Audit of introduction of hand-held Doppler and duplex ultrasound in the management of varicose veins.

Hand-held Doppler (HHD) examination and duplex ultrasound scanning of patients with varicose veins are more accurate than clinical assessment alone. To assess how the introduction of HHD and the availability of duplex ultrasound scanning affects patient management, a retrospective review was carried out comparing the year before the introduction with the subsequent 2 years. Information was extracted from a computer database containing details of all new venous outpatients, their initial management and investigations and subsequent operations. HHD and duplex ultrasound resulted in a marked increase in secondary investigations (16% versus 41%) and fewer patients being listed directly for surgery (47% versus 29%). Operations on the long saphenous vein decreased from 84% to 76% whereas short saphenous surgery increased from 6% to 21% during this time.

Screening for abdominal aortic aneurysm in Northumberland.

A study was carried out to examine the feasibility of setting up a community-based screening programme for abdominal aortic aneurysm (AAA) in men aged 65-79 years served by a district general hospital. A pilot project was run in two general practices from which 800 men were invited to undergo ultrasonography of the abdominal aorta. Of these, 628 (78.5 per cent) attended; 42 (6.7 per cent) were found to have an aneurysm (aortic diameter greater than 29 mm), ten (1.6 per cent) had a large aneurysm (diameter above 49 mm) and seven (1.1 per cent) received aortic grafts. On the basis of these findings it was felt that to screen all men aged 65-79 years (n = 12,800) or aged 65-74 years (n = 10,300) would lead to more operations than local facilities could handle. A more practical option would be to target annually men aged 65 years, with rescreening at intervals of 5 years until age 75 years, but even this would eventually lead to an unmanageable number of operations.

Five-year vascular audit from a district hospital.

Vascular patients under the care of one surgeon over a 5-year period have been reviewed, from computer-based discharge records, with regard to in-hospital measures of outcome to determine whether or not surgery was being performed to an acceptable standard. Out of 466 procedures, 30 per cent of patients had at least one complication, 14 per cent had further surgery and 9 per cent died. Outcome was examined within the following treatment groups: aorto/iliac aneurysm, aortofemoral bypass, femoroproximal popliteal bypass, femorodistal popliteal bypass, femorocrural bypass, embolectomy and percutaneous transluminal angioplasty. Patients having below-knee bypass surgery were found to have an unacceptably high rate of complications, reoperations and amputations. An overall rate of reoperation for postoperative bleeding of 5 per cent was also considered to be high. With these exceptions, it was concluded that the surgery was being performed to an acceptable standard, but that comparative audit of this type remained difficult while there was a deficiency of national statistics against which the work of individual surgeons could be judged.

Effect of branched chain amino acid infusions on body protein metabolism in cirrhosis of liver.

Thirty seven patients with established cirrhosis of the liver were subjected to measurement of body protein metabolism using L-(1-14C) labelled leucine as a tracer. The effects of disease severity and those of solutions containing 0%, 16%, 35%, 53%, and 100% branched chain amino acids were evaluated. Significant increases in protein synthesis were noted with solutions containing 35%, 53%, and 100% branched chain amino acids, but in patients receiving 100% branched chain amino acids without additional essential amino acid supplement the increase in synthesis was matched by a significant increase in protein breakdown. Protein balance was thus improved only in patients receiving 35% and 53% branched chain amino acids. It was concluded that the high increase in protein breakdown in patients receiving 100% branched chain amino acids was undesirable, and such a solution should not be recommended for clinical use.

Body protein metabolism and plasma amino acids in cirrhosis of the liver. The effect of varying the branched chain amino acid content of intravenous amino acid solutions.

