Good long term patency rates associated with an alternative technique in vascular access surgery--the adductor loop arteriovenous graft.

INTRODUCTION: We have modified the arteriovenous groin loop procedure and present a technique associated with good patency rates and low infection rates. METHODS: We describe an alternative femoro-femoral arteriovenous loop technique which utilises the mid-thigh sub-sartorial Superficial Femoral Artery and Femoral Vein. We then performed a retrospective analysis of all such cases performed in our unit to date and analysed the patency and infection rates associated with the technique. RESULTS: 16 cases have been performed to date with a median follow-up of 18 months. The primary and secondary patency rates at one year were 70% and 90% respectively. The overall infection rate was only 12.5%. CONCLUSIONS: Our technique is associated with good patency rates and low infection rates. In addition it preserves modesty whilst on dialysis and the groin vessels for further vascular access surgery if needed.

Existing delays following the presentation of ruptured abdominal aortic aneurysm allow sufficient time to assess patients for endovascular repair.

OBJECTIVES: The greatest benefit of endovascular AAA repair (EVAR) may be in the management of rupture (RAAA). However, the detailed anatomical assessment required for EVAR has lead to concerns of surgical delay and death during cross-sectional imaging. In this study, we prospectively assessed patients with RAAA and correlated time of hospital arrival with time of surgery or death to ascertain whether these concerns are justified. METHODS: All patients presenting with RAAA between October 2000 and December 2002 were included. The hospital arrival time, onset of surgery or time of death, were recorded, as were demographic and physiological parameters. RESULTS: One hundred consecutive patients were studied, median age 75 years (range 54-94). Seventy-nine patients underwent attempted conventional surgical repair and 21 were palliated. The median delay from arrival to operation was 159 min (range 16-1450 min). Mortality in the surgical group was not affected by the length of delay (p = 1.0) or by CT scanning (p = 0.34). The median time from arrival to death in the non-surgical group was 435 min (15 min-6 days). CONCLUSIONS: Most patients who present with ruptured AAA experience a significant delay prior to surgery. This study suggests it is safe to assess the majority of RAAA patients for EVAR.

Immunomonitoring of renal transplant recipients in the early posttransplant period by sequential analysis of chemokine and chemokine receptor gene expression in peripheral blood mononuclear cells.

INTRODUCTION: We sought to determine whether sequential changes in chemokine ligand/receptor gene expression in the early posttransplant period of human renal allografts can be detected in peripheral blood mononuclear cells (PBMCs) and whether any such changes are predictive of clinical events. METHODS: Blood samples from 106 renal transplant recipients and 29 donor nephrectomy patients were taken preoperatively and daily for 14 days. Within the study period 22 patients had biopsy-proven acute rejection. From each blood sample PBMCs were separated and gene expression levels for chemokines CCL3, CCL4, CCL5, CXCL10, and their receptors CCR1, CCR5, and CXCR3, were determined using real-time quantitative PCR. RESULTS: Different gene expression patterns were seen between the rejector and nonrejector groups with decreases in CCL4 and CCR5 expression on days 6 to 8 and increases in CCR1 expression on days 9 and 10 posttransplant. With CXCL10, decreases in expression were seen in the nonrejector group but increases were seen in the rejector group posttransplant. With data aligned to time of rejection diagnosis, statistically significant increases, that preceded the clinical detection of acute rejection were seen in CCR1 and CXCL10 expression. Both their expression levels returned to pretransplant baseline values after successful antirejection therapy. CONCLUSION: We have demonstrated that changes in chemokine receptor/ligand gene expression by sequential monitoring in PBMCs can be detected in the early posttransplant period. In particular, CCR1 and CXCL10, which showed increased expression prior to rejection and returned to baseline levels with antirejection therapy, may have potential use in immunomonitoring and as predictive factors of rejection prior to its clinical manifestation.

Predicting outcome in ruptured abdominal aortic aneurysm: a prospective study of 100 consecutive cases.

OBJECTIVES: Case selection for surgery in patients presenting with ruptured abdominal aortic aneurysms (RAAA) is often difficult. A previous retrospective review identified five pre-operative risk factors associated with mortality [J Vasc Surg 23 (1996) 123]. In this study we aimed to identify whether these criteria could be usefully applied prospectively in patients presenting with RAAA. METHODS: All patients presenting with RAAA from October 2000 to December 2002 were included. The criteria were recorded with the time they were available and the time surgery commenced. The decision to operate was made on clinical grounds and no patient was refused surgery on the basis of these criteria. RESULTS: One hundred consecutive patients were studied, median age 75 (range 54-94). The operative mortality was 32.9% (26/79 patients). Surgical mortality increased with the number of positive criteria and was 8% (2/24), 24% (7/29), 55% (11/20) and 100% (6/6) for scores, 0, 1, 2 and > or =3, respectively. Age and conscious level were available in every patient. However, an ECG, haemoglobin and creatinine results were only available in 94, 81, and 69%, respectively. CONCLUSIONS: The scoring system accurately predicted operative mortality. The score was available in the majority of cases and may help the surgeon give informed consent to patients and relatives prior to surgical intervention.

Influence of patient and donor cytokine genotypes on renal allograft rejection: evidence from a single centre study.

