Doctors' knowledge of radiation -- a two-centre study and historical comparison.

AIM: To investigate knowledge of the use of ionizing radiation in 2010 and whether there has been any change in this knowledge since the study was first undertaken over 7 years ago. MATERIALS AND METHODS: In both studies a single chest x-ray was classed as one unit of radiation. Doctors from all grades were asked to evaluate the average radiation dose incurred with 13 commonly undertaken radiological procedures, including magnetic resonance imaging (MRI), computed tomography (CT), etc. Answers within 20% of the actual dose were marked as correct. RESULTS: Two hundred and forty-two questionnaires were completed (130 in 2003; 112 in 2010). Equal numbers of juniors, middle grades, and consultants were questioned, and scores were comparable (23.3% in 2003; 29.4% in 2010). The majority of doctors (92% in 2003; 86% in 2010) correctly noted that ultrasound and MRI involve no radiation. Doctors underestimated the radiation doses of all investigations by a smaller margin in 2010 compared to 2003 (i.e., more accurately), with only one exception: CT of the abdomen. CONCLUSION: Despite evidence of some improvement, doctors of all grades still have a very poor knowledge of radiation exposure even with the most common investigations. The worsening appreciation of the radiation involved in CT scanning is especially worrying considering its increasing use in practice today.

A meta-analysis of 21,178 patients undergoing open or endovascular repair of abdominal aortic aneurysm.

BACKGROUND: Several studies have compared outcomes after elective open and endovascular approaches to abdominal aortic aneurysm (AAA) surgery, with varying results. METHODS: A random-effects meta-analysis was undertaken to compare operative outcomes, postoperative complications, 30-day mortality and long-term patient survival after surgery. Endpoints were compared using odds ratios (ORs), weighted mean differences (WMDs) or log hazard ratios (HRs) as appropriate. RESULTS: Forty-two studies comprising 21,178 patients (10,855 open; 10,323 endovascular) were included. In the elective setting (20,715 patients), the endovascular method was associated with a shorter stay in intensive care (WMD--36 h; P < 0.001) and a shorter total postoperative stay (WMD--5.4 days; P < 0.001). Cardiac (OR 1.76; P = 0.002) and respiratory (OR 4.01; P < 0.001) complications were more common after open surgery. In the endovascular group, 30-day mortality was lower (OR 0.46; P < 0.001). Endovascular surgery was also associated with an improved long-term aneurysm-related mortality (HR 0.39; P < 0.001). For ruptured AAA (463 patients), the less invasive operation was associated with a reduced stay in intensive care (WMD--100.4 h; P = 0.005) and a significantly lower 30-day mortality (OR 0.45; P = 0.005). CONCLUSIONS: The endovascular repair of AAA offers a clear benefit in terms of reduction in postoperative adverse events and 30-day mortality. In the longer term, it is also associated with a reduction in aneurysm-related mortality, but not in all-cause mortality.

History of the management of popliteal artery aneurysms.

Management of popliteal aneurysms remains controversial. Debate continues as to when an asymptomatic popliteal aneurysm should be treated and, with concerns regarding the fate of a bypassed popliteal aneurysm and the advent of intravascular stents, what procedure is best. This paper reviews the history of popliteal artery aneurysm management with particular emphasis on treatment and results before the modern era of arterial reconstruction. The aim of treatment then was to induce thrombosis. Now it is to prevent thrombosis.

Arterial thrombosis associated with malignant disease.

OBJECTIVE: The association between cancer and venous thrombosis is well established, however, that between malignancy and arterial thrombosis is less well described. Isolated cases have been reported and chemotherapy has been implicated as a cause though its significance compared with the malignant disease process itself is not known. This study examines the outcome of patients with malignant disease who present with arterial thrombosis. METHOD: Details of patients with malignant disease who presented with arterial thrombosis were analysed. RESULTS: Twenty patients presented with malignancy and arterial thrombosis, 16 presented in the last four years. The most common malignancy was metastatic breast cancer. Thrombosis involved the leg in 19 cases and the arm in one. Four patients also had venous thromboembolic events and one had a carotid artery thrombosis. Eight patients underwent operative treatment for their thrombosis. Five out of six thromboembolectomies and two out of three bypass procedures failed. Twelve had conservative or palliative treatment. Outcome was generally poor, two patients had major amputations and seventeen died at median follow-up of eight weeks. Survival rate from the time of presentation of arterial thrombosis was 50% at three months and 17% at one year. CONCLUSION: Patients with critical limb ischaemia due to atherosclerotic disease have an expected survival of approximately 80% at one year. The outcome of patients with arterial thrombosis associated with malignant disease is far worse. Arterial thrombosis is an agonal event in many of these patients. Conservative or palliative treatment may be the most appropriate management.

