Adventitial cystic disease of common femoral artery.

Adventitial cystic disease (ACD) is an uncommon cause of ischemia. The majority of ACD is located in the popliteal artery. Over 49 extrapopliteal locations have been described. We report on a case of femoral artery ACD in a young patient with claudication. The diagnosis was made with duplex ultrasound and confirmed with computed tomographic angiogram. The patient underwent a surgical treatment. One year postoperatively, the patient is active with no claudication. To our knowledge, this is the first reported case of extrapopliteal artery ACD in Canada.

Assessment of patient waiting times for vascular surgery.

OBJECTIVES: To assess patient waiting times for vascular surgery and to determine if complications of the disease develop while the patients are awaiting surgery. DESIGN: Prospective cohort study. SETTING: A university-affiliated tertiary care institution. PATIENTS: All 554 patients who underwent scheduled vascular surgical procedures between April 1995 and October 1996. OUTCOME MEASURES: A literature review carried out to develop guidelines for acceptable waiting times for surgery associated with various vascular disorders based on their natural history (benchmark target); actual waiting times, defined as the interval from the date each patient was booked for surgery to the date of admission to hospital for the procedure; the proportion of patients admitted within the benchmark targets; and whether prolonged waiting time placed patients at risk for complications of their disease. RESULTS: Of the 554 patients, 382 (69%) were admitted within the benchmark waiting times. Of 84 patients having an abdominal aortic aneurysm, the aneurysm ruptured during the waiting period in 6, and 4 of them died, for a complication rate of 7% and a death rate of 5%. Two of the 6 aneurysms ruptured after the patient had waited longer than the target time. Three of 100 patients with symptomatic carotid artery stenosis awaiting admission for carotid endarterectomy suffered ischemic stroke, for a 3% complication rate; all had waited longer than the target period. One patient suffered occlusion of a femoropopliteal bypass graft while awaiting revision of a stenosed bypass graft. CONCLUSIONS: This study suggests that although most patients are admitted for operation within the benchmark time, one-third are admitted late and may suffer serious complications of their disease while awaiting admission for the procedure.

Effect of soaking in Hank's balanced salt solution or milk on PDL cell viability of dry stored human teeth.

This study was designed to evaluate the effect of soaking in either Hank's balanced salt solution (HBSS) or milk on periodontal ligament (PDL) cell viability in avulsed teeth. Dry storage times of 30, 60, and 90 min were evaluated. PDL cell viability was determined after removal of the cells from the root surfaces of extracted teeth using a modification of the procedure described by Nakashima (Arch Oral Biol 1991;36:655-63). After trypsinization and subsequent treatment in collagenase, the cells were stained with trypan blue, and viable and non-viable cells were counted using a hemocytometer and converted to percentages for statistical comparison. The results of this study demonstrated no significant difference in the number of viable cells with or without soaking in HBSS or milk at any of the dry storage times. In addition, there was no significant difference in PDL cell viability between the 30-and the 60-min dry periods. Although the soaking procedure had no obvious negative consequence, no significant improvement in PDL cell viability by the addition of this step was demonstrated under the conditions of this study.

Validation of a high voltage leak detector for use with pharmaceutical blow-fill-seal containers--a practical approach.

Proposed requirements for pharmaceutical package integrity testing outlined in the EU Guide for Sterile Medicinal Products may make it necessary to evaluate and validate alternate ways to perform 100% leak inspection. One such method is high voltage leak detection (HVLD). Even though HVLD has been used for glass ampoules and vials for years, qualification and validation strategies are not well established. In this article, we describe and discuss our practical approach to validation and the protocols used to qualify and validate a high voltage leak detector for use with blow-fill-seal containers. For this work, we used laser drilled pinholes as a model for pinholes produced during manufacturing and defined a "window diagram." This diagram allowed us to plot the parameters of influence and the settings of the HVLD in an easy to visualize pictorial display. In the validation step, we initially determined the most sensitive standard integrity test for our product and container design from the available choices, the vacuum chamber, dye bath and microbial challenge visual inspection tests. In the next phase of our work, the HVLD was crossed-validated against the most sensitive of these tests, the dye bath visual inspection test. This was accomplished with a large number of containers mixed with deliberately defective ampoules. Our conclusion from this work is that the HVLD is an appropriate and feasible integrity test for 100% inspection of blow-fill-seal containers.

Infectious aortitis due to penicillin-resistant Streptococcus pneumoniae.

Infectious aortitis is uncommon and typically affects elderly immunocompromised men, with a Salmonella or Staphylococcal infection of an atheromatous or aneurysmal aorta. We present a fit young man who developed infectious aortitis with peripheral embolization due to a penicillin-resistant Streptococcus pneumoniae bacteremia.

Factors which influence the rate of receiving a routine second newborn screening test in Washington State.

