Management of systemic sclerosis: British Society for Rheumatology guideline scope

This guideline will provide a practical roadmap for management of SSc that builds upon the previous treatment guideline to incorporate advances in evidence-based treatment and increased knowledge about assessment, classification and management. General approaches to management as well as treatment of specific complications will be covered, including lung, cardiac, renal and gastrointestinal tract disease, as well as RP, digital vasculopathy, skin manifestations, calcinosis and impact on quality of life. It will include guidance related to emerging approved therapies for interstitial lung disease and account for National Health Service England prescribing policies and national guidance relevant to SSc. The guideline will be developed using the methods and processes outlined in Creating Clinical Guidelines: Our Protocol. This development process to produce guidance, advice and recommendations for practice has National Institute for Health and Care Excellence accreditation.

Toxic epidermal necrolysis-like lupus

Toxic epidermal necrosis (TEN)-like lupus is a rare condition characterized by epidermal loss and mucosal ulceration occurring in patients with acute severe flares of systemic lupus erythematosus. The clinical picture may mimic drug-induced Stevens-Johnson syndrome/TEN; however, the absence of a suitable culprit drug, and the context of acute lupus point to the correct diagnosis. In a case series of three patients, further discriminating features included a slower onset of epidermal loss, more limited mucosal ulceration and a lack of ocular involvement when compared with drug-induced TEN. Histology may show similar features, including basal layer vacuolation, apoptosis and full-thickness epidermal necrosis. Patients with TEN-like lupus may have additional features of lupus, and a lupus band on direct immunofluorescence. It is important to identify this condition correctly, so that these patients can be appropriately managed with early input from Rheumatologists and prompt treatment with high-dose combined immunosuppressant therapy.

Long-term outcomes of daily oral vs. pulsed intravenous cyclophosphamide in a non-trial setting in ANCA-associated vasculitis

We aimed to compare risk of death, relapse, neutropenia and infection requiring hospital admission between unselected ANCA-associated vasculitis (AAV) patients according to whether cyclophosphamide induction was by daily oral (PO) or pulse intravenous (IV) route. We identified all newly diagnosed AAV patients treated with PO or IV cyclophosphamide between March 2007 and June 2013. We used Cox and logistic regression models to compare mortality, relapse and adverse events and adjusted these for age, renal function and other significant confounders. Fifty-seven patients received PO and 57 received IV cyclophosphamide. One-year survival was 86.0% in PO and 98.2% in IV patients; all-time adjusted hazard ratio (HR) for PO compared to that of IV cyclophosphamide was 1.8 (95% CI 0.3–10.6, P = 0.54). One-year relapse-free survival was 80.7% in PO compared to 87.3% in IV patients, all-time adjusted HR 3.8 (0.2–846, P = 0.37). During the first 12 months, neutropenia of ≤ 0.5 × 10⁹/L occurred in 9 (16%) PO and 0 (0%) IV cyclophosphamide patients (P = 0.003). The number of patients admitted with one or more infections was 16 (28%) in the PO group and 9 (16%) in the IV group, adjusted OR 2.2 (0.6–8.6, P = 0.23). We observed an increased risk of neutropenia, a trend towards increased risk of death and an admission with infection with PO cyclophosphamide. This adds certainty to previous studies, indicating that PO administration induces greater marrow toxicity. Infection-related admissions within 12 months of starting cyclophosphamide were higher than those in clinical trials, possibly reflecting the unselected nature of this cohort.

What do surgeons and trainees think of WBAs and how do they use them?

Differences in how workplace-based assessments are viewed by trainees and those who train them.

The diagnostic accuracy and cost-effectiveness of magnetic resonance spectroscopy and enhanced magnetic resonance imaging techniques in aiding the localisation of prostate abnormalities for biopsy: a systematic review and economic evaluation

BACKGROUND

In the UK, prostate cancer (PC) is the most common cancer in men. A diagnosis can be confirmed only following a prostate biopsy. Many men find themselves with an elevated prostate-specific antigen (PSA) level and a negative biopsy. The best way to manage these men remains uncertain.

OBJECTIVES

To assess the diagnostic accuracy of magnetic resonance spectroscopy (MRS) and enhanced magnetic resonance imaging (MRI) techniques [dynamic contrast-enhanced MRI (DCE-MRI), diffusion-weighted MRI (DW-MRI)] and the clinical effectiveness and cost-effectiveness of strategies involving their use in aiding the localisation of prostate abnormalities for biopsy in patients with prior negative biopsy who remain clinically suspicious for harbouring malignancy.

