Implementation of best medical therapy for cardiovascular risk factors in vascular surgery patients treated in a tertiary referral regional unit.

OBJECTIVE: Current clinical evidence reports that antiplatelet, statin, angiotensin-converting enzyme inhibitor and beta blockade therapies have advantageous effects on vascular surgery patient morbidity and mortality. Unfortunately, such patients appear to be less likely to receive optimal medical management when compared with coronary artery disease patients. This study assessed medical therapy prescribing in patients attending a regional vascular surgery unit. METHODS: A retrospective review between February 2010 and February 2011 was performed for patients undergoing aortic aneurysm, carotid, peripheral arterial and amputation surgeries. Gender, age, smoking history, body mass index and cardiovascular risk factors were documented from inpatient charts. Current admission medications and subsequent modification by the vascular team were recorded. RESULTS: Two hundred and forty-four patients (male = 165, mean age = 71 years) were identified. Prevalence of hypertension, hypercholesterolaemia, myocardial infarction, angina, stroke and diabetes was higher than in the general population. A total of 201 (82.3%) patients were on antiplatelets or antithrombotics upon admission to the vascular ward, which was improved to 231 (94.6%) patients on discharge. A total of 180 (73.7%) patients were on lipid-lowering therapy upon admission, which was improved to 213 (87.2%) patients on discharge. A total of 115 (47.1%) patients were on ACE-inhibitor or angiotensin 2 receptor blocker medications on admission and this was improved to 118 (48.3%) upon discharge. A total of 87 (35.6%) patients were on a beta-blocker, which was improved to 93 (38.1%) patients upon discharge. CONCLUSION: Despite increased implementation of best medical therapy in the community with compliance rates greater than 73% for aspirin and statin therapy, further improvement is warranted. Vascular surgeons should remain vigilant for further opportunities to optimise medical therapy in this high-risk patient group particularly with antithrombotic, lipid lowering and antihypertensive therapies.

Inferior vena cava thrombosis: a review of current practice.

Inferior vena cava (IVC) thrombosis remains under-recognised as it is often not pursued as a primary diagnosis. The aetiology of IVC thrombosis can be divided into congenital versus acquired, with all aetiological factors found among Virchow's triad of stasis, injury and hypercoagulability. Signs and symptoms are related to aetiology and range from no symptoms to cardiovascular collapse. Painful lower limb swelling combined with lower back pain, pyrexia, dilatation of cutaneous abdominal wall veins and a concurrent rise in inflammatory markers are suggestive of IVC thrombosis. Following initial lower limb venous duplex, magnetic resonance imaging (MRI) is the optimal non-invasive imaging tool. Aetiology directs treatment, which ranges from anticoagulation and lower limb compression to open surgery, with endovascular therapies increasingly favoured. The objective of this review is to assess current literature on the aetiology, presentation, investigation, treatment, prognosis and other factors pertaining to IVC thrombosis.

Bone marrow micrometastases in esophageal carcinoma: a 10-year follow-up study.

Detection of bone marrow micrometastases (BMMs) in patients with esophageal carcinoma may indicate a metastatic phenotype. We assessed if the presence of BMMs had adverse prognostic significance in a 10-year follow-up study. Patients undergoing surgery for esophageal cancer were prospectively recruited between February 1999 and August 2000. Bone marrow aspirates were obtained from the iliac crest of patients under general anesthesia at the time of surgery. Immunocytochemical analysis using anticytokeratin antibodies CAM 5.2 and AE1/AE3 was undertaken to determine the presence of BMMs. Union International Contre le Cancer staging was recorded for all patients. Patient follow-up was completed over a 10-year period through analysis of the Northern Ireland Cancer Registry. Forty-two patients (male = 35) were included, with a mean age of 67.2 years (range 39-83). BMMs were detected in 19 patients (45.2%). International Contre le Cancer tumor staging was stage I = 6, stage II = 10, stage III = 24, and stage IV = 2. BMMs were associated with lymphovascular invasion (P= 0.02) and advanced T stage (P= 0.02). Overall, 10-year survival was 21.4% (n= 9), with a median follow-up of 877.5 days (interquartile range 391.5-2546.3). There was no statistically significant difference between the survival of patients with or without BMMs (1451.4 vs. 1431.6 days, P= 0.99). Univariate analysis demonstrated a trend toward decreased survival for patients with positive lymph nodes (P= 0.07), an increased T stage (P= 0.06), and lymphovascular invasion (P= 0.07). Multivariate analysis demonstrated that none of the variables were significant predictors of mortality. Although the presence of BMMs correlates with recognized adverse tumor characteristics in patients with esophageal cancer, micrometastases detected in the bone marrow at time of surgery does not influence long-term survival.