This study was conducted to determine whether newborns from different ethnic and socioeconomic groups in Washington State are equally likely to have a routine second newborn screening (NBS) test and if there are identifiable factors associated with not having a second test. For many years, the standard of care for NBS in Washington has been that newborns should receive a routine second screening test at age 7-10 days. However, data collected by State Department of Health (DOH) staff for the past several years indicated that only about 80% of newborns receive a routine second NBS test. The data presented here suggest that identifiable factors (i.e., barriers) exist in accessing a routine second NBS test in Washington. Increased educational efforts targeting certain high-risk infants, their parent/caretakers, and primary care providers are apparently needed to ensure equal access to a routine second test.

Inconsistencies in pedigree symbols in human genetics publications: a need for standardization.

To determine consistency in usage of pedigree symbols by genetics professionals, we reviewed pedigrees printed in 10 human genetic and medical journals and 24 medical genetics textbooks. We found no consistent symbolization for common situations such as pregnancy, spontaneous abortion, death, or test results. Inconsistency in pedigree design can create difficulties in the interpretation of family studies and detract from the pedigree's basic strength of simple and accurate communication of medical information. We recommend the development of standard pedigree symbols, and their incorporation into genetic publications, professional genetics training programs, pedigree software programs, and genetic board examinations.

Muscle function in chronic compartment syndrome of the leg.

Chronic compartment syndrome (CCS) is a recognized cause of recurrent leg pain in the exercising patient. Decreased muscle function has been implied in this condition. This study compared the ankle dorsiflexion torque of 10 CCS patients with that of 18 control subjects during 20 repeated, maximal, isokinetic contractions at 60 degrees/sec. Peak torque, relative peak torque, and endurance data were collected. Results showed significantly lower peak torque and relative peak torque in the CCS group (p < or = 0.05), supporting the implication of muscle weakness in CCS. Paradoxically, endurance was significantly higher in the CCS group (p < or = 0.01), and there was a significant (p < or = 0.01), negative correlation (r = -0.50) between peak torque and endurance. The relationship between the findings and CCS is discussed. Strengthening may be useful in very mild cases or in postfasciotomy patients.

Comparison of percutaneous with intra-operative balloon angioplasty for arteriosclerotic occlusive disease.

The purpose of this study was to compare the technical success and short-term outcome of intraoperative balloon angioplasty (IBA) with percutaneous transluminal angioplasty (PTA) in the iliac and femoropopliteal segment. From January 1988 to February 1991, 99 consecutive patients underwent 114 angioplasties in the iliac (37 PTA, 26 IBA) and femoropopliteal segment (15 PTA, 36 IBA). Mean age and sex distributions were similar between the groups. Claudication was the primary indication for both groups. All patients who underwent IBA had another concomitant surgical procedure performed. Immediate technical success for PTA and IBA were 50/52 (96%) and 58/62 (94%), respectively. Cumulative patency up to 12 months following angioplasty of the iliac artery was 94% for PTA and 78% for IBA (P-value NS). For the femoropopliteal segment, 12 month patency results were 100% for PTA and 78% for IBA (P-value NS). Complications requiring surgical intervention occurred in 3 (6%) PTA and 5 (8%) IBA cases. Results from this study indicate that technical success and early patency are similar for PTA and IBA in the iliac and femoropopliteal segments. However angioplasty-related complications were not avoided by performing balloon angioplasty in the operating room.

Investigations into the clinical utility of latex D-dimer in the diagnosis of deep venous thrombosis.

The serial use of non-invasive tests has been shown to be a safe method of managing outpatients who are suspected of having lower limb deep venous thrombosis (DVT). Objective testing has shown that the majority of these outpatients do not have venous thrombosis. A rapid test to exclude DVT in these patients, without the need for expensive and inconvenient serial noninvasive vascular testing, would have practical and economic advantages. Studies measuring the fibrin degradation product D-dimer using enzyme-linked immunoassays (EIA) in patients with venographically proven DVT suggest that it should be possible to exclude this condition by the use of one of the rapid latex bead D-dimer tests. We have examined 190 patients with suspected DVT using both a latex and an EIA D-dimer assay. The latex D-dimer test used in this study was negative in 7 of the 36 proven cases of DVT. This sensitivity of only 80% is not sufficient to allow this type of assay, in its current form, to be used as an exclusion test for DVT. The same plasma samples were tested with an EIA assay. This information was used to mathematically model the effects of selecting a range of D-dimer discriminant cut off points for the diagnosis of DVT. These results indicate that 62% of suspected clinically significant DVT could have this diagnosis excluded, with a 98% sensitivity, if the rapid latex or equivalent D-dimer test could be reformulated to measure less than 185 ng/ml of D-dimer.

Negotiating self-care in rehabilitation nursing.