DATA SOURCES

Databases searched--MEDLINE (1946 to March 2012), MEDLINE In-Process & Other Non-Indexed Citations (March 2012), EMBASE (1980 to March 2012), Bioscience Information Service (BIOSIS; 1995 to March 2012), Science Citation Index (SCI; 1995 to March 2012), The Cochrane Library (Issue 3 2012), Database of Abstracts of Reviews of Effects (DARE; March 2012), Medion (March 2012) and Health Technology Assessment database (March 2012).

REVIEW METHODS

Types of studies: direct studies/randomised controlled trials reporting diagnostic outcomes.

INDEX TESTS

MRS, DCE-MRI and DW-MRI. Comparators: T2-weighted magnetic resonance imaging (T2-MRI), transrectal ultrasound-guided biopsy (TRUS/Bx). Reference standard: histopathological assessment of biopsied tissue. A Markov model was developed to assess the cost-effectiveness of alternative MRS/MRI sequences to direct TRUS-guided biopsies compared with systematic extended-cores TRUS-guided biopsies. A health service provider perspective was adopted and the recommended 3.5% discount rate was applied to costs and outcomes.

RESULTS

A total of 51 studies were included. In pooled estimates, sensitivity [95% confidence interval (CI)] was highest for MRS (92%; 95% CI 86% to 95%). Specificity was highest for TRUS (imaging test) (81%; 95% CI 77% to 85%). Lifetime costs ranged from £3895 using systematic TRUS-guided biopsies to £4056 using findings on T2-MRI or DCE-MRI to direct biopsies (60-year-old cohort, cancer prevalence 24%). The base-case incremental cost-effectiveness ratio for T2-MRI was <£30,000 per QALY (all cohorts). Probabilistic sensitivity analysis showed high uncertainty surrounding the incremental cost-effectiveness of T2-MRI in moderate prevalence cohorts. The cost-effectiveness of MRS compared with T2-MRI and TRUS was sensitive to several key parameters.

LIMITATIONS

Non-English-language studies were excluded. Few studies reported DCE-MRI/DW-MRI. The modelling was hampered by limited data on the relative diagnostic accuracy of alternative strategies, the natural history of cancer detected at repeat biopsy, and the impact of diagnosis and treatment on disease progression and health-related quality of life.

CONCLUSIONS

MRS had higher sensitivity and specificity than T2-MRI. Relative cost-effectiveness of alternative strategies was sensitive to key parameters/assumptions. Under certain circumstances T2-MRI may be cost-effective compared with systematic TRUS. If MRS and DW-MRI can be shown to have high sensitivity for detecting moderate/high-risk cancer, while negating patients with no cancer/low-risk disease to undergo biopsy, their use could represent a cost-effective approach to diagnosis. However, owing to the relative paucity of reliable data, further studies are required. In particular, prospective studies are required in men with suspected PC and elevated PSA levels but previously negative biopsy comparing the utility of the individual and combined components of a multiparametric magnetic resonance (MR) approach (MRS, DCE-MRI and DW-MRI) with both a MR-guided/-directed biopsy session and an extended 14-core TRUS-guided biopsy scheme against a reference standard of histopathological assessment of biopsied tissue obtained via saturation biopsy, template biopsy or prostatectomy specimens.

STUDY REGISTRATION

PROSPERO number CRD42011001376.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Drawing lines at the sand: evidence for functional vs. visual reef boundaries in temperate Marine Protected Areas

Marine Protected Areas (MPAs) can either protect all seabed habitats within them or discrete features. If discrete features within the MPA are to be protected humans have to know where the boundaries are. In Lyme Bay, SW England a MPA excluded towed demersal fishing gear from 206 km(2) to protect rocky reef habitats and the associated species. The site comprised a mosaic of sedimentary and reef habitats and so 'non reef' habitat also benefited from the MPA. Following 3 years protection, video data showed that sessile Reef Associated Species (RAS) had colonised sedimentary habitat indicating that 'reef' was present. This suggested that the functional extent of the reef was potentially greater than its visual boundary. Feature based MPA management may not adequately protect targeted features, whereas site based management allows for shifting baselines and will be more effective at delivering ecosystem goods and services.

Systematic review and economic modelling of the relative clinical benefit and cost-effectiveness of laparoscopic surgery and robotic surgery for removal of the prostate in men with localised prostate cancer

BACKGROUND

Complete surgical removal of the prostate, radical prostatectomy, is the most frequently used treatment option for men with localised prostate cancer. The use of laparoscopic (keyhole) and robot-assisted surgery has improved operative safety but the comparative effectiveness and cost-effectiveness of these options remains uncertain.

OBJECTIVE

This study aimed to determine the relative clinical effectiveness and cost-effectiveness of robotic radical prostatectomy compared with laparoscopic radical prostatectomy in the treatment of localised prostate cancer within the UK NHS.

