Socioeconomic deprivation does not affect prescribing of secondary prevention in patients with peripheral arterial disease.

AIM: Aim of the study was to assess the effect of socioeconomic deprivation on prescribing of cardiovascular secondary prevention medications in patients referred with peripheral arterial disease (PAD). METHODS: A retrospective review of vascular clinic referrals was performed. All patients referred from primary care with suspected PAD over a two month period were included. The deprivation score, prescription of cardiovascular secondary prevention medications, smoking status and the presence of cardiovascular co-morbidities (coronary artery or cerebrovascular disease--CAD/CVD) were assessed. Comparison was made between socioeconomic groups using the Carstairs Deprivation (DepCat) Score and between patients with and without a history of currently existing cardiovascular co-morbidities. RESULTS: The study included 391 patients. Almost two thirds of patients (253) were from the most deprived socioeconomic groups and were significantly younger at presentation (median age DepCat 7: 63 yrs, DepCat 1-2: 74.5 yrs, P<0.0001). The majority of patients with a prior history of CAD/CVD were prescribed secondary preventative medications at the time of referral with suspected PAD whereas those with no prior history of CAD/CVD, (212 patients, 54%) were significantly less likely to be prescribed antiplatelets (47% vs. 83%), statins (45% vs. 86%) or ACEi/ARBs (29% vs. 68%) (all P<0.05). Secondary prevention prescribing did not differ between socioeconomic groups. CONCLUSION: Secondary prevention prescribing is inadequate in patients with suspected PAD regardless of socioeconomic group and is significantly lower in those without previously diagnosed CAD/CVD. There remains a lack of appreciation of the high cardiovascular risk associated with PAD.

Unnecessary inter-hospital referral of minor hand injuries: a continuing problem.

BACKGROUND: Trauma patients are a burden on resources in terms of personnel, operating time and bed occupancy. The plastic surgery trauma clinic was established in January 1999 and has been running Monday to Friday mornings from 9 am to 1 pm since its establishment. AIM: To analyse and compare referral patterns to the Plastic Surgery trauma clinic over three time periods. METHOD: Three time groups were analysed and compared: data from this initial study (2000-2001), a retrospective chart review (2002-2003), as well as a prospective study (2006-2007). RESULTS: Numbers of attendances at the Trauma Clinic seem to be increasing every year despite encouragement by letter after the initial study for local centres to treat many of the minor injuries not requiring plastic surgical skills. CONCLUSION: Admission rates have remained below 50% of the patients seen in the clinic; however 50% of patients required only local anaesthetic procedures performed in the clinic, or no treatment at all (27.6% of patients in 2003, 35.3% in 2006).

Occupational injuries in foreign-national workers presenting to St James's Hospital Plastic Surgery service.

This study was undertaken to investigate our impression that migrant foreign-national workers were more at risk of sustaining work place injuries requiring referral to our Plastic Surgery service than their indigenous Irish counterparts. Data were collected prospectively from August 2006 to February 2007 on all work-related injuries presenting to the Plastic Surgery service in St James's Hospital, Dublin. 201 work-related injuries were recorded during the six month study period. 40% (n = 81) of the study group were foreign-national workers. Foreign-national workers account for only nine percent of the total Irish workforce. 31% (n = 25) of the study group required a translator. Over half (55%) of all the foreign-national workers in the current study had been in their present job for less than six months at the time of injury compared to only nine percent of Irish workers. This study highlights that foreign-national workers in Ireland are at a disproportionately high risk of occupational injury when compared to their Irish colleagues and emphasises the need for targeted occupational health and safety measures in this vulnerable group.

Intraoperative retrograde mesenteric angioplasty for acute occlusive mesenteric ischaemia: a case series.

Acute mesenteric ischaemia secondary to atherosclerotic disease of the superior mesenteric artery is a surgical emergency associated with a poor prognosis, and requires prompt diagnosis and early revascularisation in order to improve outcome. The traditional management of surgical resection of necrotic bowel plus mesenteric revascularisation by surgical bypass is associated with significant morbidity and mortality. We describe the use of a combined surgical and endovascular approach, using intraoperative retrograde superior mesenteric angioplasty at the time of laparotomy. Four patients have been treated by this combined technique with three surviving, although one subsequently required an open surgical revascularisation procedure.

The use of clopidogrel in carotid endarterectomy: an audit of current practice.

