A nurse-run clinic for patients with incidentally discovered small abdominal aortic aneurysms is feasible and cost-effective.

INTRODUCTION: Patients with incidentally discovered small abdominal aortic aneurysms (AAA) require assessment by a vascular surgery department for possible enrollment in a surveillance programme. Our unit implemented a vascular nurse-run AAA clinic in October 2010. The aim of this study was to assess the feasibility of a specialist nurse-run small AAA clinic. METHODS: Demographic and clinical data were collected prospectively for all patients seen in the new vascular nurse clinic between October 2010 and November 2012. A validated AAA operative mortality score was used to aid decision making by the vascular nurse. RESULTS: Some 250 patients were seen in the clinic. 198 (79.2%) patients were enrolled in surveillance, 40 (16%) declined enrollment and 12 (4.8%) were referred to a consultant clinic for further assessment. The majority of patients were male and the mean age was 73.7 years. Co-morbidities included hypertension, a history of cardiovascular disease, and hyperlipidaemia. The majority of referrals were considered to be low operative risk. No aneurysms ruptured whilst under surveillance. CONCLUSIONS: A nurse-run clinic that assesses patients with incidentally discovered small AAAs for inclusion in AAA surveillance is a feasible alternative to assessment of these patients in a consultant-run clinic.

Defining quality assessment in vascular surgery training: an expert Delphi process.

INTRODUCTION: A robust and reproducible way of assessing training should optimise and standardise vascular surgical training. This study describes the methodology supporting the Vascular Surgery Specialty Advisory Committee regional quality assurance reports for vascular surgery training programmes in the UK. METHODS: A Delphi consensus exercise was performed to establish the domains of training that most appropriately assess the quality of a vascular surgery training programme. A total of 54 stakeholders were invited to participate, including trainees, training programme directors and members of the vascular speciality advisory committee (SAC), vascular society executive and education committees. RESULTS: A total of 39 stakeholders successfully completed the three-stage Delphi process over 15 weeks. The domains identified as most appropriate to assess the quality of a vascular training programme were: Joint Committee on Surgical Training (JCST) survey results, clinical experience, regional education programmes, radiology support, timetable, regional support for trainees, trainer support for trainees, opportunities for professional development, trainee-rated quality of consultant teaching and training, and trainee recommendation of the post. CONCLUSIONS: This study describes a method to identify and prioritise domains that are appropriate to assess the quality of a vascular training programme. The domains that were identified as appropriate to assess quality are transferable internationally and the Delphi methodology could be used by other training schemes to 'fine-tune' their own domains to review and optimise the quality of their own training programmes.

Negative pressure wound therapy as an adjunct to compression for healing chronic venous ulcers.

OBJECTIVE: To determine the efficacy of negative pressure wound therapy (NPWT), when used in combination with compression bandaging, for healing chronic resistant venous ulcers. METHOD: In this pilot study, seven patients (with a total of 12 chronic resistant venous ulcers) received adjunctive NPWT and compression bandaging for 4 weeks. Their wounds were monitored for a total of 12 weeks. RESULTS: Dormant ulcers were seen to rapidly develop into healthy wounds, with a granulating base. CONCLUSION: This regimen may have a role in stimulating chronic venous ulcers into healing wounds, or in preparing them for skin grafting.

A survey of patient views on receiving vascular outpatient letters.

AIM: To assess the attitude of patients to receiving a copy of vascular outpatient clinic letters. METHOD: 100 patients attending an outpatient vascular clinic at Christchurch Hospital were sent a copy of their outpatient letter along with a questionnaire. This gathered information on the content of the letter, their understanding of it, how useful they found it and whether they would want this practice to continue. RESULTS: The response rate was 68%. Ninety four percent of the responders believed receiving a copy of the letter was a good reinforcement of the information they received at the consultation. Ninety three percent of responders also found being copied into correspondence helpful and 96% understood the contents of the letters. Ninety seven percent wished to receive more letters in the future. CONCLUSION: These results suggest that vascular surgery patients both value and understand clinic letters, and that health professionals should consider adopting this practice into their vascular outpatient clinics.

