Endoscopic vein harvesting in lower extremity arterial bypass: a systematic review.

OBJECTIVE: Endoscopic vein harvesting (EVH) for arterial bypass surgery may be associated with lower wound complication rates than open vein harvesting (OVH), but other long-term outcomes remain controversial, and there are concerns that graft patency may be poorer after EVH compared with OVH. We conducted a systematic review of all available evidence for EVH in lower extremity arterial bypass (LEAB). METHODS: A literature search of Medline, Embase, Ovid and Cochrane databases between 1996 and 2013 was performed using the terms "endoscopic vein harvesting", "minimally invasive vein harvest", "peripheral bypass surgery", and "lower extremity bypass surgery", and detailed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Primary outcomes were graft patency and overall wound complication rates. Secondary outcomes were wound infection, length of hospital stay, and cost-effectiveness. Summary estimates were calculated by random effects meta-analysis if sufficient data were available. RESULTS: We identified 18 cohort studies and case series, with considerable clinical heterogeneity, including 2,343 patients. Meta-analysis of six studies revealed a significantly reduced rate of primary patency after EVH (hazard ratio 1.29, 95% confidence interval [CI] 1.03-1.63), with no significant difference between EVH and OVH with respect to wound infection in 12 studies (odds ratio 0.81, 95% CI 0.61-1.08). There was a lack of strong evidence to support the secondary outcomes of EVH. CONCLUSION: EVH reduces primary patency rates after LEAB, but does not demonstrate an advantage with respect to postoperative wound complications. However, the available data are heterogeneous, and uncertainty is introduced by both evolution in technology and increasing technical experience. EVH should be used with caution and in the context of formal research.

Delay influences outcome after lower limb major amputation.

AIM: To investigate if a relationship exists between hospital waiting time to major amputation and outcome. METHOD: All patients undergoing major lower limb amputation in England between April 2002 and March 2006 were identified from the Hospital Episodes Statistics (HES) data. Amputations related to trauma or malignancy were excluded. The length of wait (LOW), from date of admission to date of major amputation was calculated. A two-level regression model was used to investigate if LOW had a significant effect on recovery time and in-hospital mortality. Results were adjusted for age, sex, Charlson score, Social Deprivation, mode of intervention (bypass/angioplasty/no intervention) and mode of admission (emergency/elective). RESULTS: 14,168 major amputations were identified. 12,884 (90.9%) had no intervention prior to amputation on that admission. Length of Wait (LOW) significantly prolonged recovery in men (Exponential Estimate 1.01 1.01-1.02 p < 0.0001) and women (EE 1.02 1.01-1.02 p < 0.0001) and increased in-hospital mortality in men (OR 1.02 1.02-1.03 p < 0.0001). Risk of in-hospital death increased by 2% for each day waited. CONCLUSION: Delays in decision making or in getting a patient into the operating theatre have a negative effect on patient outcome in terms of overall length of stay and mortality after major lower limb amputation.

Centralization harnessing volume-outcome relationships in vascular surgery and aortic aneurysm care should not focus solely on threshold operative caseload.

There has been great interest in the setting of threshold operative volumes for safety to guide centralisation of vascular surgical services by healthcare commissioners. This editorial examines the evidence for designing services around a numeric safety threshold in the relationship between volume and outcome in vascular surgery. Thresholds should be aimed at the best outcomes and equity of care. Equity means access to the most up-to-date technology and all the relevant support services for elective and emergency cases. The relationship of volume and outcome with quality is complex, and demands a shift in focus to infrastructural and procedural improvements that drive high-quality services rather than the concentration of planning exclusively around an operative volume threshold.

Screened individuals' preferences in the delivery of abdominal aortic aneurysm repair.

BACKGROUND: This study aimed to determine preferences for service attributes in a population screened for abdominal aortic aneurysm. METHODS: A questionnaire was designed to encompass various aspects of service provision. Questions were calibrated against the time an individual was willing to travel to access specific attributes. Subjects attending an aneurysm screening programme were asked to complete a questionnaire before their screening ultrasound scan. Statistical analysis was through pairwise analysis of the median travel times with the signed rank test. The Wilcoxon rank sum, analysed by the Kruskal-Wallis test, was used to compare preference ratings. RESULTS: A total of 262 individuals were asked to complete the questionnaire; the response rate was 98.5 per cent. Approximately 92 per cent of individuals stated a willingness to travel for at least 1 h beyond their nearest hospital in order to access services with a 5 per cent lower perioperative mortality rate, a 2 per cent lower amputation or stroke rate, a high annual caseload of aneurysm repairs, and routine availability of endovascular repair. CONCLUSION: Patients attending aneurysm screening were willing to travel beyond their nearest hospital to access a service with better outcomes, higher surgical volumes and endovascular surgery.