Cytokines are key immune mediators and it has been suggested that cytokine gene polymorphisms affecting expression influence rejection or tolerance. This study sought to examine this hypothesis with the aim of identifying predictive genotype markers for rejection. The study group consisted of 120 consecutive first cadaveric recipient-donor pairs transplanted at a single centre, between 1994 and 1997. PCR utilising sequence-specific primers (SSP) methodology was optimised for genotyping recipient and donor DNA for the following polymorphisms: tumour necrosis factor (TNF) -alpha (-308, G/A), interleukin (IL)-10 (-1082, G/A), IL-4 (-590, C/T), transforming growth factor (TGF) -beta1 (+915, G/C). Recipient-donor pairs were divided into rejectors (n = 28) and non-rejectors (n = 92). Each group was further stratified according to number of rejection episodes and HLA-DR mismatching. Recipient-donor pairs both lacking the IL-4*T allele (recipient low producer/donor low producer) were significantly increased in the rejector group (P = 0.02). Also, the combination of recipient IL-10*A negative/donor IL-10*A positive (recipient high producer/donor low producer), was significantly decreased in multiple rejectors (P = 0.04). No significant associations were detected between TNF-alpha and TGF-beta1, and rejection. This study suggests that the combination of recipient-donor IL-4 and IL-10 genotypes may be important in renal transplantation outcome. The results appear to corroborate the protective role of both of these cytokines, possibly due to their ability to suppress inflammation. However, due to conflicting results from this and other studies, a multi-centre collaborative study may be required to determine whether cytokine genotypes are significant, independent predictors of renal allograft rejection.

Reoperation for recurrent saphenofemoral incompetence: a prospective randomised trial using a reflected flap of pectineus fascia.

OBJECTIVE AND DESIGN: in 1978 Sheppard described using a flap of pectineus fascia in an attempt to reduce the further development of neovascularised veins at the saphenofemoral junction. The perceived benefits of this manoeuvre have not been tested by a prospective randomised trial. MATERIALS AND METHODS: consecutive patients with symptomatic recurrent varicose veins referred to a single consultant were examined for evidence of further reflux from the saphenofemoral junction. This was subsequently confirmed in forty limbs (thirty-seven patients) by descending venography. All had features of a neovascularised segment. These patients were treated by complete exposure and ligation of the recurrences arising from the common femoral vein, with or without the placement of a flap of pectineus fascia (prospectively randomised). The patients were assessed a minimum of eighteen months later by both clinical examination and duplex ultrasound scanning. RESULTS: six patients were lost to follow-up. This left seventeen limbs remaining in each half of the study. The characteristics in each group were broadly matched. CONCLUSIONS: this study failed to demonstrate any apparent benefit from the application of a flap of pectineus fascia. Most patients showed evidence of re-recurrence arising from the common femoral vein.

Raman spectroscopic library of natural and synthetic pigments (pre- approximately 1850 AD).

To assist in the greatly increasing number of applications of Raman microscopy as a tool for non-intrusive, in situ archaeometric analysis, the Raman spectra of over 60 pigments, both natural and synthetic, known to have been in use before approximately 1850 AD, have been studied by Raman microscopy. Fifty-six pigments have yielded high quality spectra which have been arranged, by colour, into a spectroscopic library for reference purposes. The spectroscopic files may be downloaded from http:/(/)www.ucl.ac.uk/chem/resources/raman/speclib .html.

Organochlorine pesticides and hexachlorobenzene in tissues of fish and invertebrates caught near a sewage outfall.

Concentrations of organochlorine pesticides and hexachlorobenzene (HCB) were determined in 16 fish, 1 mollusc and 1 crustacean species living near a cliff-face sewage outfall. For the 15 organochlorine compounds scanned, HCB, chlordane, dieldrin and SigmaDDT were recorded in highest concentrations. There was considerable variation in concentrations between muscle and liver and between species. Livers had higher concentrations of organochlorines and a higher percentage lipid than muscle. The highest concentrations were recorded in livers of the elasmobranch and tetraodontiform fishes. Organochlorines were only recorded at low concentrations in muscle, often at or near detection limits. No organochlorines were detected in the two invertebrate species.

Variability in organochlorine analysis in fish: an interlaboratory study and its implications for environmental monitoring and regulatory standards.

Samples of muscle, from four types of fish, that had been spiked at 0.25 and 1.0 mg/kg with hexachlorobenzene (HCB), gamma BHC (lindane), technical chlordane, p,p'-DDT, p,p'-DDE and p,p'-DDD were analyzed by eight laboratories. Some laboratories could not reliably detect organochlorine compounds even though they were registered as national testing laboratories. The analytical accuracies of laboratories that were able to reliably detect the spiked compounds were very variable and exceeded acceptable limits. Within-laboratory precision was generally acceptable. There was significant interlaboratory variability among the estimates of percent lipid for each fish type. This variability negated the use of percent lipid for standardization of organochlorine concentrations for comparison between studies. The results highlight the need for standard analytical protocols that are regularly tested by interlaboratory studies. They also indicate that interchangeability of data between studies is limited due to low analytical accuracy. Therefore, comparison of analytical data to absolute environmental and regulatory standards is difficult. The use of "latitudinal confidence ranges" when setting regulatory standards is recommended.