In situ normothermic regional perfusion for controlled donation after circulatory death--the United Kingdom experience.

Organs recovered from donors after circulatory death (DCD) suffer warm ischemia before cold storage which may prejudice graft survival and result in a greater risk of complications after transplant. A period of normothermic regional perfusion (NRP) in the donor may reverse these effects and improve organ function. Twenty-one NRP retrievals from Maastricht category III DCD donors were performed at three UK centers. NRP was established postasystole via aortic and caval cannulation and maintained for 2 h. Blood gases and biochemistry were monitored to assess organ function. Sixty-three organs were recovered. Forty-nine patients were transplanted. The median time from asystole to NRP was 16 min (range 10-23 min). Thirty-two patients received a kidney transplant. The median cold ischemia time was 12 h 30 min (range 5 h 25 min-18 h 22 min). The median creatinine at 3 and 12 months was 107 µmol/L (range 72-222) and 121 µmol/L (range 63-157), respectively. Thirteen (40%) recipients had delayed graft function and four lost the grafts. Eleven patients received a liver transplant. The first week median peak ALT was 389 IU/L (range 58-3043). One patient had primary nonfunction. Two combined pancreas-kidney transplants, one islet transplant and three double lung transplants were performed with primary function. NRP in DCD donation facilitates organ recovery and may improve short-term outcomes.

Palliation of abdominal aortic aneurysms in the endovascular era.

OBJECTIVES: To establish outcome of patients with abdominal aortic aneurysm (AAA) deemed unfit for repair. DESIGN: Retrospective non-randomised study. MATERIALS AND METHODS: Identification of males with >5.5 cm or females with >5.0 cm AAA turned down for elective repair between 01/01/2006-24/07/2009 from a prospective database. Comorbidities, reasons for non-intervention, aneurysm size, survival, use of CPEX (cardio-pulmonary exercise) testing and cause of death were analysed. Although well-established at the time, patients unfit for open operation were not considered for endovascular repair. RESULTS: Seventy two patients were unsuitable for AAA repair. Aneurysm size ranged from 5.3 cm to 12 cm. Functional status, comorbidity and patient preference determined decision to palliate. Sixty percent of patients were alive at study close. Aneurysm rupture was cause of death in 46%. CPEX testing was performed in 54%, whose mortality was 28%, vs. 54% in the non-CPEX group (P < 0.05). Median survival of patients with 5.1-6.0 cm AAA was 44 months and 11% died of rupture. Between 6.1 and 7.0 cm median survival was 26 months and 20% died of rupture. However, with >7 cm aneurysms, survival was 6 months and 43% ruptured. CONCLUSION: Under half the deaths in our comorbid cohort were due to rupture. However, decision to palliate may be revisited as risk-benefit ratio changes with aneurysm expansion.

Isolated tibial vessel disease: treatment options and outcome.

Tibial vessel disease is an important cause of limb ischaemia, particularly in diabetics. Revascularisation by angioplasty and bypass is increasingly feasible. The aim of this study was to review treatment and outcome in patients with this patterns of disease. We have performed 25 procedures in 20 patients since September, 1989. Six patients (5 diabetic) underwent 9 tibial angioplasties for stenotic lesions causing critical ischaemia or short-distance claudication. In 6 procedures there was single vessel run-off. Eight angioplasties were radiologically successful with a median increase in ankle-brachial index (ABI) of 0.15 [range: 0.00-0.44] at a median follow-up of 9 months. A further 4 patients (3 diabetic) with critical ischaemia underwent popliteal-distal, in-situ vein bypass for tibial occlusions. Distal anastomosis was onto the dorsalis pedis artery or distal anterior artery. Three grafts remain patent with successful limb salvage and ABI's greater than 1.0. Angioplasty is also useful for distal disease progression following femoro-popliteal bypass. Six patients with "at-risk" grafts underwent 8 tibial angioplasties for stenotic lesions in distal run-off. Radiologically, 6 procedures were successful with a median increase in ABI of 0.21 [range: 0.00-0.38] at a median follow-up of 7 months. There were less favourable results when a "graft-distal" bypass performed to salvage an occluded femoro-popliteal graft with diseased run-off vessels. Three of 4 grafts reoccluded within 3 months, 2 patients requiring amputation. We advocate an aggressive policy towards localised distal disease causing foot ischaemia.

The Dalkon syndrome--a rare condition?

A patient who presented acutely with severe pelvic sepsis related to Dalkon shield is reported. Although the Dalkon syndrome has been described (Tatum HJ, Connell EB. Intrauterine contraception. Duvant: Creative Informatics, 1985) the term is not widely used and controversy surrounds this condition. However, the condition may still present to the modern day gynaecologist.