Quantification of tumour and circulating vascular endothelial growth factor (VEGF) in patients with oesophagogastric cancer: a long-term follow-up study.

Vascular endothelial growth factor (VEGF) is an angiogenic cytokine that regulates tumour angiogenesis. The prognostic significance of VEGF expression remains incompletely investigated for patients with oesophagogastric cancer. This study assesses the significance of tumour VEGF (T-VEGF) and circulating VEGF (C-VEGF) expression in a 10-year follow-up of patients with oesophagogastric cancer. Patients undergoing surgical resection were prospectively recruited between February 1999 and August 2000. Circulating VEGF, derived both from plasma (P-VEGF) and serum (S-VEGF), and T-VEGF were assessed using a commercial enzyme-linked immunosorbent assay (ELISA). As platelet count may contribute to C-VEGF, pre-operative platelet levels were also recorded to exclude a confounding effect. Patients were followed up over a 10-year period using the Northern Ireland Cancer Registry. Sixty-one patients were recruited (men=45) with a mean age of 65.7 years. The 10-year survival was 19.7% (n=12) with a median follow-up of 808 days (inter-quartile range [IQR]: 349.5-2358.5). Union for International Cancer Control (UICC) tumour staging was Stage I=9 (14.8%), Stage II=15 (24.6%), Stage III=33 (54.1%) and Stage IV=4 (6.6%). The only significant relationship between clinicopathological features and the study variables was for S-VEGF, which was elevated in patients with advanced T-stage (P = 0.05). Circulating VEGF did not correlate with platelet count. Although a trend towards decreased survival was observed for patients who had positive lymph nodes (P = 0.08) and advanced UICC stage (P = 0.09) on univariate analysis, only lymphovascular invasion significantly predicted poor prognosis in this cohort (P = 0.05). Therefore, ELISA quantification of circulatory or tumour VEGF does not appear to be a significant predictor of mortality in patients with oesophagogastric cancer.

Assessment of the quality of care and financial impact of a virtual renal clinic compared with the traditional outpatient service model.

BACKGROUND: Patients with chronic kidney disease (CKD) have better outcomes when they have access to specialist nephrology services early in the course of their disease. However, up to 30% of patients with advanced kidney disease face late referral. Virtual clinics represent a potentially innovative mechanism for early assessment of high patient volumes efficiently and cost effectively while maintaining high standards of care. METHODS: A retrospective observational cohort study was completed over a 4-year period from April 2004 to March 2008 at a regional nephrology centre within Northern Ireland. All new patient attendances at the nephrology clinic were identified and those managed via the virtual renal clinic approach were included in this study. A cost comparison of this innovative modality was made with the traditional outpatient service model. RESULTS: There were 427 patients (51.3% female, 48.7% male) managed through the virtual renal clinic. Comorbidities included 180 patients (42.1%) with known CKD and 31 patients (7.3%) with newly identified kidney disease. A total of 118 patients (27.6%) had hypertension while 6 (1.4%) and 57 (13.3%) had type I and II diabetes mellitus (DM) respectively. Referral indications included 211 patients (49.4%) with abnormal renal biochemistry, 35 (8.2%) with proteinuria, 12 (2.8%) with haematuria and 87 patients (20.4%) with a combination of issues. A conservative treatment plan consisting of biochemical surveillance was appropriate for 246 patients (57.6%) while medication review was completed for 113 patients (26.5%) and surgical referral was indicated in 20 patients (4.7%). The virtual renal clinic provided a minimum cost saving of £111.56 per patient attendance compared with traditional outpatient care resulting in 23.3% of patient referrals being managed by the virtual clinic approach in 2009. CONCLUSION: Delayed referral to a renal specialist adversely affects patient outcomes. This study suggests that the implementation of a virtual renal clinic for non-complex renal pathologies can offer a cost-effective, rapid referral mechanism for patient assessment combined with readily available specialist advice.

Self-expanding metal stent insertion for inoperable esophageal carcinoma in Belfast: an audit of outcomes and literature review.

