The fate of patients referred to a specialist vascular unit with large infra-renal abdominal aortic aneurysms over a two-year period.

INTRODUCTION: The basic premise in managing patients with abdominal aortic aneurysms (AAA) must be to reduce overall mortality from the disease. Operative mortality is widely reported, but data on patients deemed unsuitable for repair are scarce. The purpose of the present study was to report the fate of patients referred with AAA, to define the proportion deemed unsuitable for surgery and to investigate the reasons for conservative treatment. METHODS: All patients who were referred to a regional vascular centre with large (>5.5 cm) infra-renal AAA between 1st January 2008 and 31st December 2009 were included. Patients were classified into two groups; those managed non-operatively, or those offered elective repair. Survival was reported by Kaplan-Meier analysis. Multivariate analysis investigated factors leading to non-operative management. RESULTS: 251 patients with a mean (s.d.) age of 75(8) years were assessed. Thirty-two (13%) patients were deemed unsuitable for repair, mostly because of medical co-morbidity (16/32). 219/251 (87%) patients underwent repair (25/251 (10%) open repair 194/251 (77%) EVAR) with 1/219 (0.5%) 30-day mortality. AAA repair was associated with significantly greater survival (p < 0.001, log-rank test) at 2 years. In multivariate analysis Glasgow Aneurysm Score, female gender and respiratory disease were significant predictors of the decision to treat patients conservatively (p < 0.001). CONCLUSION: Most patients were suitable for surgical intervention with low perioperative mortality. Data on "turndown" rates should be routinely reported to quantify the denominator for operative success.

Inadequacies in the first aid management of burns presenting to plastic surgery services.

Burn injury is a significant cause of mortality and morbidity in Ireland. Simple first aid measures such as immediate wound cooling and removal of the source of injury can significantly improve clinical outcome. We conducted a six-month study, investigating the first aid measures taken by both patients and their primary carers following burn injury. Of the 63 patients referred to the plastic surgery services, only 23.2% had employed the correct first aid principles. Only 20% of patients who sustained burns at work reported that first aid was available in the workplace. This study illustrates that knowledge regarding the initial management of burn injury is very poor. We suggest that a national public health education campaign could have a positive effect on the outcome of burn injury.

Hyperlipidemia of normal pregnancy in Karachi-Pakistan.

During pregnancy, changes in the levels of total cholesterol, triglyceride, low density lipoprotein-cholesterol, and high density lipoprotein-cholesterol have been described, but in the existing literature these effects remain controversial because of inconsistencies. Moreover, the degree of change varies from study to study. Therefore, the present study completely investigated changes in lipids and lipoproteins throughout the pregnancy and in the puerperium. We also investigated whether or not any relation between plasma lipids and other pregnancy related factors exist. Concentrations of cholesterol and triglyceride of total plasma, and lipoproteins were determined in 56 pregnant women throughout the pregnancy and in the puerperium along with 56 non-pregnant women. Compared to control group, concentrations of cholesterol and triglyceride of total plasma and lipoproteins increased significantly during second trimester and reached maximum in the third trimester. Both cholesterol and triglyceride concentrations decreased significantly within 24 hours of delivery and this was reflected in all lipoproteins. In the majority of subjects, cholesterol and triglycerides remained significantly high until 4 weeks of postpartum. The magnitude of the serum cholesterol increment appeared in part to be related to that of serum triglyceride, but these increments appeared to be independent of age, weight gain, numbers of previous pregnancies and sex of the fetus. This study concludes that hyperlipidemia is a common finding during pregnancy.

Variations in ocular pressure during menstrual cycle.

The present study investigated whether a correlation between days of the menstrual cycle and variations in intraocular pressure exists or not. The number of days since the beginning of last menses was recorded along with intraocular pressure for 1,459 women. Measurements were taken by Goldmann applanation tonometer. The differences among various days of menstrual cycle were statistically insignificant. The highest mean IOP occurred between 20th and 22nd day and the second peak from 13th to 15th days of the cycle. The lowest mean IOP was found from 16th to 19th days of the cycle. This study concludes that intraocular pressure varies with the various days of the menstrual cycle, but fluctuations are statistically insignificant and cannot affect the diagnoses of glaucoma.

Is it possible to predict limb viability in complex Gustilo IIIB and IIIC tibial fractures? A comparison of two predictive indices.

The patient with severe lower limb trauma presents a management dilemma; whether to amputate primarily or to attempt limb salvage. In recent years, many predictive indices have been published which purport to identify limbs which are non-viable. We retrospectively applied two recently described indices, the Mangled Extremity Severity Score (MESS) and the Limb Salvage Index (LSI), to 54 limbs in 50 patients with either Gustilo IIIB or IIIC complex tibial fractures. There were 22 amputations (40.7 per cent) in the series. The mean MESS score in the limb salvage group was 3.8 (range 2-10), and the mean MESS score in the amputation group was 7.7 (range 4-13) (P < 0.0001). The mean LSI score in the limb salvage group was 3.6 (range 3-8), and the mean LSI score in the amputation group was 6.9 (P < 0.01). However, in the group with MESS scores > 7 (which recommends amputation), there were three limbs which were salvaged with acceptable functional outcome. Similarly, in those with LSI scores > 6 (which recommends amputation), there were seven limbs successfully salvaged. A MESS > 7 offered a greater relative risk of amputation (9.2) than a LSI score > 6 (5.3). We found both indices of use in predicting limb salvage and functional outcome. However, neither is sufficiently accurate to be considered absolutely reliable in clinical practice.

Effect of third trimester of pregnancy on diurnal variation of ocular pressure.

This study was planned to evaluate the effect of pregnancy on diurnal variation of intraocular pressure (IOP) after placing control on all the IOP affecting factors. The IOP was measured with the Goldmann applanation tonometer. Both in the control and 3rd trimester subjects, the peak of mean IOP appeared in the morning when the subjects waked, and the trough of mean IOP happened at 2 am to 4 am. The diurnal intraocular pressure curves revealed that the IOP peaks were 15.4 +/- 0.9 and 12.9 +/- 0.6 mmHg in the control and third trimester pregnant subjects, respectively. Whereas the trough were 13.1 +/- 0.4 and 11.8 +/- 0.3 mmHg, respectively. The mean diurnal variation were 2.3 +/- 0.6 mmHg (P < 0.01), and 1.1 +/- 0.8 mmHg in the control and third trimester subjects, respectively. There are two main findings of present study: first, compared with non-pregnant control subjects, the IOP was significantly lower (P < 0.001) in the third trimester pregnant subjects. Second, in the third trimester of pregnancy, the lower IOP level was associated with the less degree of IOP fluctuations at various hours of the day.