MGMT, a risk factor for both genetic and environmental forms of dementia.

MGMT, the gene coding for the DNA-repair protein O6 -methylguanine methyltransferase, which has been recently shown to be a risk factor for inherited forms of Alzheimer's disease (AD), notably among women, might also be linked to Western Pacific amyotrophic lateral sclerosis and Parkinsonism-dementia complex (ALS/PDC), one phenotype of which is an AD-like dementia. Guam ALS/PDC is strongly considered to be an environmental disorder caused by oral exposure to natural toxins (i.e., genotoxic/epigenotoxic chemicals), notably methylazoxymethanol (MAM) that alkylates guanine to form O6 -methylguanine, found in the seed of cycad plants traditionally used for food. Thus, the DNA-repair protein MGMT might participate in both AD and in the AD-related disorder ALS/PDC.

Management of acute and chronic iliofemoral venous outflow obstruction: a multidisciplinary team consensus.

The aim of this manuscript was to establish a consensus for the management of acute and chronic venous obstruction among specialists in the UK. Specialist physicians representing vascular surgery, interventional radiology and hematology were invited to 3 meetings to discuss management of acute and chronic iliofemoral obstruction. The meetings outlined controversial areas, included a topic-by-topic review; and on completion reached a consensus when greater than 80% agreement was reached on each topic. Physicians from 19 UK hospitals agreed on treatment protocols and highlighted areas that need development. Potential standard treatment algorithms were created. It was decided to establish a national registry of venous patients led by representatives from the treating multidisciplinary teams. Technical improvements have facilitated invasive treatment of patients with acute and chronic venous obstruction; however, the evidence guiding treatment is weak. Treatment should be conducted in centers with multi-disciplinary input; robust, coordinated data collection; and regular outcome analysis to ensure safe and effective treatment and a basis for future evolvement.

Pelvic venous reflux in males with varicose veins and recurrent varicose veins.

Objectives To report on a male cohort with pelvic vein reflux and associated primary and recurrent lower limb varicose veins. Methods Full lower limb duplex ultrasonography revealed significant pelvic contribution in eight males presenting with bilateral lower limb varicose veins. Testicular and internal iliac veins were examined with either one or a combination of computed tomography, magnetic resonance venography, testicular, transabdominal or transrectal duplex ultrasonography. Subsequently, all patients received pelvic vein embolisation, prior to leg varicose vein treatment. Results Pelvic vein reflux was found in 23 of the 32 truncal pelvic veins and these were treated by pelvic vein embolisation. Four patients have since completed their leg varicose vein treatment and four are undergoing leg varicose vein treatments currently. Conclusion Pelvic vein reflux contributes towards lower limb venous insufficiency in some males with leg varicose veins. Despite the challenges, we suggest that pelvic vein reflux should probably be investigated and pelvic vein embolisation considered in such patients.

Anatomical abnormalities of the pelvic venous system and their implications for endovascular management of pelvic venous reflux.

Background Pelvic venous reflux is often treated with pelvic vein embolisation; however, atypical pelvic venous anatomy may provide therapeutic challenges. Methods We retrospectively reviewed seven patient files and reported symptoms, diagnostic imaging, aberrant anatomy and means by which the interventional radiologist successfully completed the procedure. Any follow-up data were included if available. Results Four anatomical abnormalities were found: internal iliac veins draining into the contralateral common iliac vein, duplicated inferior vena cava, reverse-angle renal veins with atypical left ovarian vein drainage and direct drainage of the internal iliac vein to the inferior vena cava. All patients were successfully treated with pelvic vein embolisation. Conclusion Abnormal embryologic development may cause variable pelvic venous anatomy. Knowledge of this will enable interventional radiologists to successfully treat such patients.

Pelvic vein embolisation of gonadal and internal iliac veins can be performed safely and with good technical results in an ambulatory vein clinic, under local anaesthetic alone - Results from two years' experience.