Successful palliation of dysphagia in patients with inoperable esophageal carcinoma has a major effect on quality of life. Self-expanding metal stents (SEMS) are currently recommended for rapid symptomatic relief when life expectancy is less than 3 months. We assessed complication and reintervention rates along with survival outcomes in patients with inoperable esophageal carcinoma undergoing stent insertion. A retrospective audit was performed from April 2007 to June 2009 for all inoperable primary esophageal carcinoma patients who had an esophageal stent inserted for dysphagia. Case notes were reviewed for clinical, pathological, stent and complication details, while ICD-10 causes of death were obtained from the Department of Health and Social Services, Northern Ireland. Fifty-six stents were inserted into 53 patients (66.0% male, mean age of 70 years). Inoperability was defined by metastatic spread (n= 34, 64.2%), locally advanced disease (n= 7, 13.2%), and severe medical comorbidities (n= 12, 22.6%). The median time from diagnosis to stent insertion was 109 (interquartile range [IQR] 43-187) days. Fifty stents (94.3%) were successfully deployed, while three patients (5.7%) required an additional stent as the primary stent had not bridged the tumor (proximal deployment = 2, suboptimal stent length = 1). Post-SEMS dysphagia scores were significantly better than pre-SEMS scores (2.90 vs. 1.54, P < 0.001). There were 27 complications identified in 23 (43.4%) patients (major complications = 9, minor complications = 14). Twelve patients (22.6%) required additional endoscopic procedures. The 30-day mortality rate was 11.3% (n= 6). Only one patient (1.9%) remains alive with a cumulative median survival rate of 84 (IQR 38-156) days. Esophageal stent insertion in this group of patients still presents a clinical challenge, with complication and endoscopic reintervention rates of 43.4 and 22.6%, respectively. Our results are comparable with previously published series, and as a palliative modality stent insertion remains appropriate when expected survival is less than 3 months. A range of SEMS is currently available with broadly similar efficacy and safety profiles. Data regarding the newly available fully covered SEMS suggest that they should be avoided.

The effect of sporting events on emergency department attendance rates in a district general hospital in Northern Ireland.

BACKGROUND: Previous studies have reported a conflicting relationship between the effect of live and televised sporting events on attendance rates to emergency departments (ED). The objectives of this study were to investigate the relationship of major sporting events on emergency department attendance rates and to determine the potential effects of such events on service provision. METHODS: A retrospective analysis of ED attendances to a district general hospital (DGH) and subsequent admissions over a 24-h period following live and televised sporting activities was performed over a 5-year period. Data were compiled from the hospital's emergency record books including the number of attendances, patient demographics, clinical complaint and outcome. Review patients were excluded. Analysis of sporting events was compiled for live local, regional and national events as well as world-wide televised sporting broadcasts. RESULTS: A total of 137,668 (80,445 men) patients attended from April 2002 to July 2007. Mean attendance rate per day was 80 patients (men = 47). Mean admission rate was 13.6 patients per day. Major sporting events during the study period included; Soccer: 4 FA Cup and 1 World Cup (WC) finals; Rugby: 47 Six Nations, 25 Six nations games involving Ireland, 1 WC final, 2 WC semi-finals, 2 WC quarter-finals and 4 WC games involving Ireland; and Gaelic Football [Gaelic Athletic Association (GAA)]: 5 All-Ireland finals, 11 semi-finals, 11 quarter-finals and 5 provincial finals. There was a significantly higher patient admission rate during the soccer FA Cup final, Rugby Six Nations and games involving Ireland and for GAA semi- and quarter-final games (p = 0.001-0.01). There was no difference identified in total attendance or non-admission rates for sporting events throughout the study period. Although there was no correlation identified between any of these sporting events and total emergency department attendances (r < 0.15, p > 0.07), multinomial logistic regression demonstrated that FA Cup final (p = 0.001), Rugby Six Nations (p = 0.019), Rugby WC games involving Ireland (p = 0.003), GAA All-Ireland semi- and quarter-finals (p = 0.016; p = 0.016) were predictors of patient admission rates. CONCLUSION: This study suggests that live or televised sporting events do not significantly affect ED attendances to a DGH. However, some events appeared to be predictors of patient admission rates. Although it may be beneficial to consider the effect of sporting events on service stratification during these periods, the overall effect is probably minimal and should not create a major concern for future service provision despite the implementation of the European Working Time Directive.