Endovascular and open approaches to non-thrombosed popliteal aneurysm repair: a meta-analysis.

OBJECTIVE: Endovascular repair of popliteal artery aneurysms is a relatively new technique that is still undergoing evaluation. The aim of this study was to compare outcomes following open and endovascular approaches. METHODS: All published studies comparing outcomes following open and endovascular popliteal aneurysm were included. Endpoints included operative duration, length of stay, and postoperative complications including short-term patency rates. Outcomes were combined using a random-effects meta-analytical technique and differences assessed using odds ratios (OR), weighted mean difference (WMD) and log hazards ratio (HR). RESULTS: Three studies comprising 141 patients (37 endovascular; 104 open) were included. No significant differences in patient characteristics were seen. Operative duration was significantly longer for endovascular repair (WMD 120 minutes, p<0.001). Thirty day graft thrombosis (OR 5.05, p=0.06) and reintervention (OR 18.80, p=0.03) were more likely following endovascular repairs. Postoperative length of stay was shorter in the endovascular group (WMD--3.9 days, p<0.001). There was no significant difference in long-term primary patency rates (HR 1.70, p=0.53). CONCLUSIONS: Endovascular repair of popliteal artery aneurysms offers similar medium-term benefits as an open repair. However, short-term graft thrombosis and reintervention rates are significantly greater. With the current technology it is difficult to justify endovascular treatment of popliteal aneurysms.

Appendicectomy deferred to a CEPOD list: the patients' opinion.

AIMS: Implementation of NCEPOD guidelines to avoid out-of-hours operating, Junior doctors' 'New Deal' and EWTD have significantly altered surgical practice. Patients admitted 'out of hours', who need an emergency procedure, are often deferred until the next day. We have attempted to assess patients' opinions of this management plan. METHODS: Consecutive patients admitted with uncomplicated appendicitis and operation deferred to the next day according to NCEPOD guidelines were studied. A surgeon, other than the one carrying out the initial assessment, performed the operation on a scheduled morning emergency list. A full explanation was given to patients regarding reasons for deferring operation, and they found out that a different surgeon would be performing their operation. Patients completed a questionnaire post-operatively. RESULTS: 42 patients were studied; median age 24 years (range 17-69); 32 men, 10 women. Thirty presented after 6 p.m. and eight after midnight. The remaining four were admitted during the day. Only one third of the patients recalled reasons for deferred operation with seven not remembering being given an explanation. Two thirds (n=27) of the patients slept poorly pre-operatively, principally due to pain (17) and ward noise (10). Operation on the same night as their admission was the preferred option in 24 patients. All of these slept poorly. Some 22 patients would have preferred the admitting surgeon to have performed their operation; 16 expressed no preference. Only four patients preferred a 'new' surgeon the following day. Of the 42 patients, 28 did not know who had performed their operation. CONCLUSION: Despite being told why their operation was delayed most patients would prefer not to have their procedure delayed. Lack of sleep pre-operatively is a major determinant of patient opinion. Few patients wanted a 'new' surgeon to perform their operation.

Continuity of care of emergency surgical admissions: impact on SpR training.

INTRODUCTION: Continuity of patient care is an important component of surgical education. This study assesses continuity of care in the current working climate. PATIENTS AND METHODS: Data were collected prospectively on consecutive emergency general surgical admissions during one month. Our SpR rota is a partial shift 24 hour on call with the SpR's own consultant. The SpR is free of commitments the next day following post-take work. The on call general surgery SpR was designated the 'assessor'. Data were analysed according to involvement of the 'assessor' at subsequent stages of the admission--consent, operation, review during admission and review on discharge. Data were also collected defining whether the 'assessor' and operator followed-up the patient. RESULTS: There were 200 admissions; 108 female and 92 male. Overall 23% admissions had the same 'assessor' for all stages of patient care. The 'assessor' dealt with an aspect of patient care in 11% of admissions who underwent an operation and 29% of admissions who were conservatively managed. SpR follow-up of admissions on whom they operated was 70% but only 41% of admissions who were conservatively managed were followed-up by the assessing SpR. CONCLUSION: Complete in-hospital continuity of care was poor, although SpR follow-up of patients on whom they had operated was better. Introduction of shift patterns has reduced continuity of patient care. This will have a negative impact on both surgical training and patient care.

