Duplex ultrasound outcomes following ultrasound-guided foam sclerotherapy of symptomatic recurrent great saphenous varicose veins.

OBJECTIVES: To describe duplex ultrasound (DUS) outcomes 12 months following ultrasound-guided foam sclerotherapy (UGFS) of recurrent great saphenous varicose veins (GSVV). METHODS: A consecutive series of UK National Health Service patients underwent serial DUS examinations following UGFS with 3% sodium tetradecyl sulphate for symptomatic recurrent GSVV. RESULTS: 91 treated legs (CEAP C(2/3) 58, C(4) 21, C(5) 8, C(6) 4) belonging to 73 patients (24 male) of median age 58 (range 32-86) years were enrolled between November 2004 and May 2007. The median volume of foam used was 8 (range 4-14) ml. Above-knee (AK) and below-knee (BK) GSV reflux was present in 88 (97%) and 80 (88%) legs respectively prior to treatment. AK and BK-GSV reflux was completely eradicated by a single session of UGFS in 86 (98%) and 74 (93%) legs respectively; and by two sessions of UGFS in 88 (100%) and 77 (97%) legs respectively. In those legs where GSV reflux had been eradicated, recanalisation occurred in 7/78 (9%) AK and 8/68 (12%) BK-GSV segments after 12 months follow-up. Retreatment, where undertaken, with a single UGFS session effectively eradicated all GSV reflux in all cases of recanalisation. DISCUSSION: A single session of UGFS can eradicate reflux in the AK and BK-GSV in over 93% of patients with symptomatic recurrent GSVV. Re-recurrence at 12 months is superior to that reported after redo GSV surgery, similar to that observed following other minimally-invasive techniques and, when it occurs, is effectively and simply treated by a single further session of UGFS.

Duplex ultrasound outcomes following ultrasound-guided foam sclerotherapy of symptomatic primary great saphenous varicose veins.

OBJECTIVES: To describe duplex ultrasound (DUS) outcomes 12 months following ultrasound-guided foam sclerotherapy (UGFS) of primary great saphenous varicose veins (GSVV). METHODS: A consecutive series of UK National Health Service patients underwent serial DUS examinations following UGFS with 3% sodium tetradecyl sulphate for symptomatic primary GSVV. RESULTS: 344 treated legs (CEAP C(2/3) 237, C(4) 72, C(5) 14, C(6) 21) belonging to 278 patients (103 male) of median age 57 (range 21-89) years were enrolled between November 2004 and May 2007. The median volume of foam used was 10 (range 2-16) ml. Above-knee (AK) and below-knee (BK) GSV reflux was present in 333 (96.8%) and 308 (89.5%) legs respectively prior to treatment. AK and BK-GSV reflux was completely eradicated by a single session of UGFS in 323 (97.0%) and 294 (95.5%) legs respectively; and by two sessions of UGFS in 329 (98.8%) and 304 (98.7%) legs respectively. In those legs where GSV reflux had been eradicated, recanalisation occurred in 18/286 (6.3%) AK and 23/259 (8.9%) BK-GSV segments after 12 months follow-up. CONCLUSIONS: A single session of UGFS can eradicate reflux in the AK and BK-GSV in over 95% of patients with symptomatic primary GSVV. Recanalisation at 12 months is superior to that reported after surgery and similar to that observed following other minimally invasive techniques.

Photoplethysmographic venous refilling times following ultrasound guided foam sclerotherapy for symptomatic superficial venous reflux: relationship with clinical outcomes.

INTRODUCTION: Digital photoplethysmography (PPG) provides an inexpensive, reproducible, quantitative, non-invasive assessment of lower limb venous function. AIM: To examine the relationship between venous refilling time (VRT) and severity of venous disease, and also between changes in VRT and symptomatic improvement after ultrasound guided foam sclerotherapy (UGFS) for symptomatic superficial venous reflux (SVR). METHODS: Prior to and 6 months after UGFS, 246 patients (317 limbs) completed a symptom questionnaire, underwent duplex ultrasonography and clinical assessment, and VRT measurement by digital PPG. Health related quality of life (HRQL) questionnaires were also completed. RESULTS: Median VRT improved from 11 to 31 s (P < 0.0005, Wilcoxon Signed Ranks). Abnormal VRT (<20 s) correlated well with the presence of SVR on duplex (sensitivity 75%, specificity 94%). Pre-treatment there was a significant relationship between reducing VRT and increasing CEAP clinical grade (P < 0.0005, chi(2)), extent of SVR on duplex (P < 0.0005) and a non-significant relationship with overall increasing symptom severity (P = 0.097). Relief of all symptoms was more likely when there was normalisation of VRT after treatment (80% vs. 65%, P < 0.0005, chi(2)). Pre-treatment VRT correlated with both generic physical (r = 0.428, P = 0.002) and disease-specific (r = -0.413, P = 0.003, Spearman's rank) HRQL. CONCLUSIONS: UGFS for SVR improves VRT measured by digital PPG and that improvement correlates with symptom relief.

