Necrotizing soft tissue infections in intravenous drug users: a vascular surgical emergency.

OBJECTIVE: To assess the short and long-term outcomes of necrotizing soft tissue infection (NSTI) in intravenous drug users (IVDU) in a regional vascular centre. METHODS: This was a retrospective analysis of all IVDUs with NSTI admitted to the regional vascular surgical unit between January 2009 and July 2014. Clinical outcome measures were interval between admission and surgery, length of ITU/HDU and hospital stays, post-operative complications, in hospital and one year mortality. RESULTS: 25 patients were admitted. The median age was 39 years (range 30-53 years) with a female to male ratio of 1:3.3. The median interval between admission and surgery was 23 hours (range 2-195 hours), however, this was significantly less when the admitting specialty was directly to vascular surgery (median 4 hours, range 2-7) compared with other specialties (median 38 hours, range 7-195 hours). Ten patients required HDU/ITU care with a median duration of 4 days (range 1-12 days). Five patients (20%) required amputation, of whom two (40%) had a prosthetic limb fitted. There was one in hospital death (4%). Another patient died while awaiting limb fitting 4 months post discharge, giving a 1 year mortality of 8%. CONCLUSIONS: NSTI in IVDUs carries high risk of amputation with a very low rate of limb fitting. Intervention is significantly delayed when the admitting specialty is not vascular surgery, and half of these patients require HDU/ITU care, with significant morbidity and mortality. Early diagnosis and referral to vascular surgery is crucial in management of these patients.

Outcome from abdominal aortic aneurysms in Scotland, 1991-2006.

BACKGROUND: This study assessed the impact of sex, presentation and treatment on outcome from abdominal aortic aneurysm (AAA) in Scotland. METHODS: All patients admitted from January 1991 to December 2006 with a primary diagnosis of AAA were identified. Patients were stratified by age, sex, admission diagnosis (ruptured versus intact) and procedure performed (endovascular versus open repair). Multivariable logistic regression analysis was used to determine predictors of mortality. RESULTS: Some 9779 men and 2927 women were admitted with a principal diagnosis of AAA. Women were significantly older than men (median (range) age 75 (35-97) versus 71 (17-96) years; P < 0.001). A higher proportion of women presented with a ruptured AAA (29.5 versus 27.5 per cent; P = 0.043). Age (odds ratio (OR) 2.52 (95 per cent confidence interval 2.36 to 2.74); P < 0.001), female sex (OR 1.63 (1.48 to 1.78); P < 0.001) and admission diagnosis (OR 10.49 (9.53 to 11.54); P < 0.001) were independent predictors of early death, whereas endovascular repair predicted survival (OR 0.67 (0.58 to 0.76); P < 0.001). CONCLUSION: Women presenting with an AAA were older and more likely to be admitted with a ruptured aneurysm. Female sex was an independent risk factor for death from AAA.

The analgesic effect of odour and music upon dressing change.

Vascular wounds may require frequent dressing changes over a long period of time, often involving pain, which may not be adequately controlled with conventional analgesia. Complementary analgesia may be beneficial as an adjunctive therapy. This pilot study presented eight patients with two odour therapies, lavender and lemon, two music therapies, relaxing and preferred music and a control condition, during vascular wound dressing changes. Although the therapies did not reduce the pain intensity during the dressing change there was a significant reduction in pain intensity for the lavender therapy and a reduction in pain intensity for the relaxing music therapy after the dressing change. This supports the use of these complementary therapies, which are inexpensive, easy to administer and have no known side effects, as adjunctive analgesia in this patient population. Earlier administration before dressing change may enhance these effects. Further research is required to ascertain why certain complementary therapies are more effective than others at relieving pain.

Crohn's disease presenting as adenocarcinoma of the small bowel.

Crohn's adenocarcinoma of the small bowel is extremely rare. We report a patient with a 10-year history of nonspecific abdominal symptoms who was found on his first presentation to have Crohn's adenocarcinoma of the small bowel. Despite adequate surgical resection, prognosis for this condition is poor with 2-year cancer free survival of around 9%. Crohn's carcinoma should be suspected in patients with long-standing disease and those with and without excluded segments of bowel.