Endovascular aneurysm repair with preservation of the internal iliac artery using the iliac branch graft device.

OBJECTIVES: Aortoiliac aneurysms comprise up to 43% of the specialist endovascular caseload. In such cases endovascular aneurysm repair (EVAR) requires distal extension of the aortoiliac endograft beyond the ostium of the internal iliac artery (IIA) and into the external iliac artery, conventionally necessitating the embolisation of one or both IIA. This has been associated with a wide range of complications, and the use of an Iliac Branch-graft Device (IBD) offers an appealing endovascular solution. DESIGN: Medline, trial registries, conference proceedings and article reference lists were searched to identify case series reporting IBD use. Data were extracted for review. RESULTS: Nine series have reported the use of IBD in a total of 196 patients. Technical success was 85-100%. Median operating times were 101-290min and median contrast dose was 58-208g, with no aneurysm-related mortality. Claudication developed in 12/24 patients after IBD occlusion. One type I endoleak and two type III endoleaks occurred and were managed endovascularly. Re-occlusion occurred in 24/196 patients. CONCLUSION: IBD was performed with high technical success rates and encouraging mid-term patency. Formalised risk stratification and morphological data are required to identify the group of patients who will benefit most. Cost-effectiveness appraisals are needed for this technique.

Re-interventions, readmissions and discharge destination: modern metrics for the assessment of the quality of care.

AIM: To determine whether administrative data can be used to determine metrics to inform the quality agenda. To determine the relationship between these metrics and the method of abdominal aortic aneurysm (AAA) repair undertaken. METHODS: The Hospital Episode Statistics (HES) data were taken for a 5-year period (01.04.2003-31.03.2008). Cases of elective AAA repair were identified. Outcomes were determined in terms of mortality, discharge destination, re-intervention rates and emergency readmission rates. The results were interpreted in light of whether AAA repair was open or endovascular and whether patients were octogenarians or younger patients. RESULTS: There were 18,060 elective AAA repairs with a mean in-hospital mortality rate of 5.9%. Of these 14,141 were open repairs with a mean mortality of 6.5% and 3919 EVAR (22%) with a mean mortality of 3.8%. EVAR patients were less likely to be discharged to ongoing care (p < 0.001) but were associated with a higher rate of re-intervention (p = 0.001) than open repairs. No differences were seen in one-year readmission rates. Octogenarians were more likely to undergo EVAR (p = 0.001), to be readmitted within 30-days (p = 0.009), to require further interventions on their index admission (p < 0.001) and less likely to be discharged home (p < 0.001) than younger patients. CONCLUSION: Administrative data can be used to identify metrics other than mortality and length of stay. These metrics might be used to inform service provision. In particular for AAA repair, differences in these outcomes were identified between open repair and EVAR and between octogenarians and younger patients.

Indications for thrombolysis in deep venous thrombosis.

OBJECTIVES: Deep venous thromboses (DVTs) are a significant cause of morbidity and mortality in the general and inpatient population. Current anticoagulation therapy is efficient in reducing thrombus propagation but does not contribute to clot lysis or prevention of post-thrombotic limb syndrome. Catheter directed thrombolysis (CDT) is an alternative method for treating DVTs but there is no consensus regarding indications for its use. DATA SOURCES: PubMed and Cochrane library were searched for all articles on deep vein thrombosis and thrombolysis. REVIEW METHOD: Articles presenting data on DVT thrombolysis, DVT anticoagulation, mechanical thrombectomy, venous stenting and May-Thurner's syndrome were considered for inclusion in the review. RESULTS: CDT reduced clot burden, DVT recurrence and may prevent the formation of post-thrombotic syndrome. Indications for its use include younger individuals with a long life expectancy and few co-morbidities, limb-threatening thromboses and proximal ilio-femoral DVTs. There is a marked lack of randomised controlled trials comparing CDT-related mortality and long term outcomes compared to anticoagulation alone. The effectiveness of combined pharmaco-mechanic thrombectomy, although promising, need to be further investigated, as is the role of caval filters in preventing DVT-associated pulmonary emboli. CONCLUSIONS: These results suggest that the outcome of CDT in DVT management are encouraging in selected patient cohorts, but further evidence is required to establish longer term benefits and cost-effectiveness.