The effects of cilostazol on exercise-induced ischaemia-reperfusion injury in patients with peripheral arterial disease.

OBJECTIVES: Cilostazol improves walking distance in peripheral arterial disease (PAD) patients. The study objectives were to assess the effects of cilostazol on walking distance, followed by the additional assessment of cilostazol on exercise-induced ischaemia-reperfusion injury in such patients. METHODS: PAD patients were prospectively recruited to a double-blinded, placebo-controlled trial. Patients were randomised to receive either cilostazol 100mg or placebo twice a day. The primary end-point was an improvement in walking distance. Secondary end-points included the assessment of oxygen-derived free-radical generation, antioxidant consumption and other markers of the inflammatory cascade. Initial and absolute claudication distances (ICDs and ACDs, respectively) were measured on a treadmill. Inflammatory response was assessed before and 30 min post-exercise by measuring lipid hydroperoxide, ascorbate, alpha-tocopherol, beta-carotene, P-selectin, intracellular and vascular cell-adhesion molecules (I-CAM and V-CAM), thromboxane B(2) (TXB(2)), interleukin-6, interleukin-10, high-sensitive C-reactive protein (hsCRP), albumin-creatinine ratio (ACR) and urinary levels of p75TNF receptor. All tests were performed at baseline and 6 and 24 weeks. RESULTS: One hundred and six PAD patients (of whom 73 were males) were recruited and successfully randomised from December 2004 to January 2006. Patients who received cilostazol demonstrated a more significant improvement in the mean percentage change from baseline in ACD (77.2% vs. 26.6% at 6 weeks, p=0.026 and 161.7% vs. 79.0% at 24 weeks, p=0.048) as compared to the placebo. Cilostazol reduced lipid hydroperoxide levels compared to a placebo-related increase before and after exercise (6 weeks: pre-exercise: -11.8% vs. +5.8%, p=0.003 and post-exercise: -12.3% vs. +13.9%, p=0.007 and 24 weeks: pre-exercise -15.5% vs. +12.0%, p=0.025 and post-exercise: -9.2% vs. +1.9%, p=0.028). beta-Carotene levels were significantly increased in the cilostazol group, compared to placebo, before exercise at 6 and 24 weeks (6 weeks: 34.5% vs. -7.4%, p=0.028; 24 weeks: 34.3% vs. 17.7%, p=0.048). Cilostazol also significantly reduced P-selectin, I-CAM and V-CAM levels at 24 weeks as compared to baseline (p<0.05). There was no difference between treatment groups for ascorbate, alpha-tocopherol, interleukin-6 and -10, hsCRP and p75TNF receptor levels. CONCLUSIONS: Cilostazol significantly improves ACD, in addition to attenuating exercise-induced ischaemia-reperfusion injury, in PAD patients.

Smoking impairs endothelial function in human saphenous vein in an ex vivo model.

The aim of this ex vivo experimental study was to assess the effect of smoking, diabetes mellitus, and hypertension on endothelial function in human saphenous vein, a commonly used conduit for coronary and peripheral arterial bypass surgery. A segment of long saphenous vein harvested during infrainguinal bypass surgery was mounted in an organ bath for isometric tension studies. Vein rings were precontracted to submaximal contraction with phenylephrine, followed by endothelium-dependent relaxation with acetylcholine. Long saphenous vein segments were collected from 26 patients, including five females, with a mean age of 66.4 years (range 48-92). Current smokers had impaired endothelium-dependent relaxation compared to ex- and nonsmokers (10.2%, n=13, vs. 32.9%, n=13; p<0.010). However, ex-smokers and nonsmokers did not have a significant difference in relaxant responses to acetylcholine (29.1%, n=8, vs. 24.6%, n=5; p=nonsignificant [ns]). Similarly, diabetic and nondiabetic patients did not show a significant difference in endothelium-dependent relaxation (23.1%, n=10, vs. 15.6%, n=16; p=ns). The relaxant responses in hypertensive and normotensive patients were not different (20.4%, n=12, vs. 22.5%, n=14; p=ns). Smoking has a deleterious effect on the endothelial function of saphenous vein, and smoking cessation may improve the long-term durability of saphenous vein used as a bypass graft in patients undergoing arterial reconstruction.

Ultrasound is a useful adjunct to mammography in the assessment of breast tumours in all patients.