Objectives Pelvic vein embolisation is increasing in venous practice for the treatment of conditions associated with pelvic venous reflux. In July 2014, we introduced a local anaesthetic "walk-in walk-out" pelvic vein embolisation service situated in a vein clinic, remote from a hospital. Methods Prospective audit of all patients undergoing pelvic vein embolisation for pelvic venous reflux. All patients had serum urea and electrolytes tested before procedure. Embolisation coils used were interlock embolisation coils (Boston Scientific, USA) as they can be repositioned after deployment and before release. We noted (1) complications during or post-procedure (2) successful abolition of pelvic venous reflux on transvaginal duplex scanning (3) number of veins (territories) treated and number of coils used. Results In 24 months, 121 patients underwent pelvic vein embolisation. Three males were excluded as transvaginal duplex scanning was impossible and six females excluded due to lack of complete data. None of these nine had any complications. Of 112 females analysed, mean age 45 years (24-71), 104 were for leg varices, 48 vulval varices and 20 for pelvic congestion syndrome (some had more than one indication). There were no deaths or serious complications to 30 days. Two procedures were abandoned, one completed subsequently and one was technically successful on review. One more had transient bradycardia and one had a coil removed by snare during the procedure. The mean number of venous territories treated was 2.9 and a mean of 3.3 coils was used per territory. Conclusion Pelvic vein embolisation under local anaesthetic is safe and technically effective in a remote out-patient facility outside of a hospital.

Diagnosis of stenosis within the popliteal-femoral venous segment upon clinical presentation with a venous ulcer and subsequent successful treatment with venoplasty.

This case study reports the diagnosis and treatment of a lower limb venous ulcer with abnormal underlying venous pathology. One male patient presented with bilateral varicose veins and a right lower limb ulcer. Upon investigation, full-leg duplex ultrasonography revealed total incompetence of the great saphenous vein in the left leg. In the right leg, duplex ultrasonography showed proximal incompetence of the small saphenous vein, and dilation of the anterior accessory saphenous vein, which remained competent. Incidentally, two venous collaterals connected onto the distal region of both these segments, emerging from a scarred, atrophic popliteal-femoral segment. An interventional radiologist performed venoplasty to this popliteal-femoral venous segment. Intervention was successful and 10 weeks post procedure ulceration healed. Popliteal-femoral venous stenosis may be associated with venous ulceration in some cases and may be successfully treated with balloon venoplasty intervention.

Priorities for professionalism: what do surgeons think?

OBJECTIVE: To gain an understanding of the relative importance of the nine surgical competencies and their 27 attributes defined by the Royal Australasian College of Surgeons (RACS), which together provide the curriculum framework for today's surgeons. DESIGN, SETTING AND PARTICIPANTS: Between 9 August and 30 September 2010, trainees and Fellows of the RACS across Australia and New Zealand actively involved in educational activities rated, via questionnaire, the importance of the RACS competencies (technical expertise, communication, professionalism, medical expertise, judgement and decision making, scholarship and teaching, collaboration and teamwork, management and leadership, and health advocacy) and associated attributes. MAIN OUTCOME MEASURES: Importance ranking of competencies and their attributes for surgical education and training. RESULTS: Of 3054 questionnaires distributed, 1834 (60%) were returned. We identified clear priorities in the perceived relative importance of the nine competencies and 27 attributes. The most important attributes were competence, insight, and recognising conditions amenable to surgery; least important were responding to community and cultural needs, supporting others, and maintaining personal health and wellbeing. Key differences were noted for the competency of collaboration and teamwork, which was ranked as more important by trainees than by Fellows. Female trainees and Fellows regarded all attributes as more important than did male trainees and Fellows. CONCLUSION: In a complex environment with multiple pressures, the priorities of the competencies are important. Trainees and Fellows had a very similar approach to the prioritisation of the attributes. Of concern is the lesser importance given to attributes beyond individual expertise.

Educational and health impact of the Baume Report: 'A Cutting Edge: Australia's Surgical Workforce'.