Subclavian artery injury following percutaneous insertion of dialysis catheter.

Iatrogenic subclavian artery injury is a rare but recognized complication of central venous catheterization. The lesion is more severe and complex to treat when produced by large catheters such as dialysis catheters. A case is presented below with a discussion of vascular access for renal replacement therapy and the principles of treating penetrating arterial trauma at this location.

Expression of GABA transporter mRNAs in the developing and adult rat optic nerve.

There is electrophysiological evidence of a functional role for gamma-aminobutyric acid (GABA) and GABA transporters (GATs) in the neonatal rat optic nerve, and that they are down-regulated during development. The results of the present study demonstrate directly by reverse transcription-polymerase chain reaction (RT-PCR) that the mRNAs encoding for GAT-1, -2 and -3 are expressed in the optic nerves of both neonatal (5 day old) and adult rats. The results support a role for GABA in the developing rat optic nerve, a typical white matter tract which contains axons and glia, but neither neuronal cell bodies nor synapses. Significantly, the persistence of GAT mRNAs suggests an enduring function for both GABA and glial uptake mechanisms in the adult optic nerve.

Distal anastomotic vein cuff and the use of an internal vessel occluder.

In the absence of adequate autogenous vein for tibial artery bypass in limb salvage surgery, the use of prosthetic grafts with a distal anastomotic vein cuff or patch has shown promising results. Here, we describe how the Florester Internal Vessel Occluder (Meadox UK, Bedfordshire, UK) can facilitate the construction of a distal anastomotic vein cuff.

Transcutaneous oxygen monitoring as an indication of prognosis in critical ischaemia of the lower limb.

Critical ischaemia in the chronically ischaemic limb has proved difficult to define both in clinical and objective terms. This has meant that assessment of patients has in the past relied heavily on the angiographic appearances of the vessels which is also an unreliable technique. Attempts have been made to define critical ischaemia objectively in terms of the ankle systolic pressure but recent studies have shown that although the definition produced in 1982 was highly specific, the sensitivity was low with many patients with the clinical features of critical ischaemia having ankle pressures which were higher than the recommended values. Recently the transcutaneous measurement of oxygen tension has been used to assess patients with peripheral vascular disease and has proved of use in assessing distal tissue perfusion in chronically ischemic limbs. This study compares ankle systolic pressure measurements with the transcutaneous oxygen tension results from the ischaemic foot with the patient sitting and found that the latter gave a more accurate guide to the severity of ischaemia and a more accurate prediction of the short-term results in individual cases.

Transluminal angioplasty in the treatment of mesenteric vein graft stenosis.

We present 2 patients with chronic mesenteric ischemia who were successfully treated by mesenteric bypass grafts which then became stenosed and occluded. Patency was restored by percutaneous transluminal dilatation of the stenoses. Chronic mesenteric ischemia affects a population who are at high risk for surgical procedures, and second operations following occlusion of mesenteric grafts appear to carry an increased risk of both morbidity and mortality. We therefore suggest that transluminal angioplasty may prove a valuable form of treatment in these cases.

The widening indications for transluminal angioplasty in peripheral vascular disease.

A prospective study of 57 patients undergoing a total of 85 transluminal angioplasties was undertaken to assess the indications for, and the results of the procedure. We found excellent results with angioplasty in the treatment of isolated iliac artery stenoses, femoral stenoses and short femoral artery occlusions, with a low complication rate. This is the group of patients for whom angioplasty has become a widely used treatment. We feel there is a second group of patients who can benefit from transluminal angioplasty. These are the patients with extensive atherosclerosis in the lower limb vessels where surgery is difficult and the risks of anaesthesia often high due to concomitant coronary artery disease. 66% of these patients in our study obtained significant benefit from limited transluminal angioplasty with a low morbidity and zero mortality. We, therefore, conclude that transluminal angioplasty has an important role to play in the management of these patients.