Association of SARC-F Score and Rockwood Clinical Frailty Scale with CT-Derived Muscle Mass in Patients with Aortic Aneurysms.

OBJECTIVES: Patients with aortic aneurysms (AA) are often co-morbid and susceptible to frailty. Low core muscle mass has been used as a surrogate marker of sarcopenia and indicator of frailty. This study aimed to assess association between core muscle mass with sarcopenia screening tool SARC-F and Clinical Frailty Scale (CFS) in patients with AA. METHODS: Prospective audit of patients in pre-operative aortic clinic between 01/07/2019-31/01/2020 including frailty assessment using Rockwood CFS and sarcopenia screening using SARC-F questionnaire. Psoas and sartorius muscle area were measured on pre-operative CT scans and adjusted for height. Association was assessed using Spearman's rank correlation coefficient. RESULTS: Of 84 patients assessed, median age was 75 years [72,82], 84.5% were men, 65.5% were multimorbid and 63.1% had polypharmacy. Nineteen percent were identified as frail (CFS score >3) and 6.1% positively screened for sarcopenia (SARC-F score 4 or more). Median psoas area (PMA) at L3 was 5.6cm2/m2 [4.8,6.6] and L4 was 7.4cm2/m2 [6.3,8.6]. Median sartorius area (SMA) was 1.8 cm2/m2 [1.5,2.2]. CFS demonstrated weak but statistically significant negative correlation with height-adjusted PMA at L3 (r=-0.25, p=0.034) but not at L4 (r=-0.23, p=0.051) or with SMA (r=-0.22, p=0.065). No association was observed between SARC-F score and PMA or SMA (L3 PMA r=-0.015, p=0.9; L4 PMA r=-0.0014, p= 0.99; SMA r=-0.051, p=0.67). CONCLUSION: CFS showed higher association with CT-derived muscle mass than SARC-F. Comprehensive pre-operative risk-stratification tools which incorporate frailty assessment and body composition analysis may assist in decision making for surgery and allow opportunity for pre-habilitation.

Effect of operating surgeon on outcome of arteriovenous fistula formation.

OBJECTIVE: To study whether surgical trainees can perform arteriovenous fistula (AVF) surgery to a standard comparable to consultants. PATIENTS AND METHODS: Retrospective study of all vascular access surgery over a three year period at a single centre. The operating surgeon was identified from theatre log books and categorised by grade. Fistula patency was used as the primary outcome measure and was determined from patients' case-notes and from a prospectively collected electronic record of dialysis sessions. Patency was defined as "used for dialysis" if the AVF was used for dialysis for at least 6 consecutive sessions. RESULTS: One hundred and eighty six cases were used for analysis. In 60 cases (32%) the operating surgeon was the consultant, in 53 cases (29%) a trainee was supervised by a consultant, in 56 cases (30%) a trainee performed the operation independently and in 17 cases (9%) the grade of the operating surgeon could not be established. Primary and primary assisted patency rates by operating surgeon did not differ significantly (P-values 0.25 and 0.16 respectively). Age of the patient was the only predictor of patency failure in a multivariate model. Grade of operating surgeon (logrank test chi(2)=3.1, p=0.38) and type of fistula (logrank test chi(2)=2.3, p=0.52) were not significantly related to the primary survival of the fistula. CONCLUSIONS: This study showed no significant differences in AVF patency rates between trainee and consultant surgeons. Allocation of appropriate cases can result in trainees obtaining similar outcomes as consultants, demonstrating that dialysis access surgery can provide good training opportunities for junior doctors without detriment to patient care.

Measurement of arterial stiffness in subjects with and without renal disease: Are changes in the vessel wall earlier and more sensitive markers of cardiovascular disease than intima media thickness and pulse pressure?