Atrial flutter ablation: efficacy and cost-effectiveness of a single decapolar electrode to demonstrate bidirectional isthmus block.

AIMS: To evaluate whether a single decapolar electrode is a reliable and cost-effective substitute for the 'Halo' catheter to map the circuit and detect bidirectional isthmus block during atrial flutter (AFL) ablation. METHODS AND RESULTS: Twenty-four patients underwent AFL ablation by using the decapolar electrode in the infero-lateral wall of right atrium (group A) while a 'Halo' catheter was used in 11 patients (group B). Both groups had similar clinical characteristics. Anti-clockwise rotation (20 patients), clockwise (3 patients) or both forms of AFL (1 patient) were detected in group A. All patients in group B had anti-clockwise AFL. Bidirectional isthmus block was completed in 22 patients of group A and in 9 of group B (P=NS) while incomplete isthmus block was detected in 2 patients in each group (P=NS). Mean fluoroscopy and procedure time was 27 +/- 47 min, 107 +/- 36 min in group A and 14 +/- 19 min, 114 +/- 65 min in group B (P=NS). AFL relapsed in 3 patients of group A (follow-up 7 +/- 4 months) and in 2 of group B (4 +/- 2 months). CONCLUSION: A single decapolar electrode is a reliable method to map the circuit and demonstrate bidirectional isthmus block during AFL ablation. The cost of the decapolar electrode is a quarter of that of the 'Halo' catheter. This represents a significant saving particularly for centres with a substantial number of AFL ablations.

The strategic use of outcome information.

BACKGROUND: Most health care executives see outcome measurement as a technical or tactical matter rather than as a strategic tool. Accordingly, provider investment in outcome measurement and management is relatively small. Nevertheless, outcome information can be key to achieving an organization's strategic objectives. Advances in risk adjustment and improvements in technology for data collection and analysis have made outcome measurement a practical tool for individual hospital use. CASE STUDIES: Strategically integrated outcome measurement efforts can give providers a competitive advantage over organizations that only use outcomes tactically. One of the best examples of an acute care provider that has used outcome information for strategic advantage is Intermountain Health Care (IHC; Salt Lake City). In 1997 IHC made clinical quality and outcomes the primary focus of its five-year strategic plan. To support the new strategy IHC's board of trustees approved the development of an outcome information system that generated data along clinical processes of care and the creation of a new management structure to use these data to hold professionals accountable and to set and achieve clinical improvement goals. From 1996 to 1999, IHC's share of the commercial health care market in Utah increased from roughly 50% to about 62% of the market, with the result that it has stopped actively marketing its services. DISCUSSION: Health care executives will not willingly invest in outcomes until they believe that they have business value. Therefore, making the business case for outcomes can help improve the quality of health care and the lives of individuals.

The track structures of ionizing particles and their application to radiation biophysics. I. A new analytical method for investigating two biophysical models.

A new approach to the interpretation of the effects of radiation on cells is described, in which sample particle tracks are constructed using a Monte Carlo computer program and the exposure of cellular targets to these tracks is simulated using a second program known as BIOPHYS. Data on the shapes and DNA contents of the cell nuclei are obtained from the literature. It is assumed that the sensitive material is DNA, and that the target is divided into cubes of approximately 2 nm (the diameter of the DNA helix) per side; the numbers of these cubes containing different numbers of ionizations are derived. Two different methods of analysing the output of BIOPHYS are described. In the first, it is assumed that lethality is caused by the occurrence of a number of ionizations equal to or greater than a certain threshold in one cube; in the second method, it is assumed that only two ionizations are required, in different parts of the cube, but that only some fraction of the cube is sensitive. These models have been applied to the interpretation of the variation of radiosensitivity with a linear energy transfer (LET) of spores of Bacillus subtilis exposed wet and dry, and good fits to the published experimental data were obtained using both models. Fits to experimental data for a range of other cell lines will be presented in a second paper.