The authors conducted a study to examine nurse and patient perceptions of self-care and the performance of self-care in rehabilitation settings. The grounded-theory method was used to conduct and analyze in-depth interviews of 12 nurses and 12 rehabilitation patients. Every nurse and every patient had expectations regarding who would control each aspect of the patient's self-care. When these expectations were noncongruent, negotiation usually occurred. Successful negotiation resulted in a balance of self-care, the optimal balance between nurse and patient control.

Atherectomy. Early use of three different methods.

The authors report their initial experience in 52 patients with three different techniques of peripheral artery atherectomy--the Tracwright (Kensey), used in 19 patients, the Simpson AtheroCath, used in 19 patients and the transluminal extraction catheter, used in 14 patients. The indications for atherectomy were claudication in 42 (80%) and limb-threatening ischemia in 10 (19%). There were no deaths. Complications included three arterial perforations, one thrombosis and one groin hematoma requiring operative evacuation. There were no distal embolizations. Atherectomy was initially unsuccessful in 15 (29%) patients. For the successfully completed procedures, the 1-year primary patency rates were as follows: Tracwright (Kensey) catheter 56%, Simpson catheter (63%) and transluminal extraction catheter (0%). Use of subsequent nonoperative procedures on recurrent stenoses produced secondary patency rates of 77% for the Tracwright (Kensey) technique, 80% for the Simpson catheter technique and 78% for the transluminal extraction catheter technique. The authors conclude that their early results justify further evaluation of these three techniques. Use of the transluminal extraction catheter is associated with higher rates of occlusion and restenosis.

Intraoperative balloon angioplasty: a surgical approach.

Percutaneous balloon angioplasty is a recognized treatment for peripheral atherosclerosis involving the iliac and femoropopliteal segments. From their experience in 38 patients the authors have examined the efficacy of intraoperative balloon angioplasty for tandem lesions requiring both balloon angioplasty and surgical intervention. Between January 1988 and July 1990, 43 intraoperative balloon angioplasties were performed in 19 women and 19 men who required inflow or outflow angioplasty in addition to surgical bypass. The indication for surgery was incapacitating claudication in 32 (74%) patients and limb salvage in 11 (26%) patients. Initial technical success was achieved in 17 (89%) of 19 patients who required iliac surgery and in 22 (92%) of 24 patients who required femoropopliteal balloon dilatations. There were four major complications (9%), all requiring surgical intervention. In two cases there was dissection with thrombosis and in two cases failure to improve the pressure gradient. Patients were followed up for up to 24 months. Two of the inflow angioplasties failed between 6 and 9 months. Two of the outflow angioplasties failed between 12 and 15 months. Three patients died in the follow-up period, two from myocardial infarction. In the authors' experience intraoperative balloon angioplasty has proven a worthwhile adjunct for tandem lesions in the iliac and femoropopliteal segments.

Diagnosing Deep Venous Thrombosis: Use of tests for accurate diagnosis.

Patients often present with unexplained lower limb pain and swelling. It is important to exclude deep venous thrombosis in the diagnosis because of the threat of sudden death. Simple clinical diagnosis is unacceptable, and noninvasive tests should be used initially. Serial testing detects proximal extension of isolated calf thrombi. Multiple diagnostic modalities are employed to diagnose a new deep venous thrombosis in patients with postphlebitic syndrome.

Laser-assisted balloon angioplasty: initial 18 months' experience.

The authors describe their initial 18-month experience with laser-assisted balloon angioplasty (LABA) of femoral arteries in 44 patients. Primary patency was achieved in 28 patients, but within 30 days the artery became occluded in 9 of them. Perforation occurred much more frequently early in the study. Complications associated with antegrade femoral artery puncture have led to more liberal use of LABA through an operative approach in the femoral artery. Attention to technical detail is critical. When LABA fails it does not appear to worsen the patient's condition clinically or radiologically. Endovascular procedures are undergoing continued, rapid change, so ongoing development and assessment of results are necessary for those who perform LABA.

Investigations into a vascular etiology for low-tension glaucoma.

Increased intraocular pressure is accepted as a primary etiologic factor for the atrophy of the optic nerve head and visual field defects of high-tension glaucoma. Other factors must be present to explain these findings in low-tension glaucoma. One of the current theories is that low-tension glaucoma is the result of decreased optic nerve perfusion on the basis of vascular disease or other factors such as altered blood viscosity. This study compared the non-invasive vascular profiles, coagulation tests, and rheological profiles of 46 consecutive cases of low-tension glaucoma with 69 similarly unselected cases of high-tension glaucoma and 47 age-matched controls. Despite the multifactorial approach and the use of previously validated objective tests, no significant group differences were detected with any of the above investigations. If vascular disease is important in the etiology of low-tension glaucoma, then it must be localized or vasospastic since this study does not support the concept of a generalized vascular etiology, either of an atheromatous or hyperviscous nature, for the genesis of low-tension glaucoma.