Clopidogrel is commonly encountered in patients presenting for carotid endarterectomy (CEA). Its use around this time is controversial and there is no randomized control trial data to determine best practice. Questionnaires were posted to all members of the Vascular Society investigating clopidogrel use at the time of CEA. 52% discontinue clopidogrel preoperatively, with 51% of those using no alternative and 49% replacing it with aspirin. Clopidogrel use is not related to the number of endarterectomies performed by each surgeon. There is no consensus on clopidogrel use during CEA. This highlights the need for quality prospective data on this subject.

Are paediatric burns more common in asylum seekers? An analysis of paediatric burn admissions.

The number of asylum seekers in Ireland has increased dramatically over the last 10 years. Based on our impression that the number of children admitted to our burn unit was disproportionately represented by children of asylum seekers we performed an audit to establish (1) what proportion of admissions are from this subgroup and (2) the characteristics of their burns. All paediatric burn admissions from May 2003 to April 2004 were reviewed. Data collected from a retrospective chart review included patient demographics and details of the burn injuries. The National Census of 2002 and the Office of the Refugee Applications Commissioner were consulted for population statistics. Total burn admissions for the period were 126: Irish nationals (n=107), non-national residents (n=2), asylum seekers (n=14) and patients of unknown asylum status (n=3, excluded from study). In the asylum seeker group, the median age was 18.6 months (range 10 months-5.3 years) with the majority less than 2 years (n=11). All burns occurred in the domestic setting. Scalds accounted for 13 cases, one contact burn occurred from a hot grill. The median total body surface area burned was 5.7% (range 1.5-26%). The National Census of 2002 recorded a population of 3,917,203. With less than 12,000 asylum seekers in the country, they comprise only approximately 0.3% of the population yet they account for 11.4% of the burn patients admitted to our unit, p<0.0001. Children of asylum seekers are over-represented in our series of paediatric admissions for burns and are more likely than Irish children to sustain a burn at a younger age and in the domestic setting. This may indicate an increased risk of injury and warrants further investigation.

Psychiatric morbidity in a regional plastic surgery centre--one-year review with a proposed categorisation.

Few studies describe the incidence and nature of psychiatric morbidity in plastic surgery patients. We undertook a review of all referrals from the Plastic Surgery Service to the Psychological Medicine Service over a 1-year period (January-December 2001). Standardised socio-demographic information, nature and cause of injury/defect, surgical intervention, surgical outcome, psychiatric diagnosis and psychiatric follow-up were determined. The majority of patients referred had a significant existing psychiatric illness, had made a suicide/parasuicide attempt, or were burns patients. There was a high rate of referral of plastic surgery inpatients. Liaison with plastic surgery staff to allow rapid identification and early management of psychiatric morbidity is an important role for psychological medicine. We outline a defined categorisation of common contexts in which psychiatric morbidity may present to plastic surgery services.

Neutralising IL-12 activity as a strategy for prolonging allograft survival and preventing graft-versus-host disease.

Interleukin-12 (IL-12) is a key immunoregulatory cytokine which promotes the development of Thl-dependent, cell-mediated immune responses. Acute allograft rejection after organ transplantation and acute graft-versus-host disease (GVHD) after bone-marrow transplantation are generally attributed to cell-mediated immune mechanisms and, therefore, potentially susceptible to immunological intervention at the level of IL-12. Recent data from murine models of transplantation have highlighted the potential of IL-12 as a selective target for immunotherapy. Neutralising endogenous IL-12 for a brief period at the time of transplant promotes long-term deviation from a Th1 to a polarised Th2 alloimmune response. This confers lasting protection from GVHD but is less effective at preventing acute rejection, possibly because Th2-dependent immune responses are also capable of effecting graft rejection.

Skin allograft rejection in mice lacking inducible nitric oxide synthase.

BACKGROUND: During allograft rejection, up-regulation of cytokine-inducible nitric oxide synthase (iNOS) leads to the production of large amounts of nitric oxide (NO). The net effect of NO on the alloimmune response is, however, difficult to predict because of its diverse biological effects, which include potentially opposing roles as an effector and immunoregulatory molecule. METHODS: In this study, the role of iNOS on the in vitro and in vivo alloimmune response was defined using mutant mice that lack a functional iNOS gene. The ability of spleen cells obtained from iNOS-deficient mutants to proliferate and to produce cytokines in response to irradiated BALB/c stimulator cells was determined, and the rate at which iNOS-deficient mice were able to reject BALB/c skin allografts was observed. RESULTS: Spleen cells from homozygous iNOS-deficient (129xMF1)F1 mice, when compared with cells from heterozygous control mice, showed an increased in vitro proliferative response and produced substantially higher levels of interferon-gamma, and also more interleukin-2 and interleukin-12, in response to allogeneic stimulation. The kinetics of BALB/c skin graft rejection were comparable in heterozygous control animals and iNOS-deficient mice. Moreover, no net effect of iNOS on skin allograft rejection was apparent in mice treated with depleting monoclonal antibodies (mAb) to CD4 or CD8 T cells, either alone or in combination, or in mice treated with both anti-CD8 mAb and a neutralizing anti-tumor necrosis factor mAb. CONCLUSIONS: These results show that iNOS has an immunomodulatory effect on the in vitro alloimmune response but lack of iNOS has no net influence on the kinetics of murine skin allograft rejection in either unmodified recipients or recipients in which the early contribution of T-cell subsets and tumor necrosis factor-alpha to graft rejection has been abrogated.