A prospective study examining the association between the symptoms of anxiety and depression and severity of urinary incontinence.

OBJECTIVE: To investigate the association of the presence or absence of the symptoms of anxiety and depression compared with the 48 h pad test as an objective measure of incontinence. DESIGN: Prospective study. SETTING: Urodynamics clinic in a large teaching hospital. SUBJECTS: All patients with urinary incontinence attending for urodynamic assessment from 23.4.96 to 29.10.96. INTERVENTIONS: 48 h pad test, Hospital Anxiety and Depression scale (HAD scale). MAIN OUTCOME MEASURES: Urodynamic diagnosis of cause of incontinence. Urinary loss over 48 h as measured by weight change in pads. Presence of symptoms of anxiety or depression as defined by HAD scale score of 8 or more. RESULTS: Urodynamic investigation was performed for incontinence on 133 patients. Of these 127 (95.4%) completed the HAD scale questionnaire. Of the 43 patients (32.2%) who returned the pads 18 (41.8%) patients were found to have symptoms of anxiety and six patients (13.9%) had symptoms of depression. Patients with symptoms of anxiety had lower mean measured urinary loss over a 48 h period compared to women with no symptoms of anxiety (median loss 44.2 ml range 6.8-622.4 versus 97.1 ml range 8.2-4384.4 ml) (P=0.05). There was no significant association between symptoms of depression and pad test results. CONCLUSIONS: Patients presenting with incontinence who have symptoms of anxiety are on average less incontinent compared to than those without symptoms of anxiety. It suggests that anxious patients present with a lesser degree of incontinence than nonanxious patients.

The relationship between laparoscopic disease, pelvic pain and infertility; an unbiased assessment.

OBJECTIVES: To measure the relationship between laparoscopically detected pelvic pathology and pelvic pain or infertility. METHODS: Women undergoing diagnostic laparoscopy either for the investigation of pelvic pain, for sterilisation or for the investigation of infertility were studied. The indication for surgery was recorded before laparoscopy. At operation a series of 35-mm slide photographs were taken of the pelvis and later scored by two independent assessors without knowledge of the indication for surgery. RESULTS: Satisfactory photographs were obtained in 298 women. Minimal endometriosis was not associated with pain (adjusted OR 1.3; 0.5-2.8), although moderate disease was non-significantly so (2.5; 0.4-7.1). Severe disease was significantly more common and never occurred in patients being sterilised (P = 0.02). The odds of pain were not increased in the presence of dilated veins > 9 mm diameter (OR 1.1; 0.4-3.2) or adhesions (OR 0.6; 0.2-4.7). The odds of infertility were non-significantly increased in the presence of minimal and moderate endometriosis (OR 2.0; 0.8-5.3, and OR 4.2; 0.6-25 respectively) and again significantly more common in the presence of advanced disease (P = 0.002). The odds of infertility tended to be lower in the presence of severely dilated veins (OR 0.2; 0.032-1.2). There was no clear effect of adhesions (OR 0.9; 0.1-5.9). CONCLUSIONS: The long established associations between severe endometriosis and pelvic pain, and between endometriosis in general and infertility are confirmed. However there is little or no association between minimal endometriosis, pelvic adhesions or dilated pelvic veins and pain. Previously reported associations may have been an artefact of the surgeon's knowledge of the indication for operation when assessing the pelvis.

Quality of life of octogenarians after aneurysm surgery.

Abdominal aneurysm repair in octogenarians is controversial. To justify surgery, survival with a reasonable quality of life is required. Between 1980 and 1988, 34 octogenarians underwent aortic aneurysm surgery (14 elective, 20 emergency). Of the 21 survivors, 20 were interviewed to determine their quality of life. At the time of interview the patients had a median survival of 19 months (range 4-67 months). Twenty age/sex matched normal patients, from the same GP population, were interviewed for comparison. A structured questionnaire was used to assess: physical mobility, activities of daily living, sleep and emotional problems. A symptom survey was also performed. The survival trend of elective patients was similar to that of a demographically similar 'normal' population. The survival trend of emergency patients returned to 'normal' after the first postoperative month. Quality of life of the 20 patients was comparable to the lifestyle enjoyed by normal subjects. Of the 20 patients interviewed, 18 had returned home after surgery. Elective and emergency aortic aneurysm surgery can be performed with reasonable survival and a good quality of life, and therefore cannot be denied to octogenarians on the basis of age alone.