BACKGROUND: Ultrasound is the first-line breast imaging modality in younger patients and an adjunct to mammography in older patients. The objectives of this study were to evaluate the complementary value of ultrasound to mammography in breast cancer and to investigate the use of ultrasound in patients above and below the age of 50 years. METHODS: Clinical presentation and investigations for consecutive patients undergoing triple assessment at a symptomatic breast clinic were prospectively recorded between January 2000 and August 2003. Clinical data were compared with pathological findings. Patients were divided into two groups, above and below 50 years of age for subgroup analyses. RESULTS: A total of 999 of 2185 patients had both mammography and ultrasound investigations performed and constituted the study population. Subgroup analysis of the 2185 patients demonstrated that 99 of the 127 patients who were diagnosed with breast cancer had both investigations performed (median age 57.0, range: 34-89 years). Mammography was normal/benign in 14.1%, indeterminate in 29.3% and suspicious of cancer in 56.6% of patients. Adjunctive ultrasound was normal/benign in 13.1%, indeterminate in 6.1% and suspicious of cancer in 80.8% of patients. In these 99 patients, adjunctive ultrasound was more sensitive than mammogram alone (80.8% vs. 56.6%, p < 0.001). Ultrasound upgraded nine of 14 mammographically normal and 16 of 29 mammographically indeterminate X-rays to a cancer. Mammography appeared to be more sensitive in patients over 50 years compared with those patients under 50 years (62.5% vs. 45.7%, p = 0.10). The sensitivity of ultrasound was comparable between patients above and below the age of 50 years (82.8% vs. 77.1%, p = 0.60). Further subgroup analysis demonstrated a higher sensitivity with combined mammography and ultrasound compared with mammography alone in either patient group (below 50: 45.7%-->77.1% and above 50: 62.5%-->82.8%). These results also suggested that the difference in the sensitivities of mammography vs. the combined investigation approach was more marked in patients under 50 years of age (below 50 = 31.4% vs. above 50 = 20.3%). CONCLUSION: Adjunctive ultrasound assessment improves breast cancer detection in women of all ages and should be routinely used in symptomatic breast clinics.

Fine needle aspiration at a Regional Head and Neck Clinic: a clinically beneficial and cost-effective service.

BACKGROUND: Fine needle aspiration (FNA) is an important adjuvant to the diagnosis of a palpable lesion which often permits the complete assessment of patients. The main objective of this study was to determine the clinical benefit of a dedicated FNA service at a tertiary referral Head and Neck Clinic and to assess if such a service is cost effective. METHODS: All patients attending the Head and Neck Clinic during 2004 were prospectively assessed in this study. Patient records were analysed regarding investigative modalities including FNA, the subsequent cytology result and the requirement for further histopathological investigations. A cost analysis for all investigative procedures was performed. RESULTS: A total of 135 patients (36 males) had FNAs performed during the study period. The median age was 51.5 years (range 17-92). Patients presented with lesions of lymph nodes (n = 46), thyroid (n = 41), salivary, parotid or submandibular glands (n = 22) and other cutaneous or cystic lesions (n = 26). Cytological grading results were; C1 = 26, C2 = 93, C3 = 8, C4 = 2 and C5 = 6. Patients with lesions C3 or above normally proceeded to further investigations. The overall cost of the FNA per episode in the out-patient clinic was pound114 per episode compared to day case open biopsy per patient of pound333 and an in-patient stay per patient was pound2371. FNA provided sufficient pathological diagnosis to avoid day case surgery in 57 patients (42.2%), and inpatient surgery in 65 patients (48.1%) resulting in a total saving of pound158 372 in 2004. CONCLUSION: This study demonstrates the clinical benefit and cost-effectiveness of FNA services in a dedicated Head and Neck clinic.

Completion mastectomy after breast conserving surgery.