Lung disease mortality in the United States: the National Longitudinal Mortality Study.

SETTING: The National Longitudinal Mortality Study (NLMS) offers the advantage of assessing mortality in a representative population of the United States. OBJECTIVE: To evaluate health disparities associated with lung cancer and chronic obstructive pulmonary disease (COPD) mortality in the United States and whether these associations are similar between these outcomes. DESIGN: The NLMS is a prospective study. Data from NLMS cohort years 1985, 1992, 1993, 1995 and 1996 were included, representing nearly 1.5 million person-years. Lung cancer and COPD mortality relative risks (RRs) from Cox regression analysis, including residential characteristics, marital status, education, health insurance and family income, were evaluated. RESULTS: By 1998, 1273 lung cancer deaths and 772 COPD deaths occurred. Lung cancer mortality rates were approximately two times higher than COPD mortality rates among race and ethnic groups. Cox regression analysis revealed that low education (RR = 1.77, significant, P = 0.01) and low family income (RR = 1.50, significant, P = 0.01) are associated with lung cancer and COPD mortality, controlling for age, race/ethnicity, sex and smoking status. CONCLUSIONS: COPD and lung cancer mortality have similar associations with health disparity indicators in the NLMS data, with some differences in the magnitude of the effect.

Effect of TNP on the microbiology of venous leg ulcers: a pilot study.

OBJECTIVE: To investigate the effect of topical negative pressure, delivered using Vacuum Assisted Closure (VAC, KCI), on the microbiology of chronic, non-infected venous leg ulcers (VLUs). METHOD: Patients receiving compression therapy for a chronic VLU were recruited into this prospective pilot study. The ulcer was swabbed and VAC was applied at 125mmHg continuous sub-atmospheric pressure on day 1 for six days. Standard methods for bacteriological sampling and measuring the wound surface area were applied at baseline and at the VAC dressing changes on days 3 and 6. Log median colony forming units (CFUs) per cm2 were used for statistical analyses. The bacterial species were identified. RESULTS: Seven patients were recruited into and completed the study. The median log10 CFU/cm2 on days 1, 3 and 6 were 3.5, 4.7 and 5.1 respectively. There was a significant increase in bacterial colonisation between days 1 and 6 (p<0.02). No change was observed in the identified microbiological species during therapy with VAC. CONCLUSION: This pilot study suggests that VAC therapy increases absolute numbers of bacteria colonising non-infected leg ulcers. DECLARATION OF INTEREST: KCI supplied the VAC equipment and ARANZ the SilhouetteMobile, but both had no other influence on the study.

Implementation of a supervised exercise therapy programme.

INTRODUCTION: Guidelines for peripheral vascular disease state that supervised exercise therapy (SET) programmes improve walking distance and quality of life in patients with intermittent claudication. This paper outlines the steps needed to implement a successful SET programme and discusses some of the challenges. METHODS: Edinburgh Leisure was approached to coordinate an exercise programme aimed at rehabilitation, run by level 4 members of the Register of Exercise Professionals. It is estimated to be cost effective at 500 referrals compared with physiotherapy referral. Success is measured by walking distance, reduction of symptoms and weight loss. Edinburgh Leisure also measures success with feedback and membership numbers at its health centres. RESULTS: Between 4 March 2014 and 25 January 2016, 155 patients were referred to the SET programme with a median age of 68 years (range: 39-95 years) and a male-to-female ratio of 1.2:1. Of these, 117 patients attended and 29 have completed the programme. The mean walking distance increased from 298.5m (range: 150-385m) to 360m (range: 195-482m), an improvement of 20%. Increasing class numbers and venues, and introducing evening classes to make the programme accessible to more patients has addressed initial patient engagement issues. CONCLUSIONS: Collaboration with motivated local authorities can help implement a successful healthcare intervention. Early analysis is necessary to improve the system and engage as many patients as possible. The SET programme discussed has shown similar results to those of previous studies but is available at no personal cost to regional patients with intermittent claudication.