Prioritisation of vascular outpatient appointments cannot be based on referral letters alone.

BACKGROUND: Vascular referrals include patients with conditions varying from varicose veins of cosmetic nuisance to patients with critical ischaemia, transient ischaemic attacks and abdominal aortic aneurysms. A large number of such referrals are received each week from general practitioners. It is important to prioritise patients with conditions that need to be dealt with quickly. OBJECTIVE: We prospectively reviewed referral letters to two vascular units, one in South Wales and one in the Oxford region to assess whether prioritisation can be made on the basis of referral letters. MATERIAL AND METHODS: All GP referral letters were studied for four months. Only patients with lower limb ischaemic symptoms were included. Degree of urgency requested by the GP was also noted. RESULTS: Of 174 referrals for potential lower limb ischaemia analysed, 145 (83%) proved to be due to peripheral vascular disease. Of these 145 referrals, 72% were referred for claudication. Only 37% and 13% respectively mentioned claudication distance and/or rest pain. Risk factors with reference to diabetes, hypertension, hyperlipidaemia, ischaemic heart disease, atrial fibrillation, cerebrovascular disease and smoking were made in 19%, 43%, 23%, 23%, 10%, 14%, 31% of letters respectively. Clinical signs were poorly documented, with 90% of referrals failing to mention presence or absence of critical ischaemic signs. The GP's own assessment of urgency was not stated in 66% of letters, without which only 3% of patients were seen in the clinic within four weeks, compared with 22% in those in whom urgency was stated. Six per cent of patients when reviewed in outpatients were found to have sufficiently severe symptoms to warrant immediate admission. Regional variation was observed with 57% of Royal Glamorgan Hospital referral letters documenting degree of urgency compared with only 23% of Royal Berkshire Hospital letters (p = < 0.0001). CONCLUSION: Most referral letters were poorly documented with regard to key symptoms, risk factors and clinical signs. The degree of urgency was often not stated. The creation of referral protocols is now being considered.

Management of cardiovascular risk factors by primary care physicians in patients with peripheral arterial disease.

BACKGROUND: Patients with significant coronary artery disease (CAD) are now intensively treated by primary care physicians predominantly because of government pressure and remuneration to prescribe anti-platelet and anti-hyperlipidaemic drugs. Peripheral arterial disease (PAD) with the identical risk factors appeared to us to be less intensively investigated and treated by primary care physicians. OBJECTIVE: To review the treatment of risk factors in all patients referred to two vascular clinics with a diagnosis of suspected PAD. DESIGN: Cross-sectional survey. SETTING: Vascular outpatient clinic in two district general hospitals. PARTICIPANTS: 124 consecutive new patients were studied to determine risk factors and appropriate treatment. RESULTS: Of the 124 patients, 85 (68%) were confirmed to have PAD without evidence of symptomatic CAD. In the PAD alone group, less than 25% received anti-smoking advice (p < 0.0001) and only 36% were prescribed anti-platelet drugs (p = 0.016). Seventy-three per cent of the overall referred patients with hypertension had been treated for this condition and the blood pressure was normal in 71% of the patients with PAD. In patients with hyperlipidaemia, statins had been prescribed in 92% of patients with coexistent symptomatic CAD, but only in 64% of patients with PAD alone (p = 0.009). In the patients with diabetes, only 66% of the PAD alone group had adequate control of their blood sugar (p = 0.185). CONCLUSIONS: It would appear that patients with CAD and PAD are being treated successfully for their risk factors, but patients with PAD alone, sharing the same common risk factors, are being less than optimally treated.

Combined fascia and mesh repair of incisional hernias.

Incisional hernia is a relatively common complication following abdominal operations. Due to high recurrence rates following primary suture, a prosthetic mesh is now usually used to repair the hernia. Several different types of repair are described. A combined fascia and mesh technique avoids opening the peritoneal cavity and potential damage to bowel. This study describes results of this technique. Consecutive patients undergoing the operation were contacted to assess freedom from recurrence and satisfaction with results. Some 34 patients underwent 36 incisional repairs. Of the 34 patients 21 were men and 13 were women with a median age of 69 years (range 31-86 years). The causative incisions were midline (30), Kochers (2), Pfannesteil (2) and transverse (2). The median time spent in hospital was three nights (range 1-14 days). Two patients developed seromas, another complained of pain soon after operation, one patient developed a superficial wound infection another developed a tender drain site which required exploration. One patient with significant co-morbidity died 13 days postoperatively from multiorgan failure. Freedom from recurrence of the hernia was 91% at 5 years. However patient survival was only 70% at 5 years. This technique is associated with low postoperative morbidity and a low recurrence rate. Patients presenting with incisional hernias have a poor long-term prognosis which needs to be borne in mind when planning intervention.