Craniofrontonasal dysplasia.

A series of 10 patients with craniofrontonasal dysplasia presenting to the Oxford Craniofacial Unit since 1983 is presented. In addition to the well-described combination of coronal synostosis and frontonasal dysplasia, 9 patients had very characteristic dry, curly or frizzy hair. All the patients were female. Recognition of the syndrome is important for genetic counselling, although the precise mode of genetic transmission is unclear with females predominating and males being less severely affected. Surgical correction was in two stages: early frontal advancement followed by correction of hypertelorism when the child became aware of the deformity. Four patients had their craniosynostosis treated in the Oxford Craniofacial Unit. Three patients had previously had frontal remodelling elsewhere. Nine patients had surgery for hypertelorism. The preferred technique for hypertelorism correction was facial bipartition. Following hypertelorism correction, the excess skin was allowed to redrape and subsequently dealt with by medial canthoplasties, thus avoiding a midline scar. Careful attention to the primary frontal advancement procedure is important to avoid complications following difficult dissection of the frontal bone flap at the time of hypertelorism correction.

Follicular carcinoma of thyroid presenting as back pain leading to a delay in diagnosis.

The case is described of a 53-year-old man presenting with right-sided low back and thigh pain. Non-urgent investigations showed a metastatic lesion in his right hemipelvis arising from a thyroid primary.

Home traction in the management of femoral fractures in children.

Fracture of the femur in children is a common problem which can be managed in a variety of ways. We treated such fractures in children up to the age of 13 by immobilization in a Thomas splint, after reduction, if necessary, and traction in hospital. After a short period, traction was continued at home using a mobile frame with the Thomas splint. The results of such home traction were assessed in terms of both healing of the fracture and any complications and of the parental attitudes to treatment at home. It was found that traction at home was an acceptable method for the management of such fractures. Results were comparable to other methods of treatment and parental satisfaction was very high, providing there was adequate surveillance by the district nurse and immediate access to advice. The cost-savings of such a treatment are significant.

Management of malignant melanoma of the head and neck.

A total of 91 patients with melanoma of the head and neck treated between 1973 and 1991 were studied prospectively with regard to prognostic features, treatment and outcome. Other than Breslow thickness, the only important prognostic feature was the less aggressive nature of lentigo maligna melanoma. A policy of selective excision margins, 1 cm for impalpable and 2 cm for palpable lesions, was found to be safe, although preliminary biopsy should be used if there is diagnostic uncertainty or where the expected extent of surgery entails a mutilating procedure. Local recurrence rates were not affected by the method of wound closure, which should be determined by the best functional and cosmetic outcome. These results support the trend against prophylactic neck dissection. Such dissection, when indicated for lesions of the face, pinna, anterior scalp and parotid area, should routinely include superficial parotidectomy. Uncontrolled symptomatic loco-regional recurrence is an uncommon complication that may occur despite radical primary surgery. The role of preoperative radiotherapy for high-risk melanoma in this situation warrants investigation.

Fibroblast stimulation of breast cancer cell growth in a serum-free system.

Conditioned media from 14 short term fibroblast cell lines were mitogenic for human breast cancer cells with different steroid receptor profiles in serum-free culture. Fibroblast-conditioned medium stimulated tritiated thymidine incorporation in short term culture and growth in a longer proliferation study as measured by the MTT colorimetric assay. Conditioned media from benign and malignant epithelial cells were non-stimulatory for breast cancer cells but that derived from endothelial cells showed similar stimulation to fibroblasts. Partial purification of fibroblast-conditioned medium identified a peptide with a molecular weight of approximately 8 kDa that showed no affinity for heparin and was mitogenic for MCF-7 breast cancer cells.

Safe margins in the excision of primary cutaneous melanoma.