Ultrasonographic assessment of bladder neck mobility in continent bitches and bitches with urinary incontinence attributable to urethral sphincter mechanism incompetence.

OBJECTIVE: To determine bladder neck positional changes between standing and recumbent positions in bitches and whether change is related to continence status or general anesthesia, or both, and to evaluate reproducibility of measurements. ANIMALS: 45 continent animals and 46 incontinent bitches with urethral sphincter mechanism incompetence (SMI). PROCEDURE: Distance between the bladder neck and perineal skin was measured ultrasonographically via the perineum while each dog was conscious in standing and right lateral recumbency and in right lateral recumbency under general anesthesia. Measurements of the bladder neck position obtained in right lateral recumbency under anesthesia were compared with radiographic measurements of the same parameter. Reproducibility of the ultrasonographic measurements of the distance between bladder neck and perineum was assessed on 3 occasions for each position in 50 dogs. RESULTS: In all dogs, differences in bladder neck position between standing and recumbent conscious-associated positions were not significant. However, caudal bladder neck movement between standing conscious- and recumbent anesthesia-associated positions and between recumbent conscious- and anesthesia-associated positions was significant for all dogs. Incontinent bitches had greater degree of caudal bladder movement during anesthesia. Mean difference in bladder neck positions between recumbent conscious- and recumbent anesthesia-associated positions was 0.24 cm in continent, compared with 0.73 cm in incontinent, bitches. Radiographic measurements were significantly greater than ultrasonographic measurements. Differences between repeated measurements for standing position were not significant, but those for recumbent conscious- and recumbent anesthesia-associated positions were significant. CONCLUSIONS: Additional vesicourethral support mechanisms in continent dogs, are deficient in bitches with SMI, allowing the bladder neck to move further caudad.

Impact in general practice of the policies of the organised approach to preventing cancer of the cervix.

This cross-sectional survey of cancer screening in May 1996 used a national random sample of a specified group of general practitioners (GPs). The survey included items to assess the impact of the Organised Approach to the Prevention of Cervical Cancer (OAPCC). Of the 1,271 GPs who satisfied the eligibility criteria, 855 (67%) returned a completed questionnaire. Fifty-two per cent indicated they would be 'highly' likely to introduce a discussion about cervical smears to a 58-year-old woman who was in good health and had come for a non-gynaecological consultation. Female sex, RACGP affiliation, practising in a metropolitan area and awareness of the OAPCC booklet were independent predictors of an opportunistic orientation. By contrast, 91% indicated that they would be 'highly' likely to include a Pap smear in a general health checkup. Thirty-eight per cent reported that they had found the booklet about the 1991 screening policy 'very' useful, while 38% found the NHMRC guidelines for the management of women with screen detected abnormalities 'very' useful. Around one-fifth of the GPs were not aware of these documents. Overall, 19% still recommended annual or more frequent screening. GPs from NSW and Queensland were less likely to support biennial screening than GPs from other states. Overall, 26% of GPs did not indicate that they would refer a woman who had tested positive for any grade of CIN for colposcopic assessment. Female GPs were more likely to refer women with CIN for colposcopic assessment while older doctors were less likely to do so.

Labour-saving strategies to maintain survey response rates: a randomised trial.

To evaluate response-aiding strategies feasible in large surveys, we randomly allocated general practitioners (GPs) to one of four intervention groups: Group 1 received 'exhaustive' telephone prompts by a medical peer in advance of a questionnaire; Group 2, inclusion of an embossed pen with the questionnaire; Group 3, an advance letter prompt; and Group 4, a 'single attempt' advance telephone prompt by a non-medical research assistant. Follow-up procedures were identical. Response rates by group were not significantly different overall (chi 2 = 4.59, df = 3, p = 0.20) although advance prompts by a medical peer were significantly more effective than other strategies for male GPs. The difference in overall response rates between males (63%) and females (74%) was significant (chi 2 = 15.40, df = 1, p < 0.01). No other response bias was evident. Our demonstration of a significant interaction between respondent sex and response-aiding strategy invites further research.

Assessment of urinary bladder volume in dogs by use of linear ultrasonographic measurements.