BACKGROUND: Breast conserving surgery (BCS) is increasingly offered to suitable patients diagnosed with early stage breast cancer. Occasionally the pathological margins on specimens following BCS are positive. The objective of this study is to assess the proportion of patients within our unit who required completion mastectomy after BCS and to determine if predictive factors could be identified to assist the breast surgeon identifying those patients at risk of positive margins following BCS. METHODS: All patients diagnosed with breast cancer between 2001 and 2005 were reviewed. Patients undergoing BCS had their histopathological specimens examined for any evidence of residual tumour at the margins of the resected specimen. These patients then proceeded to completion mastectomy if these margins were positive for residual tumour. Multinominal logistic regression was then performed on clinico-pathological factors for each of these patients to determine if predictive factors existed for determination of residual disease in the mastectomy specimen following BCS. RESULTS: Logistic regression demonstrated that size of the initial tumour was the only significant predictor for the presence of completion mastectomy residual carcinoma (CMRC) (p=0.014) and that tumours with an initial size > 2.5 cm were 15 times more likely to have a CMRC than tumours < 1.5 cm. This prediction model based on the initial tumour size had an 89.5% specificity and 52.2% sensitivity. The odds ratio for CMRC based on histological tumour type for each additional 1cm increase in size of the initial tumour was 2.82 for ductal carcinoma in situ, 2.60 for infiltrating ductal carcinoma and 2.26 for other tumours. CONCLUSION: This study demonstrates that residual disease in total mastectomy specimens following BCS increases significantly with increasing original tumour size. With current data, surgeons can inform patients of the risks of residual cancer associated with BCS with a view to increase the rate of primary mastectomies in those patients with presenting tumours greater than 2.5 cm.

Mediastinal shift secondary to a diaphragmatic hernia: a life-threatening combination.

An 85-year-old man was referred to our department, with a three-day history of increasing shortness of breath. Following clinical and radiological assessment, diaphragmatic herniation of bowel was identified to be causing mediastinal shift and respiratory distress. An emergency laparotomy identified a massive diaphragmatic defect which was not amenable to primary closure. A colopexy procedure was performed to comparmentalise the abdomen and obliterate the diaphragmatic defect. Despite aggressive treatment in the intensive care unit he died from multi-organ failure. This case highlights an extremely rare and life-threatening cause of mediastinal shift and respiratory distress.

Mesenteric artery occlusion secondary to activated protein C resistance: a life-threatening combination.

We present a case of mesenteric ischemia in a 32-year-old woman. The rarity of this potentially fatal condition in this age group, the diagnostic and therapeutic challenges associated with such a condition, and secondary causes that must always be investigated are highlighted. In this case, activated protein C resistance resulted in thrombosis of the superior mesenteric artery and subsequent bowel ischemia.

Estrogen-related mood disorders: reproductive life cycle factors.

Women are at higher risk throughout their reproductive lives than are men for major depression. Numerous molecular and clinical studies have implicated estrogen in modulating brain function including that related to mood. In an attempt to present a conceptual model, the literature of the past 30 years on mood and well-being throughout reproductive life is reviewed as it relates to activity of endogenous, bio-identical, and synthetic estrogen in women. Results indicate that sudden estrogen withdrawal, fluctuating estrogen, and sustained estrogen deficit are correlated with significant mood disturbance. Clinical recovery from depression postpartum, perimenopause, and postmenopause through restoration of stable/optimal levels of estrogen has been noted.

Content, accuracy and completeness of patient consent in a regional vascular surgery unit.

OBJECTIVE: Although the General Medical Council has published guidelines for procedural consent, there is evidence to suggest that deficiencies still occur in completion demographics, documentation of procedural risks and information regarding alternative therapies. We assessed the accuracy and completeness of vascular consent within our unit. METHODS: A retrospective review of patients undergoing vascular intervention between February 2010 and 2011 was performed. Patient chart examination included the analysis of consenting doctors' grade, responsible vascular consultant, completeness of procedural entry, documentation of correct side, use of abbreviations, discussion of benefits and complications, additional information and overall legibility. RESULTS: 323 patient consent forms were reviewed (male 203, mean age 68.0 years, elective surgery 241) including 50 AAA repairs, 27 carotid endarterectomies, 88 peripheral arterial reconstructions, 96 amputations and 69 elective varicose vein surgeries. 294 (91%) consent forms were completed by a specialist registrar or above with 286 (88.5%) forms having the responsible consultant documented. 85.4% of patients were consented within 48 h of surgery. 245 (75.9%) consent forms had legible printed names. However, only 75 (23.2%) had a legible signature. 306 (94.7%) consent forms had the procedure documented in full but 165 (51.0%) had used abbreviations. 103 (31.9%) had documentation of the intended benefits of surgery whilst 293 (90.7%) had documentation of potential complications. Three patients had documented evidence of receiving written information and one patient received a copy of the consent form. Of those surveyed, procedural mortality was discussed in 62.5% of open and 47.3% of endovascular AAA repairs. Stroke was documented in 96.3% of consent forms for carotid endarterectomy. Scarring was included most commonly in patients undergoing venous procedures. CONCLUSION: Vascular consent is a complex process involving a number of discussions and meetings with patients. Our unit has demonstrated compliance of nearly 90% for all consent-related processes and remains consistent with current GMC guidance. However, further improvement including the documentation of intended benefits, provision of additional written information whilst reducing the use of abbreviations is desired.