Popliteal aneurysms: controversies in their management.

Popliteal artery aneurysms (PAs) occur in older men with significant comorbidity and limited life expectancy. This needs to be remembered when planning elective operation for asymptomatic aneurysms. In the absence of significant distortion PAs <3 cm in diameter can be managed by sequential ultrasound scanning. Their rate of thrombosis is no worse than that of grafts after elective bypass. Intra-arterial thrombolysis for acute thrombosis should be restricted to intra-operative usage to clear run off.

Results of thoracoscopic sympathectomy for the treatment of axillary and palmar hyperhidrosis with respect to compensatory hyperhidrosis and dry hands.

BACKGROUND: We examined the results of thoracoscopic sympathectomy (TS) for palmar and axillary hyperhidrosis with respect to operative method, symptom control, patient satisfaction and complications. METHODS: We performed a retrospective review of patient records with mail and telephone questionnaire follow-up of 55 patients (15 men) with a median age of 26 years (range, 15-52) who underwent TS between February 1994 and December 2001. RESULTS: There were no differences in complication rates between those having bilateral TS (n = 23) and those having unilateral procedures (n = 20) with a median follow-up of 21 months (range, 2-94). Forty-three patients returned questionnaires (response rate, 78%). Forty patients (93%) were satisfied with the results. Thirty-four patients (79%) noted compensatory hyperhidrosis and 22 (51%) excessively dry hands. CONCLUSION: Despite high rates of compensatory sweating, the majority of patients are very satisfied with the results. The high rate of excessively dry hands is a previously unreported finding and important to discuss when obtaining consent.

MRSA in lower limb amputation and the role of antibiotic prophylaxis.

AIM: Methicillin Resistant Staphylococcus Aureus (MRSA) colonisation is reported in 3-20% of vascular patients. Many develop infective complications. MRSA is associated with poor prognosis. Aim of the study is to assess MRSA in lower limb amputation and efficacy of antibiotic prophylaxis. METHODS: Prospective study of lower limb amputation. MRSA screen and wound swabs were taken at operation. Antibiotic prophylaxis included teicoplanin (400 mg) 1 dose at operation. RESULTS: Twenty-five patients underwent 33 primary amputations. At operation 15 legs (45%) were colonised with MRSA and 18 legs (58%) had active wound infection; MRSA (4) and other (14). Following surgery 3 patients died. Twenty-two legs (76%) had primary healing. Infection developed in 7 stumps (24%), MRSA (5) and Pseudomonas (2). Stump infection increased time to wound healing (p<0.0001). MRSA stump infection increased revision amputation (p=0.009) and duration of hospital stay (p<0.0074). MRSA wound infection at operation increased the risk of MRSA stump infection (p=0.007). Non-MRSA wound infection at operation was not associated with a worse outcome. No patient colonised with MRSA at operation developed postoperative MRSA stump infection. CONCLUSIONS: MRSA is more prevalent that previously reported. MRSA infection has a poor prognosis. Prophylaxis may be effective for patients colonised with MRSA.

Intra-operative peritoneal lavage--who does it and why?

INTRODUCTION: Intra-operative peritoneal lavage (IOPL) is widely practised but its benefits are unclear. The frequency and pattern of its use amongst general surgeons is investigated. METHODS: A postal questionnaire was sent to 153 general surgical consultants and registrars enquiring about their use of IOPL. The surgeon was asked the volume and type of lavage fluid used, under various circumstances. RESULTS: 118 (77%) questionnaires were returned. 115 (97%) surgeons used IOPL. The majority of surgeons (61%) lavaged until the fluid was clear, 20% used more than 1 l and 17% used between 500-1000 ml. In the case of the dirty abdomen (i.e. gross pus or faecal peritonitis), 47% used saline as the lavage fluid, 38% aqueous betadine, 9% water and 3% antibiotic lavage. Similar results were found in the case of a contaminated abdomen (i.e. a breached hollow viscus). 34% of surgeons used IOPL during clean cases. 36% used water lavage during intra-abdominal cancer surgery; 21% lavaged with saline and 17% with betadine. More registrars (47%) than consultants (29%) lavaged with water during cancer surgery. Consultants, however, used more aqueous betadine. CONCLUSIONS: The frequency of use and choice of lavage fluid varies widely. The successful management of the septic abdomen rests on at least 3 tenants - systemic antibiotics, control of the source of infection and aspiration of gross contaminants. There is little good evidence in the literature to support IOPL in the management of the septic abdomen. The use of IOPL during cancer surgery is supported by in vitro evidence. The current use of IOPL, as shown by this study, appears not to be evidence based.