The incidence of raised procoagulant factors and hyperhomocysteinaemia in Chinese patients with chronic venous insufficiency.

BACKGROUND: For reasons that are poorly understood, there appear to be differences in the prevalence of chronic venous insufficiency (CVI) and venous thromboembolism between Caucasians and Asians. OBJECTIVES: To compare levels of procoagulant factors and homocysteine (Hcy) in Hong Kong (HK) Chinese and United Kingdom (UK) Caucasian populations of patients with CVI (patients of CEAP clinical stages C4 - C6). METHODS: HK Chinese and UK Caucasian patients with CEAP clinical grade 4-6 venous disease were enrolled. Patients with conditions known to be associated with thrombophilia (TP) were excluded. UK and HK patients were matched by gender, age (within 5 years) and by CEAP clinical grade. All subjects underwent clinical examination, venous duplex ultrasound, and measurement of Hcy and factors (F) VIII, IX and XI. RESULTS: 63 Patients were enrolled in each group: Mean age 64y (HK group); 67y (UK group). 37% were female; 19% had active venous ulceration. One-third of patients in each group had deep venous reflux. High Hcy, FIX and FXI were significantly more common in the UK group. Multiple TP was more common in the UK group: raised levels of >or=2 factors in 26 vs. 14 patients (P = 0.022, chi(2)). Median Hcy (14.3 vs. 10.8 micromol/L; P < 0.0005, Wilcoxon signed rank [WSR]), FIX (131 vs. 115%; P = 0.048), and FXI (114 vs. 97%; P = 0.002) were significantly higher in the UK group. There was no significant difference in FVIII levels. CONCLUSIONS: Raised procoagulant factors were more common in Caucasians compared with Chinese patients with CVI in this study. As with the inherited thrombophilias, the pattern of raised procoagulant factors in Chinese patients appears to differ from that in Caucasians.

Medium-term results of ultrasound-guided foam sclerotherapy for small saphenous varicose veins.

BACKGROUND: The results of surgery for small saphenous varicose vein (SSV) varicosities may be suboptimal in terms of recurrence and complications. The role of minimally invasive alternatives remains incompletely defined. The aim was to review the medium-term outcomes of ultrasound-guided foam sclerotherapy (UGFS) for SSV. METHODS: Eighty-six patients (92 legs) undergoing UGFS for SSV were assessed before, and 1, 6 and 12 months after treatment. Outcome measures were occlusion of, and abolition of reflux in, the SSV (technical success), absence of visible varicose veins (clinical success) and improvement in disease-specific health-related quality of life (HRQL) following treatment (Aberdeen Varicose Vein Symptom Severity Score (AVSS)). RESULTS: The technical and clinical success rates at 12 months were 91 and 93 per cent respectively; only three patients required a second treatment. After treatment of isolated SSV varicosities there was a significant improvement in AVSS, from a median of 19.0 (interquartile range 13.4-26.8) before treatment to 10.2 (4.0-18.3) and 9.7 (3.5-19.1) at 6 and 12 months respectively. The only complication was a popliteal vein thrombosis that required anticoagulation. CONCLUSION: UGFS was an effective treatment for SSV, with abolition of reflux and visible varicose veins, and improvement in HRQL for at least 12 months.

Patients' expectations before and satisfaction after ultrasound guided foam sclerotherapy for varicose veins.

