Long-term follow-up for percutaneous transluminal angioplasty in renal artery fibromuscular dysplasia.

AIM: Percutaneous transluminal angioplasty (PTA) is an effective treatment for renal artery stenosis secondary to fibromuscular dysplasia (FMD). This study aimed to evaluate the short-and long-term outcomes of percutaneous transluminal angioplasty in patients with hypertension and renal artery fibromuscular dysplasia (FMD). Additionally, we sought to identify specific patient factors that may affect outcomes. METHODS: This study prospectively enrolled 29 patients with uncontrolled hypertension and renal artery FMD diagnosed by duplex ultrasound and angiography. All patients underwent PTA with the goal of cure or improvement of hypertension. Follow-up was at one-month, 6 months, 12 months and then yearly with minimum follow-up of 2 years and maximum of 5 years. RESULTS: Technical success from the intervention was 100%. 21 patients were included in the final analysis. Short-term outcomes: One month after PTA mean systolic blood pressure (138.1 mmHg), diastolic blood pressure (78.6 mmHg), and number of anti-hypertensive medications (1.4) were significantly reduced. Blood pressure improvement was driven by 14/21 (67%) patients who had significant improvement in blood pressure, while 7/21 (33%) did not. These two groups (improved vs. not improved) differed significantly in mean age at intervention (40.6 vs. 58.3 years), duration of hypertension (3.1 vs. 15.4 years), systolic blood pressure (150.4 mmHg vs. 162.1 mmHg), diastolic blood pressure (86.4 mmHg vs. 95.7 mmHg), number of anti-hypertensive medications (2.2 vs. 3.0), serum creatinine (0.82 vs. 1.45), and renal resistive index (0.59 vs. 0.74) prior to intervention. Long-term outcomes: Mean follow-up was 3.86 years. Improvements in blood pressure and anti-hypertensive medications remained significant at five-year follow-up. CONCLUSION: PTA is effective at reducing blood pressure in patients with renal artery FMD. Age at intervention, duration of hypertension, and renal function may be used to predict outcomes prior to intervention.

Renal infarction complicating fibromuscular dysplasia.

Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory vascular disease that most commonly affects the renal and extracranial carotid arteries. We present 3 cases of renal infarction complicating renal artery FMD in 42-, 43-, and 46-year-old females and provide a comprehensive review of the literature on this topic. In our patients, oral anticoagulation therapy was used to treat all cases of infarction, and percutaneous angioplasty was used nonemergently in one case to treat refractory hypertension. All patients remained stable at 1-year follow-up. This is consistent with outcomes in previously published reports where conservative medical management was comparable to surgical and interventional therapies. Demographic differences may also exist in patients with renal infarction and FMD. A higher prevalence of males and a younger age at presentation have been found in these patients when compared to the general population with FMD.

D-day on board a tank landing ship: meat, cheese and blood transfusion.

Tank Landing Ships were used as evacuation station hospitals during D-Day of World War Two. This historical vignette describes how difficulties were overcome in blood transfusion and trauma surgery aboard these ships. Their place in the evacuation chain is discussed in relation to previous experiences in military medicine.

Low cost, high risk: accidental nutmeg intoxication.

Nutmeg poisoning is rare but probably underreported and should be considered in recreational substance users with acute psychotic symptoms as well as central nervous system neuromodulatory signs that may mimic in part an anticholinergic hyperstimulation.

The role of mini-fragment screw fixation in volar dislocations of the proximal interphalangeal joint.

Palmar fracture-dislocations of the proximal interphalangeal (PIP) joint are uncommon injuries, which can be associated with long-term complications if sub-optimally treated. We report two cases of palmar fracture-dislocations of the PIP joint treated by open reduction and internal fixation using a single mini-fragment screw. The long term results of hand and finger function were excellent.

A comparison between different formats of educational feedback to junior doctors: a prospective pilot intervention study.

OBJECTIVES: Audit feedback is conventionally given in the format of an average performance of the department relative to established guidelines. The impersonality of this feedback format may compromise audit outcome. The aim of the study was to compare personal, peer-comparison feedback, an effective method of changing physician practice, to the 'conventional' departmental one. METHODS: Eleven SHOs working at a central London A&E department were audited in terms of the adequacy of their documentation process. The study comprised patients presenting with closed head injury, acute asthma and chest pain of possible cardiac origin. Personal peer-comparison feedback and average departmental feedback was given for the first two groups, respectively. No feedback was given for the chest pain group, acting as a temporal control. The outcome measure was documentation of the minimum variables, as specified by departmental guidelines. RESULTS: The peer-comparison feedback group showed a significant improvement (p-value<0.0001) in two out of three target variables audited, in contrast to the departmental feedback group and the control group which did not show a significant improvement in any of the variables. CONCLUSIONS: Personal, confidential peer-comparison feedback was more effective than departmental feedback, in an audit of process of junior doctors. This pilot study should form the basis of a larger study (more SHOs, wider range of conditions) to establish unequivocally the best format for educational feedback.

Palmar dislocation of the proximal interphalangeal joint--an injury not to be missed.

Palmar dislocations of the proximal interphalangeal (PIP) joint are associated with long term complications if suboptimally treated. Six cases of palmar dislocation of the PIP joint are presented and a systematic approach in the diagnosis and management of such injuries in the accident and emergency department is described.

Guidelines for the management of anaphylaxis in the emergency department.

An algorithm for the emergency treatment of anaphylaxis is presented. The need for early hands-on involvement of senior personnel is stressed. Continuous assessment, monitoring of response to treatment, and a low threshold for hospital admission for observation and further treatment if necessary are required.

What goes wrong at a disaster or major incident?

From a receiving hospital's perspective a major incident is 'an accident about to happen'. The potential for chaos is present at every phase. This short paper describes in a chronological fashion the common traps and pitfalls and how to avoid them.

Can ambulance personnel intubate?

To assess the performance of intubation skills by advanced trained ambulance personnel, a prospective study was carried out of the intubation of cardiac arrest victims by ambulance personnel in the field. Twenty-eight ambulance personnel attempted the intubation of 87 patients over 2 years. Eighty-five patients were initially successfully intubated, one endotracheal tube became displaced and cuff leakage occurred on three occasions. This was treated appropriately in each instance. Ambulance personnel can perform the skills of intubation successfully in out-of-hospital cardiac arrest victims.

Bone infection and the limping child in the accident & emergency department: a diagnosis to be considered.

The child who presents to the A&E department with a limp must be taken seriously. It is of paramount importance to include in the list of causes the possibility of infection. The diagnosis and treatment of subacute osteomyelitis in children is discussed to highlight the necessity for immediate referral and inpatient management.

Hodgkin's disease of the oesophagus.

The gastrointestinal tract is commonly involved in patients with lymphoma. Involvement of the oesophagus occurs in about 1% of patients. This case report describes a patient with oesophageal obstruction due to Hodgkin's disease of the oesophagus as the sole manifestation of a second relapse 10 years after initial diagnosis of the lymphoma.