Joint recommendations for reporting carotid ultrasound investigations in the United Kingdom.

At present in the United Kingdom a number of different criteria are used to grade disease in carotid ultrasound investigations. One main cause of this has been the difference in the method of grading angiograms used in the NASCET and ECST large carotid surgery trials. It is desirable that all centres reporting carotid ultrasound investigations report to the same standard. This paper presents recommendations for the reporting of ultrasound investigations of the extra cranial arteries produced by a Joint Working Group formed between the Vascular Society of Great Britain and Ireland, and the Society for Vascular Technology of Great Britain and Ireland. The recommended criteria are based on the NASCET method of grading carotid bulb disease. Key recommendations include recording peak systolic velocity (PSV) and end-diastolic velocity (EDV) in both internal and distal common carotid arteries; measuring all velocities at a Doppler angle of 45-60 degrees; the use of internal carotid PSV of >1.25 ms(-1) and >2.3 ms(-1) and a Peak Systolic Velocity Ratio of >2 and >4 to indicate >50% and >70% stenosis respectively; and the use of the St Mary's Ratio to grade >50% stenoses in deciles. General recommendations are also given for the acquisition, interpretation and reporting of the data.

Trastuzumab-associated cardiac adverse effects in the herceptin adjuvant trial.

PURPOSE: The purpose of this analysis was to investigate trastuzumab-associated cardiac adverse effects in breast cancer patients after completion of (neo)adjuvant chemotherapy with or without radiotherapy. PATIENTS AND METHODS: The Herceptin Adjuvant (HERA) trial is a three-group, multicenter, open-label randomized trial that compared 1 or 2 years of trastuzumab given once every 3 weeks with observation in patients with HER-2-positive breast cancer. Only patients who after completion of (neo)adjuvant chemotherapy with or without radiotherapy had normal left ventricular ejection fraction (LVEF > or = 55%) were eligible. A repeat LVEF assessment was performed in case of cardiac dysfunction. RESULTS: Data were available for 1,693 patients randomly assigned to 1 year trastuzumab and 1,693 patients randomly assigned to observation. The incidence of trastuzumab discontinuation due to cardiac disorders was low (4.3%). The incidence of cardiac end points was higher in the trastuzumab group compared with observation (severe congestive heart failure [CHF], 0.60% v 0.00%; symptomatic CHF, 2.15% v 0.12%; confirmed significant LVEF drops, 3.04% v 0.53%). Most patients with cardiac dysfunction recovered in fewer than 6 months. Patients with trastuzumab-associated cardiac dysfunction were treated with higher cumulative doses of doxorubicin (287 mg/m(2) v 257 mg/m(2)) or epirubicin (480 mg/m(2) v 422 mg/m(2)) and had a lower screening LVEF and a higher body mass index. CONCLUSION: Given the clear benefit in disease-free survival, the low incidence of cardiac adverse events, and the suggestion that cardiac dysfunction might be reversible, adjuvant trastuzumab should be considered for treatment of breast cancer patients who fulfill the HERA trial eligibility criteria.

Audit of 149 consecutive carotid endarterectomies performed by a single surgeon in a district general hospital over a 12-year period.

Carotid endarterectomy has been established by two large randomised controlled trials (European Carotid Surgery Trial (ECST) and North American Symptomatic Carotid Endarterectomy Trial (NASCET)) as an important surgical procedure for the prevention of ischaemic strokes in patients presenting with transient cerebral ischaemia or non-disabling strokes attributable to severe ipsilateral carotid artery stenosis. The operation carries significant risk of death and stroke and it has been advocated by some that carotid endarterectomy should only be performed in a small number of designated regional centres in order to achieve good surgical results. It is doubtful that the regional centres alone can cope with the increasing numbers of patients requiring carotid endarterectomy and there is therefore a requirement for the procedure to be carried out by vascular surgeons in district general hospitals. It is important that surgical results are audited to ensure that comparable outcomes are achieved. We present an audit of our experience of carotid endarterectomy since 1981. A total of 149 consecutive carotid endarterectomies were performed by a single surgeon with a special interest in carotid surgery. The results are comparable to ECST with a 30-day mortality of 0% and an overall 30-day stroke rate of 5.7% (major strokes) for patients with severe, ie 70-99%, ipsilateral carotid artery stenoses. We have shown that carotid endarterectomy is an operation that can be performed safely and with good results by suitably trained surgeons in district general hospitals.

The A-V Impulse System reduces deep-vein thrombosis and swelling after hemiarthroplasty for hip fracture.

We performed a prospective randomised controlled trial of the A-V Impulse System in 82 patients treated by hemiarthroplasty for subcapital fracture of the femoral neck. The incidence of proximal deep-vein thrombosis as assessed by Doppler ultrasonography was 23% in the control group and 0% in those using the device (p less than 0.01). Calf and thigh circumferences were measured in both groups at seven to ten days after operation. In the treatment group there was a mean relative reduction of postoperative swelling of the thigh by 3.27 cm (p less than 0.001) and of the calf by 1.55 cm (p less than 0.001). The A-V Impulse System appears to be a safe and effective method of reducing the incidence of proximal deep-vein thrombosis, and of postoperative swelling.