There is increased cardiovascular (CV) mortality in subjects with chronic kidney disease (CKD). Arterial stiffness in these subjects is increased when compared to a healthy population. Markers of arterial stiffness and intima media thickness (IMT) are predictors of CV mortality. The aim of this study was to investigate whether there is any difference in markers of arterial stiffness and IMT between subjects with normal renal function and those with mild renal disease. The arterial distension waveform, IMT, diameter, and brachial blood pressure were measured to calculate Young's modulus (E) and elastic modulus (Ep) in the common carotid arteries of subjects with normal kidney function (estimated glomerular filtration rate [eGFR] >90) and those mild CKD (stage 2, eGFR 89-60). Data were available for 15 patients with normal kidney function and 29 patients with mild CKD. The subjects with mild CKD were older, but other co-variables were not significantly different. Both arterial wall stiffness parameters (E and Ep), but not IMT were significantly higher in the mild CKD group. Logistic regression demonstrated that only the arterial wall stiffness parameters (Ep and E) were independently associated with mild renal disease compared with normal, in a model adjusting for sex, age and diabetes and history of cardiovascular disease (CVD). E and Ep may be early markers of CVD in subjects with mild CKD that may manifest change before other more recognized markers such as IMT and pulse pressure.

Strategies to improve the effectiveness of abdominal aortic aneurysm screening programmes.

OBJECTIVE: Ruptured abdominal aortic aneurysms (rAAAs) occurring in patients with screen-detected aneurysms could be regarded as a failure of screening and reduce effectiveness of screening. To understand this issue, we studied the reasons why rAAAs occur in screened patients and estimated the cost-benefit ratio if these ruptures could be prevented. METHODS: All rAAAs occurring in the Huntingdon district in the UK during the study period (1991-2000) were traced via a combination of hospital admission, accident and emergency attendance, and intensive therapy unit admission records, operating theatre registers and post-mortem reports. Cross-referencing with the aneurysm-screening database identified those patients who had attended screening. Previously used cost-effectiveness models were used to estimate the cost benefits to screening. RESULTS: Ninety-three rAAAs occurred in men over the study period, of whom 23 (25%) had been invited for screening and 13 (14%) had accepted the invitation. All who had been screened (mean age 75 [65-82]) had abnormal aortic diameters (>30 mm) on their first scan. Of those invited, 10/23 (43%) did not attend their screening appointment, 4/23 (17%) were deemed not fit for open surgery, 4/23 (17%) ruptured whilst being assessed for aneurysm repair, 2/23 (9%) ruptured whilst under six-monthly surveillance, and 3/23 (13%) failed to attend scheduled six-monthly surveillance appointments. Reducing screened ruptures by one half could increase the cost-effectiveness of screening by 27%. CONCLUSION: There were no failures of the screening test. The benefits of aneurysm screening can be improved by increasing the uptake of screening, the compliance with surveillance, and by streamlining the work-up process before surgery.

Seasonal changes and alternation of food plant preference in some mesophyll-feeding leafhoppers.

The life histories of two bivoltine mesophyll-feeding leafhoppers, Lindbergina aurovittata (Douglas) and Edwardsiana rosae (L.), in South Wales are described. L. aurovittata alternates between evergreen Rubus and Quercus in the first generation and various deciduous broad-leaved trees in the second. Experiments on nymphal food preferences and adult oviposition behaviour show that nymphs of both generations tend to prefer older to younger leaves, but show little species specificity. However, adults are discriminating in oviposition preferences, which change regularly and completely in alternating generations. Similar results were obtained with E. rosae. Such obligate seasonal changes in host preferences and utilization are well known amongst aphids, but previously have not been reported in leafhoppers.

Measurement of arterial stiffness in subjects with vascular disease: Are vessel wall changes more sensitive than increase in intima-media thickness?