Potassium uptake supporting plant growth in the absence of AKT1 channel activity: Inhibition by ammonium and stimulation by sodium.

A transferred-DNA insertion mutant of Arabidopsis that lacks AKT1 inward-rectifying K+ channel activity in root cells was obtained previously by a reverse-genetic strategy, enabling a dissection of the K+-uptake apparatus of the root into AKT1 and non-AKT1 components. Membrane potential measurements in root cells demonstrated that the AKT1 component of the wild-type K+ permeability was between 55 and 63% when external [K+] was between 10 and 1,000 microM, and NH4+ was absent. NH4+ specifically inhibited the non-AKT1 component, apparently by competing for K+ binding sites on the transporter(s). This inhibition by NH4+ had significant consequences for akt1 plants: K+ permeability, 86Rb+ fluxes into roots, seed germination, and seedling growth rate of the mutant were each similarly inhibited by NH4+. Wild-type plants were much more resistant to NH4+. Thus, AKT1 channels conduct the K+ influx necessary for the growth of Arabidopsis embryos and seedlings in conditions that block the non-AKT1 mechanism. In contrast to the effects of NH4+, Na+ and H+ significantly stimulated the non-AKT1 portion of the K+ permeability. Stimulation of akt1 growth rate by Na+, a predicted consequence of the previous result, was observed when external [K+] was 10 microM. Collectively, these results indicate that the AKT1 channel is an important component of the K+ uptake apparatus supporting growth, even in the "high-affinity" range of K+ concentrations. In the absence of AKT1 channel activity, an NH4+-sensitive, Na+/H+-stimulated mechanism can suffice.

Modelling through-soil transport of phosphorus to surface waters from livestock agriculture at the field and catchment scale.

A model of phosphorus (P) losses in a small dairy farm catchment has been set up based on a linkage of weather-driven field-scale simulations using an adaptation of the MACRO model. Phosphorus deposition, both in faeces from grazing livestock in summer and in slurry spread in winter, has been represented. MACRO simulations with both forms of P deposition had been calibrated and tested at the individual field scale in previous studies. The main contaminant transport mechanism considered at both field and catchment scales is P sorbed onto mobile colloidal faeces particles, which move through the soil by macropore flow. Phosphorus moves readily through soil to field drains under wet conditions when macropores are water-filled, but in dry soil the P carrying colloids become trapped so losses remain at a low level. In the catchment study, a dairy farm is assumed to be composed of fields linked by a linear system of ditches which discharge into a single river channel. Results from linked simulations showed reasonable fits to values of catchment outflow P concentrations measured at infrequent intervals. High simulated outflow P concentrations occurred at similar times of year to high measured values, with some high loss periods during the summer grazing season and some during the winter when slurry would have been spread. However, there was a lack of information about a number parameters that would be required to carry out a more exact calibration and provide a rigorous test of the modelling procedure. It was nevertheless concluded that through soil flow of colloid sorbed P by macropore flow represents a highly plausible mechanism by which P is transported to river systems in livestock farming catchments. This represents an alternative to surface runoff transport, a mechanism to which high P losses from livestock farming areas have often been attributed. The occurrence of high simulated levels of loss under wet conditions indicates environmental benefits from avoiding slurry spreading on wet soil or during rain, and from some forms of grazing management.

Drinking water arsenic in Utah: A cohort mortality study.