A group of 434 patients treated for primary cutaneous melanoma over an 18-year period by a policy of selective excision margins based on clinical estimation of tumour thickness was studied prospectively. Clinical assessments of tumour as impalpable, palpable but not overtly nodular, and nodular correspond to thicknesses of < or = 0.75, 0.76-1.49 and > or = 1.50 mm respectively. From 1971 to 1987, 330 patients were treated with excision margins of 1, 2 and 3-5 cm based on these respective ranges. During 1988 and 1989, 104 patients were treated after reduction of the maximum width of excision to 2 cm. The overall local recurrence rate was 11 of 434 patients (2.5 per cent), with no recurrence in melanoma < or = 0.75 mm thick and no increase in the local recurrence rate after reduction of the maximum margin from 3 to 2 cm. A policy of 2-cm clearance for palpable and nodular melanoma and 1 cm for impalpable lesions is recommended. Any further reduction must be tested prospectively.

The response of primary cultured adult mouse sensory neurons to ethanol, propanol, acetaldehyde and acrolein treatments.

Primary cultures of adult mouse sensory neurons maintained for 8 days in vitro (8 div), in both the presence of non-neuronal cell (NNC) outgrowth and in NNC-reduced cultures, were exposed to doses of ethanol, propanol, acetaldehyde and acrolein. The effects on cell viability were monitored: LD50's of 600 microM acrolein and 100 mM propanol were obtained after 24 h exposures and after 48 h with 1 mM acetaldehyde and 500 mM ethanol. Morphological effects were evident by scanning electron microscopy with sub-acute doses for each agent, using both lower concentrations and shorter exposures. Membrane pitting of the perikaryon and a reduction in the proportion of neurons bearing neurites were common signs of toxic insult. The neurites of treated cells were thicker and more irregular than those of untreated cells; this proved a good indicator of specific neurotoxicity rather than merely a cytotoxic response. Fetal calf serum in the medium lessened the response of neurons to ethanol treatments. Comparison with other in vitro studies suggests these primary cultures are a more sensitive system than established cell lines of neuronal origin for use in neurotoxicity testing.

Neuronal maintenance and neurite extension of adult mouse neurones in non-neuronal cell-reduced cultures is dependent on substratum coating.

Adult mouse DRG neurones have been maintained for 14 days in cultures where non-neuronal cell proliferation was inhibited by the inclusion of 5 x 10(-6) microM-cytosine arabinoside (AraC) in the medium from the onset of culture. On uncoated plastic neurone numbers significantly declined in the absence of non-neuronal cell outgrowth compared with uninhibited co-cultures. However, when neurones were maintained in the presence of AraC on certain coated surfaces this decrease in neurone numbers was not observed. Combinations of fibronectin (FN) and laminin (LAM) proved most effective for 7 and 14 days in vitro, although either was beneficial if used separately. Microexudates produced by the fibroblast line, 3T6, also significantly improved neuronal counts for 14 days in vitro. However, a microexudate derived from primary cultures of mouse hepatocytes, although advantageous for 7 days in vitro, was not effective in maintaining neurones over the 14-day culture period, reminiscent of previous observations when synthetic cationic agents were used. Electrophoretic analysis of the fibroblast exudate indicated that fibronectin was present in the substrate-attached material generated by this cell line. The reduction in non-neuronal cell growth facilitated the monitoring of neuronal structural detail by scanning electron microscopy. Examination of neurite extension, indicative of neurone differentiation, was particularly improved. FN/LAM and the fibroblast-derived exudate increased nerve fibre growth, whilst the hepatocyte exudate had little effect on neurite regeneration, and polylysine had a detrimental effect. The data demonstrate that substrata can have a significant effect on maintenance and differentiation of adult neurones in primary culture.(ABSTRACT TRUNCATED AT 250 WORDS)

The survival of adult mouse sensory neurons in vitro is enhanced by natural and synthetic substrata, particularly fibronectin.

Primary cultures derived from adult mouse dorsal root ganglia have been maintained in the presence or absence of 5 X 10(-6)M cytosine arabinoside for periods of up to 4 weeks. In cultures in which cytosine arabinoside is present, the non-neuronal cell population is effectively reduced. When uncoated plastic substrata are used there is also a concurrent decrease in the number of neurons if the medium is supplemented with cytosine arabinoside. The effects on neuron survival of substrata coated with fibronectin, polyornithine, polylysine, and exudates prepared from mouse liver cells were studied. It was shown that neuronal densities similar to those with uninhibited media may be retained in the presence of cytosine arabinoside if fibronectin-coated substrata are prepared. With the other coating agents neuronal survival was also enhanced but to a lesser extent. The study offers a means therefore of producing purer cultures of dorsal root ganglia neurons than has previously been possible from adult mammalian sources.