OBJECTIVES: Ultrasound guided foam sclerotherapy (UGFS) is a minimally invasive treatment for varicose veins (VV) whose clinical and cost-effectiveness remains incompletely defined. The aim of the current study was to examine patients' expectations before and satisfaction after UGFS for VV in terms of relief of lower limb symptoms, improvement in appearance, and beneficial effect on life-style. METHODS: A consecutive series of 351 patients (464 limbs) undergoing UGFS for VV completed questionnaires one week prior to and six months after treatment. RESULTS: Pre and post-treatment response rates were 80%; 60% returned both questionnaires. Virtually all patients were expecting improvement in lower limb symptoms; these were exceeded in a third. Most patients expected cosmetic improvement and these were largely met. Two-thirds of patients expected significant life-style (clothes, work, social) benefits and outcomes were slightly less than expected. A quarter expected improvement in their interpersonal relationships. This benefit was greater than expected occurring in one-third of patients. Overall, a quarter of patients had their expectations exceeded and 10% (appearance and relationships) to 25% (clothing, work and social and leisure activities) were left with unmet expectations. DISCUSSION: When specifically asked most patients admit to having a wide range of expectations in relation to their VV treatment, many of them probably unanticipated by the clinician. However, present data indicate that UGFS is usually able to meet, and often exceeds, these physical and psychosocial needs and expectations. UGFS is, therefore, a highly effective treatment for VV from the patients' perspective.

Ultrasound-guided foam sclerotherapy for the treatment of chronic venous ulceration: a preliminary study.

OBJECTIVES: When compared to compression therapy alone, surgical correction of superficial venous reflux (SVR) reduces recurrence but does not appear to increase healing of chronic venous ulceration (CVU). The role of ultrasound-guided foam sclerotherapy (UGFS) of SVR as part of the treatment of CVU remains uncertain. The aim of this study is to describe CVU healing and recurrence rates after UGFS and to relate these outcomes to patterns of pre- and post-intervention venous reflux. METHODS: A prospective study of 27 consecutive patients (28 legs) of median age 69 (interquartile range 54-79) years undergoing UGFS for SVR in addition to compression for treatment of CVU of median duration 12 (IQR 6-23) months. Prior to and 1, 6, and 12 months after treatment patients underwent clinical and duplex assessment. RESULTS: 8 limbs (29%) had deep and superficial venous reflux, and 20 limbs had SVR alone. There was a history of DVT in 4 limbs, and 4 patients were on warfarin. No limbs had significant arterial disease and all received post-UGFS compression. Median volume of (3% STD) foam used was 8 (range 2-14) ml. 1, 3 and 6 months after UGFS, 22 (79%), 27 (96%) and 27 (96%) CVU had healed. At 12 months, 25 ulcers remained healed, 2 ulcers had recurred; one patient had died from carcinomatosis. DISCUSSION: Following UGFS as an adjunct to compression, 96% of CVU healed within 3 months and only 2 healed ulcers (7%) had recurred at 12 months. UGFS appears to be an attractive minimally-invasive alternative to surgery to treat SVR in patients with CVU, especially the elderly and frail.

Rat model of chronic lung infections caused by non-typable Haemophilus influenzae.

Patients with chronic obstructive pulmonary disease (COPD) often have chronic or recurrent pulmonary infections with non-typable Haemophilus influenzae. A model of these infections exploited agar bead vehicles to protect the inoculum from rapid clearance, and a chronic lung infection of at least 42 days duration was established in rats. This infection induced increases in serum IgG titres to outer-membrane (OM) and lipo-oligosaccharide (LOS) antigens; immunoblotting demonstrated that this humoral response was directed partly against the outer-membrane proteins (OMPs). Lung lavage fluid also contained an increased titre of IgG antibodies to OM and LOS 42 days after infection. Antibodies produced during infection with one strain of H. influenzae cross-reacted with OMPs from another, non-typable H. influenzae strain. Despite their encasement in agar beads, pulmonary H. influenzae remained susceptible to amoxycillin. This model of chronic pulmonary infections due to non-typable H. influenzae appears to resemble the situation in COPD patients and may be useful for experimental therapeutic studies.

What is the role of histidine in studies of faecal mutagenicity?