The association of drinking water arsenic and mortality outcome was investigated in a cohort of residents from Millard County, Utah. Median drinking water arsenic concentrations for selected study towns ranged from 14 to 166 ppb and were from public and private samples collected and analyzed under the auspices of the State of Utah Department of Environmental Quality, Division of Drinking Water. Cohort members were assembled using historical documents of the Church of Jesus Christ of Latter-day Saints. Standard mortality ratios (SMRs) were calculated. Using residence history and median drinking water arsenic concentration, a matrix for cumulative arsenic exposure was created. Without regard to specific exposure levels, statistically significant findings include increased mortality from hypertensive heart disease [SMR = 2.20; 95% confidence interval (CI), 1.36-3.36], nephritis and nephrosis (SMR = 1.72; CI, 1.13-2.50), and prostate cancer (SMR = 1.45; CI, 1.07-1. 91) among cohort males. Among cohort females, statistically significant increased mortality was found for hypertensive heart disease (SMR = 1.73; CI, 1.11-2.58) and for the category of all other heart disease, which includes pulmonary heart disease, pericarditis, and other diseases of the pericardium (SMR = 1.43; CI, 1.11-1.80). SMR analysis by low, medium, and high arsenic exposure groups hinted at a dose relationship for prostate cancer. Although the SMRs by exposure category were elevated for hypertensive heart disease for both males and females, the increases were not sequential from low to high groups. Because the relationship between health effects and exposure to drinking water arsenic is not well established in U.S. populations, further evaluation of effects in low-exposure populations is warranted.

Alcohol and the gastrointestinal tract.

The effects of acute and chronic ethanol ingestion on esophageal motility and the potential complications of these alterations are reviewed. Injury to the gastric mucosa and the small intestine and alterations in intestinal absorption can also result from alcohol abuse.

Infection in immunocompromised patients with malignant blood disorders in a district general hospital.

The pattern and management of infection in immunocompromised patients over a period of 3 years in a district general hospital has been studied. A total of 222 positive cultures was obtained in 607 episodes of suspected infection all involving patients with malignant blood disorders. Febrile episodes requiring intravenous antibiotics occurred in 248 instances involving 107 patients. The pattern of organisms cultured and the responses to various antibiotic regimes are reported. The costs of antibiotic therapy are considered in the light of the overall response. Of the patients studied, 54 died, infection having a likely causative or contributory part in 21 of them (less than 10% of infective episodes). We conclude that the infective complications of these disorders, particularly in older patients, can be efficiently managed in a district general hospital when full supportive facilities are available.

Computerized axial tomography versus complex motion as a predictor of surgical findings in middle ear and mastoid cholesteatoma.

In order to evaluate the efficacy of polytomography and computerized tomography in the prediction of surgical findings in cases of suspected cholesteatoma of the middle ear and mastoid, we evaluated preoperatively 52 ears by both radiographic methods. We utilized a check list of 14 radiological signs or surgical findings to generate measures of sensitivity and specificity. The strengths of each radiographic method are outlined and the considerable weaknesses in predictive value are discussed.

Antidepressant-like effect of brain-derived neurotrophic factor (BDNF).

Previous studies have shown that infusion of brain-derived neurotrophic factor (BDNF) into the midbrain, near the PAG and dorsal/median raphe nuclei, produced analgesia and increased activity in monoaminergic systems. Alterations in monoaminergic activity have also been implicated in the pathogenesis and treatment of depression. The present studies examined the ability of centrally administered BDNF to produce antidepressant-like activity in two animal models of depression, learned helplessness following exposure to inescapable shock and the forced swim test. In the learned helplessness paradigm, vehicle-infused rats pre-exposed to inescapable shock (veh/shock) showed severe impairments in escape behavior during subsequent conditioned avoidance trials, including a 47% decrease in the number of escapes and a 5 fold increase in escape latency, as compared to vehicle-infused rats which received no pre-shock treatment (veh/no shock). Midbrain BDNF infusion (12-24 micrograms/day) reversed these deficits, and in fact, BDNF-infused rats pre-exposed to inescapable shock (BDNF/shock) showed escape latencies similar to veh/no shock and BDNF/no shock rats. In the forced swim test, BDNF infusion decreased the immobility time by 70% as compared to vehicle-infused controls. Non-specific increases in activity could not account for these effects since general locomotor activity of BDNF- and vehicle-infused animals was not different. These findings demonstrate an antidepressant-like property of BDNF in two animal models of depression, which may be mediated by increased activity in monoaminergic systems.