Surgical management of radiation enteritis.

Seventy patients (17 men and 53 women) were seen with radiation-injured gut between 1958 and 1984. The median age at treatment with radiotherapy was 54 years. External radiotherapy was used in all cases, combined with internal treatment for cervical cancer. Ninety-seven gastrointestinal lesions were produced. There were 63 strictures, 14 fistulas, 12 perforations, and eight bleeds. The period between radiotherapy and clinical manifestation of the lesion was approximately 2 years, being longest for strictures. The majority of the lesions were in the rectosigmoid or mid and distal small bowel. Sixty-one patients required one or more operations, and review of the operative results up to 1977 showed a high incidence of anastomotic leak and death after resection and primary anastomosis. However, we noticed that the ascending, transverse, and descending colon were relatively free of radiation-induced disease. Since then we have used a nonirradiated part of the colon for one end of the anastomosis. Thus terminal ileal resection has been followed by an ileotransverse anastomosis and rectosigmoid resection by mobilization of the splenic flexure to bring it down for anastomosis. With these techniques there has been one leak in 14 anastomoses and none of the 12 patients have died. These results are significantly better (p less than 0.02) than our previous figures when 14 of 27 anastomoses leaked, with 10 deaths. We conclude that use of nonirradiated bowel for at least one end of an anastomosis significantly improves the results of resection of irradiated bowel.

Nonspecific stimulation of host defenses against bacterial challenge in immunosuppressed mice.

Muramyl dipeptide (MDP) has been shown to be a safe and effective host defense stimulant in both normal and malnourished hosts exposed to a bacterial challenge. We investigated its effect in mice compromised by pretreatment with either cyclophosphamide or steroids. The bacterial challenge, designed to simulate a surgical wound infection, consisted of a Klebsiella pneumoniae-laden suture. The MDP treatment resulted in lower local and systemic bacterial spread and increased survival in mice immunosuppressed by cyclophosphamide than in untreated controls. No such effect was demonstrated in animals compromised by steroids. These results suggest that MDP exerts its effect primarily on the macrophage.

Nonspecific enhancement of resistance to local bacterial infection in starved mice.

We studied the effect of muramyl dipeptide (MDP) on enhancing resistance to local bacterial challenge in starved mice. The challenge consisted of the intramuscular insertion of a suture laden with Klebsiella pneumoniae. Mice that had been pretreated with MDP had a statistically lower rate of bacterial recovery at the site of the challenge, had consistently fewer bacteria in the blood, and had improved short-term survival. By enhancing local bacterial containment, MDP pretreatment of immunocompromised animals reduces the level of bacteremia and subsequent mortality.

Radiology of acalculous gall-bladder disease - a new sign.

Radiography of excised gall-bladders, immersed in water, has shown that chronically infected gall-bladders frequently contain fat. This fat can be seen in vivo, and the frequency of the finding was assessed by reviewing 43 patients with acalculous gall-bladder disease. Other radiological signs in the cholecystograms were looked for retrospectively, and their incidence assessed. In 20 cases out of 40, no radiological abnormality was found.

A reassessment of the influence of steroids on neutrophil phagocytosis.

The impact of corticosteroids on host defense processes has been studied frequently because of its obvious clinical significance in many surgical patients. A technique that quantifies intraleukocyte iodination was used to measure polymorphonuclear leukocyte phagocytosis in heat inactivated and nonheat inactivated sera in the presence of two different corticosteroids: hydrocortisone sodium phosphate (HSP) and methylprednisolone sodium succinate (MSS). HSP produced a significant reduction in phagocytosis in the cells of healthy subjects when both heat inactivated autologous and isologous serum samples were used. MSS showed no such effect. Conversely, MSS produced a significant reduction in phagocytosis in the cells of healthy subjects when nonheat inactivated autologous serum was used but not when isologous serum was used. These data generally tend to confirm previous studies suggesting that MSS is less deleterious to some host defense processes than HSP and may be the steroid of choice when infection threatens the recipient.