OBJECTIVE: To evaluate accuracy of formulas derived from linear ultrasonographic measurements and used in human beings to assess urinary bladder volume as a method of estimating bladder volume in dogs and to test reproducibility of ultrasonographic measurements of linear bladder dimensions. ANIMALS: 64 live dogs (for bladder volume determination) and 31 fresh canine cadavers (for ultrasonographic assessment of reproducibility of measurements). PROCEDURE: Maximal length, longitudinal and transverse depth (DL and DT), and width were measured from the maximal longitudinal and transverse images. Bladder volume was estimated, using 6 formulas, and calculated volumes were compared statistically with the actual volume obtained by catheterization, using paired nonparametric tests. Reproducibility of bladder dimensions was investigated by measuring length, DL, DT, and width 3 times from each image of section. Measurements of depth (DL and DT) also were compared. RESULTS: Calculations of bladder volume from linear dimensions, using a formula described for use in human beings, gave a satisfactory indication of actual bladder volume; the median difference between actual and calculated volumes was only 5 ml. Bladder volume estimations were less accurate when large-volume bladders were measured. Matching between repeated measurements was significant (P < 0.005 for longitudinal bladder length and P < 0.0001 for bladder depth and width). Measurements of DL and DT were significantly (P < 0.01) different, with DL greater than DT. CONCLUSIONS: Ultrasonographic assessment of bladder volume in dogs by application of the formula is sufficiently accurate for most clinical purposes. CLINICAL RELEVANCE: Ultrasonography would be a useful method of estimating bladder volume in dogs with severe obstruction or dysfunctional voiding of urine.

Applying a health outcomes approach in a health service unit.

An explicit focus on health outcomes has the potential to improve health if applied at the local level. However, clinical services require clear and practical support in the measurement and analysis of health outcome indicators. This paper suggests 12 steps for departments or services to take in promoting an outcomes orientation, based on our experiences in the Central Sydney Area Health Service. These include determining commitment at the service level, setting up a working group, specifying service consumers, their health problems and intervention processes, specifying desired health changes, consulting the literature and peers, identifying existing resources, pilot-testing and refining outcome measures, collecting data and responding to sub-optimal results with evidence-based interventions. The paper also reviews common criticisms of the health outcomes approach and key issues which have arisen in the course of applying these steps at the local level.

Role of questioning skills in patient assessment.

This article is a critical analysis of the literature on patient assessment, nurses' questioning skills and effective methods of teaching questioning skills. Current practice and rituals are highlighted and recommendations regarding the search for excellence are included.

Functional assessment of CD2, CD3 and CD28 on the surface of peripheral blood T-cells from infants at low versus high genetic risk for atopy.

Recent studies from several laboratories suggest that the rate of postnatal maturation of T-cell function(s) associated with in vitro activation may be slower in children at high genetic risk for atopy (HR), compared to their normal (low risk; LR) counterparts. The present study compared the in vitro activity of the function-associated surface molecules CD2, CD3 and CD28 in panels of 27 HR and 13 LR infants, with a reference panel of 10 adults, employing assay systems involving T-cell stimulation with MoAbs against these molecules. The response maxima induced by saturating levels of the MoAbs were equivalent in all 3 groups, but T-cells from the HR infants required 10-50 fold higher levels of anti-CD3 stimulation to attain their maximum response, relative to adults (p = 0.02); T-cells from LR infants were also less responsive to anti-CD3 than adults, but these differences were smaller and did not attain statistical significance. It is suggested that these differences are attributable to varying proportions of competent T-memory cells (which respond to low levels of anti-CD3) in PBL from these populations, the postnatal accumulation of which proceeds slowest in the HR group.

Quantitative analysis of cyanogen bromide-cleaved peptides for the assessment of type I: type II collagen ratios in equine articular repair tissue.

Cyanogen bromide was used to solubilise and specifically fragment purified equine Type I and II collagen and equine articular surface repair tissue. The resultant peptides were separated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis and quantified by densitometric scanning. Measurement of the relative amounts of the peptides alpha 2(I) CB3, 5 and alpha 1(II)CB10 provided an accurate method of establishing the ratio of Type I to Type II collagen in mixtures of purified equine collagens. The method was sensitive to 6% Type II collagen when the band areas were corrected for peptide molecular weight and the number of chains in the parent tropocollagen molecule which contain that particular peptide. Use of this technique showed that repair tissue in full thickness osteochondral defects in the dorso-distal margins of the intermediate carpal bones of ponies did not contain detectable amounts of Type II collagen 11 weeks after defect induction.