Predicting the effect of livestock inputs of E. coli on microbiological compliance of bathing waters.

Three alternative approaches to predicting delivery of faecal indicators from livestock sources to surface water in the catchment of the River Irvine, Ayrshire, Scotland, are described. These are a soil transport model which assumes all E. coli are transported through the soil, a regression model using observed E. coli concentrations in surface waters, and a distributed catchment model (PAMIMO). Each of these is linked to a simple group of equations describing inputs of E. coli from livestock to land, transport and inactivation in the river Irvine and mixing and inactivation in the sea. The models predict E. coli content of bathing water for Irvine beach. The regression model gives the best predictions of bathing water quality. The low values predicted by the soil transport model suggests that preventing surface runoff of faecal indicators from livestock would provide an adequate solution to the problem of bathing water contamination.

Empirical analysis of multidimensional measures of community adjustment for young adults with mental retardation.

Confirmatory factor analysis procedures were used to evaluate multidimensional measures of community adjustment in a sample of 239 young adults with mild to severe mental retardation. Alternative measurement models were evaluated in one-half of the sample, with the final model cross-validated in the second half of the sample. The final cross-validated model was also evaluated as a function of level of retardation. Evidence was found for at least six broad dimensions of community adjustment when combined with other multidimensional research findings. The measurement of one dimension varied as a function of degree of retardation. Use of validated multidimensional measures of community adjustment in future research studies was discussed.

Vascular surgical intervention for complications of cardiovascular radiology: 13 years' experience in a single centre.

This study investigates incidence and outcome of iatrogenic vascular complications needing surgery in a single vascular unit serving interventional vascular radiology and interventional cardiology. Evolution of diagnostic and interventional cardiovascular radiology, along with the introduction of non-surgical therapies for such complications, may have influenced the number of vascular complications requiring emergency surgery. Vascular surgical data were collected from information prospectively entered on computerised database and case note review. Radiology data were collated from prospective entries in logbooks and computerised database. In all 24,033 cardiovascular radiological procedures were performed between 1984 and 1996 (61% cardiac), numbers increasing annually. During this period, 62 patients (40 peripheral; 22 cardiac) required emergency surgical intervention after radiological procedures. Mean age was 61.9 years (range 1-92 years), male to female ratio was 1:1. The absolute number of cases requiring surgical intervention peaked in 1989, subsequently reducing annually. Sites of vascular injury included common femoral artery (40), brachial artery (6), iliac artery (6), popliteal artery (5), other (5). A total of 87 vascular surgical operations was performed (range 1-6 operations per patient). Interventions included thrombectomy/embolectomy (29), bypass grafting (16), direct repair (27). Seven major amputations were performed (two bilateral). Mortality after surgery was 9.7%. Mean inpatient hospital stay was 11.3 days (range 0-75 days). A Poisson regression model indicates a 5% reduction in risk for each successive year of observation; however, this did not reach statistical significance (P = 0.16, 95% CI 12% decreased risk to 2% increased risk). The risk of surgical intervention after diagnostic or interventional cardiovascular radiology is diminishing but still requires vigilance. Necessity for surgical intervention is associated with a high risk of morbidity and mortality.

Computerised audit of carotid endarterectomy: audit loopholes closed?

The number of carotid endarterectomies being performed in the UK is increasing. The role of carotid endarterectomy (CEA) in the prevention of stroke depends on the procedure being associated with as few operative strokes as possible. Good clinical practice, with minimum morbidity, depends upon the integration of recent advances. Continuing audit has been used to examine changes in surgical practice and in case mix. There was a combined death and permanent stroke rate of 3.6% after 333 CEAs in a 6-year period (1990-1995) compared with 4.4% in 203 CEAs in an earlier 5-year audit period (1985-1989). The impact of an increase in the number of operations performed after recovered strokes, those performed by trainees and the use of prosthetic patches on the results of CEA has been assessed. Specific areas to be targeted in future audits are identified.