BACKGROUND AND AIMS: It is widely accepted that subjects with vascular disease have increased arterial stiffness and intima-media thickness (IMT) when compared with healthy controls. The aim of this study was to investigate indices of arterial stiffness and IMT in the common carotid arteries (CCAs) of subjects with and without peripheral arterial disease (PAD), in order to look for evidence of change in wall quality and quantity to explain increased stiffness that has been found in the arteries of subjects with vascular disease. METHODS AND RESULTS: The arterial distension waveform (ADW), IMT, diameter and brachial blood pressure were measured to calculate Young's Modulus (E) and elastic modulus (Ep) in the common carotid arteries of subjects with and without PAD. 38 subjects with confirmed PAD were compared with 43 normal controls matched for age, sex, smoking and hypertension. The mean diameter (8.35mm [95% CI 7.93-8.77] vs. 6.93mm [6.65-7.20] P<0.001, increase 20%), IMT (0.99mm [0.92-1.07] vs. 0.88mm [0.82-0.93] P=0.020, increase 12.5%), Ep (315kPa [185-444] vs. 190kPa [164-216] P=0.034, increase 66%) and E (1383kPa [836-1930] vs. 744kPa [641-846] P=0.006, increase 86%) were all significantly higher in subjects with PAD. CONCLUSIONS: This study suggests that increased stiffness observed in subjects with peripheral vascular disease is a result of change in both quantity and quality of the arterial wall. Changes in indices of arterial stiffness were much higher than changes in IMT and diameter. These preliminary observations may be an indication that indices of arterial stiffness are a sensitive early marker of atherosclerosis.

A comparison between the short term and long term benefits of screening for abdominal aortic aneurysms from the Huntingdon Aneurysm screening programme.

BACKGROUND: The UK Multicentre Aneurysm Screening Study (MASS) showed a 44% reduction in AAA-related mortality after 4 years and predicted an increased number of deaths prevented in the longer term. We aim to compare the 5 and 13 years benefit from aneurysm screening in the Huntingdon Aneurysm screening programme. METHODS: Incidence and mortality of ruptured AAA (RAAA) after 5 and 13 years of screening in a population based aneurysm screening program. RESULTS: Five years of screening resulted in a reduction in the incidence of RAAA of 49% (95% CI: 3-74%). Nine out of 11 ruptures in the invited group did not survive (mortality 82%; 95% CI: 48-98%) compared to 38 non-survivors from 51 ruptures in the control group (mortality 75%; 95% CI: 60-86%). Five years of screening resulted in an RAAA-related mortality reduction of 45% (95% CI: -15 to 74%). After 13 years of screening the incidence of RAAA was reduced by 73% (95% CI: 58-82%). Twenty-one out of 29 ruptures in the invited group did not survive (mortality 72%; 95% CI: 53-87%) compared to 64 non-survivors from 82 ruptures in the control group (mortality 78%; 95% CI: 68-86%). Thirteen years screening resulted in a reduction of mortality from RAAA of 75% (95% CI: 58-84%). The number needed to screen to prevent one death reduced from 1380 after 5 years to 505 after 13 years. The number of elective AAA operations needed to prevent one death reduced from 6 after 5 years to 4 after 13 years. CONCLUSION: AAA screening becomes increasingly beneficial as screening continues over the longer term. Benefits continue to increase after screening has ceased.

Medical treatment of prostatic obstruction. An objective assessment.

Thirteen men suffering from prostatic obstruction were treated with an 8-week course of intramuscular injections of prostatic extract. Nine of these men had preliminary and subsequent evaluations of detrusor function and outflow obstruction by means of pressure/flow studies. Improvement in symptoms and measurements were only minimal and occurred in less than one-half of the cases. The greatest increase in flow rate recorded prostatectomy and no significant changes resulting from the injections could be seen on the histologic sections of their glands. These results did not confirm previous reports recommending this form of treatment for prostatic obstruction.

A study of concentrations of trimethoprim-sulphamethoxazole in the human prostate gland.

The ability of trimethoprim (TMP) and sulphamethoxazole (SMX) components of co-trimoxazole to penetrate the human prostate gland was investigated. After a single 4-tablet dose TMP was evenly distributed between prostate and plasma, whereas SMX was mainly associated with plasma. Following a week's therapy significant accumulation of TMP was seen in the prostate relative to plasma whereas SMX although still associated with plasma had increased drug levels in prostate compared with the single dose study. It is concluded that co-trimoxazole produces effective antibacterial levels in the human prostate and has indications in the treatment of prostatitis.

Training Hungarian primary health care teachers: the relevance of a UK postgraduate course for health educators.