Postoperative collection and reinfusion of autologous blood in total knee arthroplasty.

A series of 40 patients undergoing primary unilateral total knee arthroplasty were entered into a randomised controlled trial to assess the safety and efficacy of postoperative autologous blood salvage and reinfusion. The mean volume of autologous blood reinfused was 520 ml per patient (51% of the mean total drainage). Homologous blood transfusion was required in only 35% of patients in the study group compared with 95% of patients in the control group (P less than 0.001). The mean volume of homologous blood transfused was 0.9 units per patient in the study group compared with 2.5 units in the control group (P less than 0.001), a saving of 64%.

Cutting the cost of emergency surgical admissions.

Over a one-month period, 207 general surgical emergency admissions (excluding urology) to a district general hospital were audited. The potential to improve the delivery of emergency care and reduce inpatient stay was studied. During the year of study, 44 per cent of all surgical admissions were emergency patients who consumed 61 per cent of inpatient bed days. Most emergency admissions were for gastroenterological problems although patients with arterial disorders tended to have relatively prolonged inpatient stays. Operations were performed in 34 per cent of emergency admissions with six post-operative deaths. Delays in operative treatment were mainly due to waiting for space on scheduled operating lists. A number of post-operative patients remained in hospital over the weekend awaiting discharge on Monday. Most emergency admissions were treated conservatively. Delays in discharge of fit patients occurred whilst the results of inpatient investigations were awaited. Twelve patients were admitted for complications of previous procedures. Emergency patients accounted for over half the inpatient bed days. There is considerable scope for improving the process of delivery of emergency surgical care and reducing inpatient stay.

Licorice consumption among high school students.

A survey was carried out of licorice intake among 603 4th and 5th form pupils of two Dunedin high schools. Licorice was eaten on a regular (weekly) basis by 29 percent of the girls and 17 percent of the boys. At least 200 g (of black licorice confectionery) was eaten weekly by 5.9 percent of the girls and 4.9 percent of the boys; at least 500 g was eaten weekly by 1.8 percent of the girls and I percent of the boys. The intake reported by two pupils exceeded 1000 g per week.

Clinical audit; who is auditing who?

Clinical audit is the principal means by which current clinical practice is improved. Doctors in training must gain positive experience of audit as juniors, so as to establish the importance of audit for future practice. Good audit requires involvement of doctors in training, a high level of participation and a leading role to be taken by the professional bodies. To examine the degree to which such criteria are met currently, the quality and prevalence of clinical audit, the participation of junior doctors in audit, and the preparedness of medical professional bodies' to guide audit were assessed. One hundred and twenty-six junior and senior house officers in three Edinburgh hospitals were administered questionnaires in person, whilst eight Royal Colleges, the British medical Association and the General Medical Council were assessed by the quality of their written guidelines for audit. The data showed that only thirteen out of twenty four specialties, which employed half the juniors, utilised clinical audit. Half of these audit programs were structured to lead to improved patient care. Surprisingly, only three out of ten professional bodies were able to provide good quality audit information. In conclusion, clinical audit is not universal practice and many existing audit programs are inappropriately structured. Commonly, doctors at all levels seemed unaware of the goals of clinical audit. In addition, the majority of professional bodies provide poor information, thereby impeding successful audit by doctors in training. Clinical audit will not succeed until such deficiencies are rectified.

Corticotrophin-releasing factors in the hypothalamus of the developing fetal sheep.

Corticotrophin-releasing hormone (CRH) and arginine vasopressin (AVP) are secreted from the hypothalamic median eminence to elicit the secretion of ACTH from the pituitary corticotrophs. During fetal development there is progressive maturation of the hypothalamic-pituitary-adrenal axis, manifest as increasing plasma ACTH and cortisol concentrations, which in species such as sheep culminates in the onset of birth. However, the precise nature of the hypothalamic signal controlling fetal pituitary ACTH secretion remains poorly understood. To investigate the ontogeny of this hypothalamic signal, the present study examined immunoreactive and bioactive ACTH-releasing factors in the developing fetal sheep hypothalamus. Immunoreactive CRH and AVP were measured by radioimmunoassay in extracts of hypothalami taken at day 70, day 100, and day 130 gestation (term = 145 days). There was a progressive and significant (P < 0.01) increase in hypothalamic CRH and AVP concentrations which was particularly marked between d100 and d130 gestation. AVP was always present in higher concentrations that CRH, although this difference was significantly reduced by day 130 gestation as the result of a large increase in the content of CRH relative to AVP. Sephadex G50 chromatography revealed that immunoreactive CRH and AVP in hypothalamic extracts existed as single molecular forms corresponding to synthetic peptides at each gestational age. In addition, these immunoreactive forms of CRH and AVP possessed significant ACTH-releasing bioactivity as measured in primary cultures of adult sheep anterior pituitary cells. Furthermore, significant bioactivity was present in high and low molecular weight fractions eluted after chromatography which did not contain any CRH or AVP immunoreactivity.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparative study of the cosmetic appeal of abdominal incisions used for hysterectomy.