Effect of atrial natriuretic factor on Na+-K+-Cl- cotransport of vascular smooth muscle cells.

We previously demonstrated that vascular smooth muscle cells possess a prominent Na+-K+-Cl- cotransport system that can be markedly stimulated by elevations in levels of intracellular cyclic guanosine 3',5'-monophosphate (cGMP). Since others have shown that atrial natriuretic factor (ANF) can bind to specific membrane receptors and can enhance cGMP levels in vascular smooth muscle cells, we asked whether ANF could also stimulate Na+-K+-Cl- cotransport in vascular smooth muscle cells. It was discovered that rat atriopeptin III stimulated Na+-K+-Cl- cotransport of vascular smooth muscle cells in a concentration-dependent manner. In contrast, rat atriopeptin III had no effect on two other sodium transport systems known to be present in vascular smooth muscle cells (i.e., Na+-H+ exchange and Na+-K+-adenosine triphosphatase (ATPase). These studies indicated that ANF selectively stimulates Na+-K+-Cl- cotransport of vascular smooth muscle cells. We then asked whether ANF-stimulated Na+-K+-Cl- cotransport was dependent upon the ability of ANF to enhance intracellular cGMP levels. When rat atriopeptin III-stimulated increases in cGMP were inhibited with the quinolinedione LY 83583, rat atriopeptin III could no longer stimulate Na+-K+-Cl- cotransport of vascular smooth muscle cells. Thus it appeared that the effects of ANF were dependent upon the ability of ANF to elevate intracellular cGMP levels. Finally, we asked whether ANF effects on Na+-K+-Cl- cotransport were related to the biological activity of ANF.(ABSTRACT TRUNCATED AT 250 WORDS)

Na-K-Cl cotransport in normal and glaucomatous human trabecular meshwork cells.

PURPOSE: Previous results from this laboratory showed that intracellular volume of trabecular meshwork (TM) cells is regulated by the Na-K-Cl cotransport system. Other studies suggest that TM cell volume, in turn, is a determinant of permeability across the TM. Given that a decrease in outflow facility across the TM is thought to be the primary cause of elevated intraocular pressure in primary open-angle glaucoma, the present study was conducted to investigate the possibility that Na-K-Cl cotransport function may be altered in glaucomatous TM cells compared with normal TM cells. METHODS: Normal and glaucomatous human TM cells were cultured from donor eyes and trabeculectomy specimens, respectively. Trabecular meshwork cell monolayers were evaluated for Na-K-Cl cotransport activity, assessed as ouabain-insensitive, bumetanide-sensitive K influx using 86Rb as a tracer for K. Cotransporter protein expression was determined by western blot analysis, and intracellular volume was determined radioisotopically using [14C]urea and [14C]sucrose as markers of total and extracellular water space, respectively. RESULTS: Na-K-Cl cotransport activity of glaucomatous TM cells was found to be reduced by 32% +/- 2% compared with that of normal TM cells, whereas western blot analyses showed that cotransporter protein expression in glaucomatous TM cells was reduced by 64% +/- 14% compared with expression in normal TM cells. Also, exposure of normal TM cells to 10 microM norepinephrine or 50 microM 8-bromo-3',5'-cyclic adenosine monophosphate was found to diminish Na-K-Cl cotransport activity, whereas these agents were without effect on glaucomatous TM cell cotransport. Finally, resting cell volume of glaucomatous TM cells was found to be increased compared with that of normal TM cells, whereas intracellular volume of both cell types was reduced after exposure to 10 microM benzmetanide or 10 microM bumetanide. CONCLUSIONS: These findings indicate that Na-K-Cl cotransport function and regulation are altered in glaucomatous TM cells compared with that of normal TM cells. However, the observation that cell volume of glaucomatous TM cells is greater than that of normal TM cells, despite reduced Na-K-Cl cotransport activity, suggests that other volume-regulatory ion flux pathways may be involved in the reduced outflow of glaucoma.