Mutagenicity testing can be used to assay faeces for genotoxic substances and the results are reported to correlate with population risk for colorectal cancer (Ehrich et al., 1979). It has been suggested that histidine in faeces may cause false positive results (Venitt and Bosworth, 1983). To determine the relationship between histidine and false positive mutagenicity assays aliquots of non-mutagenic faecal extract and saline were supplemented with histidine and subjected to the Ames Salmonella/mammalian microsome mutagenicity assay (Ames et al., 1975). Using high-pressure liquid chromatography the analytical recovery of histidine from water and faecal extract supplemented with histidine was equivalent (r = 0.998, p less than 0.001). Histidine was measured in faecal extracts (1 in 10 dilutions) from 35 volunteers, 10 patients with inflammatory bowel disease and 4 with rectal cancer. These extracts were also assayed for mutagens using the Salmonella/mammalian microsome mutagenicity assay. None of the faecal extracts gave mutagenicity ratios above 2. Faecal extracts from volunteers were free of detectable histidine. Although 9 of those from inflammatory bowel disease patients contained histidine (mean +/- SEM 255 +/- 34 mumoles l-1) as did 1 extract from a rectal cancer patient (50 mumoles l-1), none contained sufficient histidine to give a false positive Salmonella/mammalian microsome mutagenicity assay result (800 mumoles l-1 in test solution). Our results do not implicate histidine as a cause of error in faecal mutagenicity testing by the Salmonella/mammalian microsome mutagenicity assay.

Secondary femoral-distal bypass.

Thirty-nine secondary femoral-distal (femorotibial and femoroperoneal) bypasses were reviewed and compared to 89 primary femoral-distal bypasses (done during the same time period) to investigate the efficacy of secondary femoral-distal bypass. Graft patency at 2 years by life table analysis was similar in both groups (38% primary group vs 36% secondary group). However, limb salvage was significantly less in the secondary group (52% vs 68% at 2 years, p less than 0.05). This decrease was primarily due to poorer limb salvage using composite grafts (prosthetic/vein) compared to vein grafts in patients who underwent secondary femoral-distal bypasses (37% vs 76% at 2 years, p less than 0.05). Postoperative wound infections and mortality were similar in both groups. Thus, femoral-distal bypass after failure of a previous infrainguinal reconstruction offers good long-term limb salvage with acceptable surgical risk when autologous vein is available for use as the arterial conduit.

The setting up and implementation of a venous thromboembolism prophylaxis policy in clinical hospital practice.

Clinical management policies are meant to lead to the delivery of better health care. However, as we demonstrate in this review, having an oral or written venous thromboembolism prophylaxis policy does not necessarily lead to the majority of general surgical inpatients receiving the appropriate prophylaxis. We discovered, through prospective clinical audit, that for a clinical policy to be effective in delivering the appropriate health care, it must be repeatedly scrutinized and implemented in the correct manner. Only after several rounds of the audit cycle were we able to achieve the deliverance of venous thromboembolism prophylaxis to the majority of general surgical patients on our unit. This has wider implications, not just for the implementation of a venous thromboembolism prophylaxis policy, but also for all clinical management policies, and illustrates the importance of clinical audit in clinical practice.

Peroperative detection of patients with rectal cancer at high risk of local recurrence.

Identification at the time of surgery of patients with rectal carcinoma at high risk of local recurrence may allow a more rational decision to be made regarding the operative procedure to be performed. We have examined tumour bed biopsies and lymph nodes peroperatively using imprint cytology in 20 consecutive patients undergoing radical surgery for rectal carcinoma. The results were checked by subsequent paraffin section histology. We were unable to find lymph nodes in 6 cases (30%) peroperatively. Cytological and histological reporting of the tumour bed biopsies and lymph nodes concurred in 91% and 88% of specimens respectively. Peroperative cytology can differentiate between malignant and benign fixation of rectal tumours, can differentiate between hyperplastic and malignant lymph nodes and may be of value in identifying patients with rectal cancer at high risk of local recurrence.

The importance of laparotomy in the diagnosis and management of intestinal bleeding of obscure origin.

Thirty-seven patients who had had either a colonoscopy or a selective mesenteric angiogram while being investigated for severe or persistent gastrointestinal bleeding of obscure origin were reviewed. Failure to make a prompt diagnosis was partly responsible for the 16% hospital mortality in the series. Colonoscopy was diagnostic on 6 out of 38 examinations but detected 43% of lesions in the colon. Angiography achieved only 3 diagnoses in 17 examinations. Fourteen patients had an exploratory laparotomy which was diagnostic in 9. We believe that early laparotomy still has an important place in the diagnosis and treatment of intestinal bleeding of obscure origin.