OBJECTIVE: To assess the cosmetic appeal of abdominal incisions used for hysterectomy. DESIGN: A comparative study. SETTING: St James's University Hospital, Leeds. PARTICIPANTS: One hundred women, including 50 consecutive women attending a gynaecology clinic for the first time and 50 hospital staff. RESULTS: Sixty-eight percent of women preferred a Pfannenstiel incision as the incision of first choice, while 31% chose the laparoscopic assisted vaginal hysterectomy incisions (LAVH). When women who had undergone previous abdominal surgery were compared with women with no previous surgery, there was a significant difference in their choice (80% Pfannenstiel, 18% LAVH compared with 54% Pfannenstiel, 45% LAVH). CONCLUSIONS: In gynaecological surgery there is already a cosmetically-favoured incision. One cannot assume that if a gynaecologist uses a minimally invasive surgical technique at hysterectomy that this will be cosmetically acceptable to the woman. Gynaecologists should not use cosmetic appeal in counselling women for LAVH and should concentrate on the other proven benefits of minimally invasive surgery.

Modulation of arginine vasopressin secretion from cultured ovine hypothalamic cells by glucocorticoids and opioid peptides.

In sheep, arginine vasopressin (AVP) appears to be a more potent ACTH-releasing factor than ovine corticotrophin-releasing hormone. In order to investigate the neuroendocrine regulation of AVP secretion we have developed a novel system for maintaining fetal ovine hypothalamic neurones in serum-free culture. Hypothalamic neurones derived from fetal sheep at day 70 gestation (term = 145 days) secreted AVP under basal conditions and in response to repeated potassium-induced depolarizations, for up to 35 days in vitro. AVP secretion was time- and calcium-dependent. AVP secreted from ovine hypothalamic cells co-eluted with synthetic AVP on a Sephadex chromatography column and diluted in parallel with AVP standard in the radioimmunoassay. The addition of cortisol (150 nM) to medium bathing ovine hypothalamic cells significantly inhibited basal, and potassium-induced AVP secretion without altering the AVP content of the cell cultures. Furthermore, the opioid peptide [D-Pro10]Dynorphin(1-11) which acts via the kappa opioid receptor, significantly inhibited basal and potassium-stimulated AVP secretion, an effect which was abolished when cells were cultured in the presence of cortisol. These data show that hypothalamic AVP is a site for negative feedback regulation within the ovine hypothalamic-pituitary-adrenal axis. Furthermore, these data suggest that the kappa opioid system inhibits AVP secretion from ovine hypothalamic neurones, a response which is modulated by glucocorticoids.

A prospective placebo controlled double blind randomised study to investigate the use of indoramin to prevent post-operative voiding disorders after surgical treatment for genuine stress incontinence.

A prospective placebo controlled double blind randomised study was undertaken to investigate the use of indoramin an alpha blocker to prevent post-operative voiding disorders after surgical treatment for genuine stress incontinence. Fifty-six patients were randomised to receive indoramin 20 mg orally twice a day or identical placebo from the first post-operative day until discharge from hospital. After seven exclusions, 49 patients were included in the study. There was no significant difference between the treatment (indoramin) group and placebo group for any of the outcomes measured. The routine use of indoramin to prevent post-operative voiding problems cannot be justified on the basis of these data.

Approximate standard errors in semiparametric models.

We consider semiparametric models with p regressor terms and q smooth terms. We obtain an explicit expression for the estimate of the regression coefficients given by the back-fitting algorithm. The calculation of the standard errors of these estimates based on this expression is a considerable computational exercise. We present an alternative, approximate method of calculation that is less demanding. With smoothing splines, the method is exact, while with loess, it gives good estimates of standard errors. We assess the adequacy of our approximation and of another approximation with the help of two examples.

Adipose tissue and lipid droplet embolism following periurethral injection of autologous fat: case report and review of the literature.

The authors present a case of a death associated with pulmonary adipose tissue and lipid droplet embolism following autologous fat harvesting, periurethral injection and videocystourethroscopy for the treatment of recurrent genuine stress incontinence.