Body protein metabolism and plasma amino acids were measured in 37 patients with stable cirrhosis of the liver to assess the effect of disease severity (Child's classification). Thirty two patients underwent a second series of measurements while nutrition was administered intravenously as one of five different infusions. Four infusions were formulations of amino acids with dextrose of varying branched chain amino acid content (100%, 53%, 35% and 16% branched chain to total amino acids). The fifth infusion was dextrose alone. No differences were detected in body protein synthesis and breakdown between patients on the basis of disease severity although some small differences were noted in the plasma amino acids. Infusion of dextrose alone and the 16% BCAA solution led to negative protein balance and a lowering of the plasma branched chain amino acid concentrations. Improved protein balance was observed with 35% BCAA, this solution also lowered the levels of methionine and aromatic amino acids. In those patients given 53% BCAA protein balance was achieved and the plasma branched chain amino acids elevated. Protein balance also occurred with 100% BCAA, in association with marked increases in underlying protein synthesis and breakdown and with this infusion there were marked elevations in the plasma branched chain amino acids and depression of the other plasma amino acids. The increase in protein breakdown with this last formulation was unexpected and may be harmful. On the basis of these findings it is suggested that the composition of the 53% and 35% solutions may be optimal to protein metabolism and manipulation of plasma amino acids in this group of patients.

Mixing of antacids with stomach contents. Another approach to the prevention of the acid aspiration (Mendelson's) syndrome.

An investigation was carried out into the readiness with which magnesium trisilicate mixture BPC, Andursil suspension (Geigy) and 0.33 M aqueous sodium citrate mixed with gastric contents, to evaluate their suitability for use as an antacid before the induction of anaesthesia in obstetric patients. Laboratory investigations demonstrated that magnesium trisilicate and Andursil did not mix adequately with gastric contents, whereas sodium citrate mixed readily. A clinical investigation of sodium citrate revealed significant improvement in the mixing of gastric juice with the antacid if the patient was turned into the right lateral position following its administration (p < 0.05), but highly significant improvement followed a rotation through 360 degrees (p < 0.005). It was thought that these findings were caused by the division of the stomach into two sacs, a phenomenon confirmed by radiological studies and the use of a pig's stomach as a model of the human stomach.

Relationship between stomach contents and analgesia in labour.

The volume of stomach contents found in patients undergoing Caesarean section was studied. The largest volumes were found in patients who had received pethidine analgesia and the smallest volumes in patients who had received either extradural analgesia or no analgesia. Intermediate volumes were found in patients who had received pethidine in addition to extradural analgesia. Pethidine, rather than the emotional stress of labour, was thought to cause gastric retention. Patients having elective Caesarean sections had considerably less gastric retention than patients in labour.

The place of apomorphine prior to obstetric analgesia.

The use of apomorphine is investigated as an alternative to the use of a stomach tube to empty the stomachs of patients in labour prior to the induction of general anaesthesia. Apomorphine was found to be much pleasanter for the patients, to be just as effective as a stomach tube and to have no deleterious effects on the infant.

A fresh look at magnesium trisilicate.

Confusion exists about the correct way to use magnesium trisilicate as an antacid prior to inducing general anaesthesia in the pregnant woman. The effectiveness of two-hourly doses of antacid is discussed with special reference to the rate at which the stomach empties. Consequently, it is important to know whether the patient is in labour and if so the type of analgesic used. Some of the chemical characteristics of Mist. Mag. Trisil. B.P.C. are discussed. It is shown that it is capable of raising the pH of the stomach contents above 3.0 within two minutes in comparatively small doses. Clinically it is shown to be almost completely effective in a large series of patients. Inadequate mixing of the alkali with the stomach contents when it is given as an immediate pre-induction dose leads to a hazard of acid regurgitation when anaesthesia is induced in these patients.

A comparison of apomorphine and stomach tubes for emptying the stomach before general anaesthesia in obstetrics.

A comparison has been made between two methods of emptying the stomach before general anaesthesia in obstetric patients: aspiration by a stomach tube, and apomorphine-induced vomiting. It was found that most patients preferred apomorphine to the stomach tube. During the operation stomach contents were aspirated in both groups. The mean volumes aspirated were not significantly different. It would appear that neither method guarantees an empty stomach at induction and failure to induce vomiting with apomorphine does not signify that the stomach is empty. Patients, undergoing elective operations, starved for 6 hours and who were not subjected to either method of gastric emptying were found to have significant quantities of stomach contents during anaesthesia. There was no evidence that apomorphine had a deleterious effect on the Apgar scores of the infants at birth.