OBJECTIVES: The Baume Report (1994) on Australia's surgical workforce had the potential to impact upon the health and educational sectors. This paper analyses the recommendations of this report and their impact at the time and 15 years later (2009). METHODS: A questionnaire-based study was performed with the 18 senior Fellows and the Royal Australasian College of Surgeons (RACS) solicitor who had been instrumental in facilitating responses to the review. RESULTS: The 19 respondents were asked to evaluate 22 areas from the Baume Report. The most highly ranked areas identified as being reasonable in 1994 were: additional funding being made available for more training positions, identifying workforce deficits, moving towards compulsory continuing professional development and having evidence of competence before introducing new technology. In 2009, the most highly ranked areas were: funding for more training positions; compulsory continuing professional development, involving the profession in improvements and broadening the training environment beyond public hospitals. Areas considered to be substantially addressed were: the selection process and encouragement of diversity, workforce numbers and deficits, confirming the educational merit of the training program and the role of professional colleges. CONCLUSIONS: The Baume Report highlighted many issues including workforce planning, the role of professional organisations in society and the complex interface between health and education. Issues of ongoing standards through a surgical career, access for patients to surgical services, funding for more training posts to provide the appropriate workforce level and distribution, and the assessment and introduction of technology remain priorities. Time has not diminished the relevance of these issues. WHAT IS KNOWN ABOUT THIS TOPIC?: The impact of key government reviews can always be substantial. The Baume Report was directed to postgraduate specialist medical training, particularly surgical training. There have been substantial changes in the health and educational sectors since the report, with significantly more regulation and transparency. WHAT DOES THIS PAPER ADD?: Analysis of the Baume Report after 15 years by the senior office bearers of the RACS who were actively involved in handling and implementing many of the recommendations provides an insight into the dynamics of specialist training. It outlines the significant changes that have occurred and the things that still need to be done. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: Professional bodies have an influential presence across society. They are particularly focused on the standards required to become a practitioner of that profession and the ongoing maintenance of these standards. However, this comes with responsibility for and accountability to society and the community. External reviews, particularly with a political imperative, change both the dynamics and key relationships, issues that the professional bodies must commit to addressing in a positive manner.

Endovascular management of an infected superficial femoral artery pseudoaneurysm.

This article describes an endovascular technique of treating an infected pseudoaneurysm by direct thrombin injection via a catheter placed inside the aneurysm sac while maintaining temporary balloon occlusion of the neck of the false aneurysm.

Uterine fibroid managed by uterine artery embolization and delivered vaginally by obstetric outlet forceps: a case report.

BACKGROUND: Fibroid embolization is a nonsurgical treatment of symptomatic fibroids and is particularly useful in patients with multiple comorbidities. CASE: A 44-year-old woman with multiple comorbidities underwent uterine artery embolization for uterine fibroids. The postprocedure symptoms were controlled with conservative management along with vaginal myomectomy using outlet forceps. CONCLUSION: Postprocedure symptom control is important, and some patients may need emergency medical management of pain and infection and surgical management of partially expelled fibroids.

Interventional radiology in the management of Budd Chiari syndrome.

Budd Chiari syndrome is an uncommon condition in the Western world but interventional radiology can contribute significantly to the management of the majority of patients. This review examines the role and technique of interventions including hepatic vein dilatation and stent insertion as well as thrombolysis and TIPS. Liver transplantation and surgical shunt surgery are discussed in relation to radiological interventions. With appropriate selection and technique, surgery is only required in a minority of patients.

Lessons from EVA-3S and SPACE.

Carotid endarterectomy (CEA) was established as the gold standard for treatment of carotid occlusive disease by several landmark papers published in the 1990s. With the continued trend toward less invasive therapies, carotid artery stenting (CAS) has challenged CEA for treatment of significant carotid artery disease. Several trials have now compared CEA and CAS and a subsequent Cochrane review indicated that the 30-day complication rates were equivalent. Unfortunately, comparative long-term data are still lacking. Two new trials comparing CAS with CAE in patients with symptomatic internal carotid artery disease have recently been published, but to what extent have they usefully added to the available data?