OBJECTIVES: This study constituted a formative evaluation of the relevance of the MSc course to the needs of Hungarian primary health care educators. DESIGN: A qualitative, naturalistic approach using in-depth interviews was used to construct the meaning of the experience of the MSc for the Hungarian participants. Interviews were triangulated using observation and documentary analysis. SETTING: The University of Exeter's Institute of General Practice. SUBJECTS: Eight Hungarian primary health care professionals. RESULTS: The evaluation data revealed that the attitude of the Hungarian students to their role as medical educators had been substantially changed by exposure to western models of adult education. There were a number of 'clashes of expectation' between the Hungarian students and the course staff in relation to the course requirements. Reconciliation of these differing expectations required a sequence of ongoing adjustments to the course content and delivery. CONCLUSIONS: Existing postgraduate courses for health educators can accommodate the needs of medical teachers from countries who are developing their primary health care education systems. Successful accommodation is facilitated by ensuring an adequate preparation in relation to language fluency, academic requirements of the course, familiarization with modern approaches to adult education as well as with the local health care delivery system.

LDL cholesterol is associated with small abdominal aortic aneurysms.

OBJECTIVE: To examine the relationship between serum lipids and abdominal aortic aneurysms (AAA). METHODS: Two hundred and six males (>50 years) with AAA (> or =30 mm) detected in a population based screening programme were compared with 252 age-matched male controls in a nested case-control study. Smoking status, previous medical and family histories, height, weight, blood pressure, ankle brachial pressure index (ABPI) and non-fasting lipid profile were recorded. RESULTS: Cases were found to have significantly higher LDL cholesterol than controls. LDL cholesterol was an independent predictor of the risk for aneurysms in a logistic regression model adjusting for smoking status, family history of AAA, history of ischaemic heart disease, presence of peripheral vascular disease, use of lipid lowering medication and treatment for hypertension. There was a linear effect with increased levels of LDL cholesterol increasing the risk of having a small aneurysm (test for trend p=0.03). CONCLUSION: The highly significant association between LDL cholesterol and small aneurysms suggests that LDL, possibly acting via inflammatory mediated matrix degeneration, could be an initiating factor in the development of AAA. The ability of statin therapy to prevent AAA formation requires further investigation.

ACE inhibitors increase type III collagen synthesis: a potential explanation for reduction in acute vascular events by ACE inhibitors.

INTRODUCTION: Large trials have shown that angiotensin converting enzyme inhibitor (ACE-I) therapy reduces the risk of myocardial infarction and stroke. Acute vascular events are thought to be initiated by plaque rupture. Animal models of atherosclerosis show an increase in extra cellular matrix when given ACE-I therapy. ACE-I therapy could influence collagen synthesis, one of the major constituents of the atherosclerotic cap. METHODS: A nested case-control study was performed within the Huntingdon Aneurysm Screening Project. Subjects were assessed for arterial disease, drug history and smoking. Blood samples were taken for a measure of collagen synthesis, the amino-terminal propeptide of type III procollagen (PIIINP), lipid levels, iron metabolism and cotinine levels. RESULTS: Information was available for 420 subjects. Thirty-five were taking ACE-I therapy and 385 were not. Mean serum PIIINP level was 3.5 microg/l (sd 1.3 microg/l, range: 1.7-16.5 microg/l. There was a marked increase in mean collagen turnover between subjects taking ACE-I therapy compared to those not. Mean PIIINP level for cases and controls was 4.26 microg/l (95% CI: 3.73-4.79 microg/l) versus 3.61 microg/l (95% CI: 3.48-3.75 microg/l). No differences were found for patients taking other antihypertensive drugs. After adjusting for age, weight, height, lipid levels and ferritin, PIIINP levels remained significantly higher in cases than controls: 4.14 microg/l (95% CI: 3.72-4.57 microg/l) versus 3.62 microg/l (95% CI: 3.49-3.75 microg/l) (P-value 0.02). DISCUSSION: These results suggest that ACE-I therapy up-regulates collagen synthesis, and could improve plaque stabilisation. This may provide an explanation for the decrease in acute vascular events observed in patients on ACE-I therapy.