legs of patients with lower limb venous disease.

Clearance of subcutaneous 125I-labelled fibrin was prolonged from the legs but not from the arms of patients with uncomplicated varicose veins and patients with healed ulcers, compared with controls. The euglobulin clot lysis time (ECLT) of blood from the arms and legs of those with healed ulcers was prolonged; venous congestion significantly shortened the ECLT of blood from all limbs except legs with healed ulcers. The clearance of interstitial fibrin of both legs and arms correlated with the response of the ECLT to venous congestion (P less than 0.05). The clearance of interstitial 125I-labelled albumin in five patients with healed ulcers was faster from the legs than from the arms, whereas the clearance of interstitial 125I-labelled fibrin was faster from the arms in all cases. These results suggest that there is a defect in interstitial fibrinolytic activity as well as vein wall production of plasminogen activator in legs with chronic venous insufficiency.

Intravenous urography after acute urinary retention.

The results of a 12-month prospective study of 113 patients show that intravenous urography has no place in the management of men with acute urinary retention without haematuria.

Trial without catheter following acute retention of urine.

A total of 60 patients with acute urinary retention were studied to establish whether a trial without a catheter was justified and to identify subgroups of patients most likely to benefit from this practice. The patients were randomly allocated to 3 groups; the catheters were removed either immediately after the bladder was emptied, or 24 or 48 h later; 17 patients urinated satisfactorily after removal of the catheter. Re-establishment of micturition was not associated with the length of history or severity of symptoms of prostatism, with age or the presence of urinary tract infection. The mean retained volume of urine in patients with a satisfactory result was 786 ml and 1069 ml in the failures. Of the 34 patients with retained volumes of less than 900 ml, 15 were successful in re-establishing micturition compared with 2 of 26 of those with retained volumes greater than 900 ml. The time of catheter removal was not important. The 17 successful patients were reviewed 6 months later. None reported further urinary retention; 6 had required prostatectomy for severe symptoms, 6 had minor symptoms and 5 were symptomless. It was concluded that a trial without a catheter is worthwhile, since 11 of 60 patients had not required surgery, but it should be avoided in patients with a residual volume exceeding 900 ml.

Synchronous small and large bowel cancer developing after pelvic irradiation.

This case report supports the belief that there is a causal relationship between therapeutic radiation and subsequent bowel malignancy.