DATA SOURCES

MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, BIOSIS, Science Citation Index and Cochrane Central Register of Controlled Trials were searched from January 1995 until October 2010 for primary studies. Conference abstracts from meetings of the European, American and British Urological Associations were also searched. Costs were obtained from NHS sources and the manufacturer of the robotic system. Economic model parameters and distributions not obtained in the systematic review were derived from other literature sources and an advisory expert panel.

REVIEW METHODS

Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies of men with clinically localised prostate cancer (cT1 or cT2); outcome measures included adverse events, cancer related, functional, patient driven and descriptors of care. Two reviewers abstracted data and assessed the risk of bias of the included studies. For meta-analyses, a Bayesian indirect mixed-treatment comparison was used. Cost-effectiveness was assessed using a discrete-event simulation model.

RESULTS

The searches identified 2722 potentially relevant titles and abstracts, from which 914 reports were selected for full-text eligibility screening. Of these, data were included from 19,064 patients across one RCT and 57 non-randomised comparative studies, with very few studies considered at low risk of bias. The results of this study, although associated with some uncertainty, demonstrated that the outcomes were generally better for robotic than for laparoscopic surgery for major adverse events such as blood transfusion and organ injury rates and for rate of failure to remove the cancer (positive margin) (odds ratio 0.69; 95% credible interval 0.51 to 0.96; probability outcome favours robotic prostatectomy = 0.987). The predicted probability of a positive margin was 17.6% following robotic prostatectomy compared with 23.6% for laparoscopic prostatectomy. Restriction of the meta-analysis to studies at low risk of bias did not change the direction of effect but did decrease the precision of the effect size. There was no evidence of differences in cancer-related, patient-driven or dysfunction outcomes. The results of the economic evaluation suggested that when the difference in positive margins is equivalent to the estimates in the meta-analysis of all included studies, robotic radical prostatectomy was on average associated with an incremental cost per quality-adjusted life-year that is less than threshold values typically adopted by the NHS (£30,000) and becomes further reduced when the surgical capacity is high.

LIMITATIONS

The main limitations were the quantity and quality of the data available on cancer-related outcomes and dysfunction.

CONCLUSIONS

This study demonstrated that robotic prostatectomy had lower perioperative morbidity and a reduced risk of a positive surgical margin compared with laparoscopic prostatectomy although there was considerable uncertainty. Robotic prostatectomy will always be more costly to the NHS because of the fixed capital and maintenance charges for the robotic system. Our modelling showed that this excess cost can be reduced if capital costs of equipment are minimised and by maintaining a high case volume for each robotic system of at least 100-150 procedures per year. This finding was primarily driven by a difference in positive margin rate. There is a need for further research to establish how positive margin rates impact on long-term outcomes.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Impacts of anthropogenic activity on the ecology of class 1 integrons and integron-associated genes in the environment

The impact of human activity on the selection for antibiotic resistance in the environment is largely unknown, although considerable amounts of antibiotics are introduced through domestic wastewater and farm animal waste. Selection for resistance may occur by exposure to antibiotic residues or by co-selection for mobile genetic elements (MGEs) which carry genes of varying activity. Class 1 integrons are genetic elements that carry antibiotic and quaternary ammonium compound (QAC) resistance genes that confer resistance to detergents and biocides. This study aimed to investigate the prevalence and diversity of class 1 integron and integron-associated QAC resistance genes in bacteria associated with industrial waste, sewage sludge and pig slurry. We show that prevalence of class 1 integrons is higher in bacteria exposed to detergents and/or antibiotic residues, specifically in sewage sludge and pig slurry compared with agricultural soils to which these waste products are amended. We also show that QAC resistance genes are more prevalent in the presence of detergents. Studies of class 1 integron prevalence in sewage sludge amended soil showed measurable differences compared with controls. Insertion sequence elements were discovered in integrons from QAC contaminated sediment, acting as powerful promoters likely to upregulate cassette gene expression. On the basis of this data, >1 × 10(19) bacteria carrying class 1 integrons enter the United Kingdom environment by disposal of sewage sludge each year.

Determining the rate of varicella vaccine rash in children with moderate-severe eczema

OBJECTIVES

To determine the rate and severity of vesicular reactions following varicella vaccine in children with moderate-severe eczema. Secondary endpoints included the rates and severity of local reactions and eczema severity change within 42 days of vaccination.

METHODS

Prospective open intervention pilot study of varicella vaccine in children aged 12 months to 13 years with moderate-severe eczema. Children were given varicella vaccine alone and followed for 42 days after vaccination.

RESULTS

Fifty children, aged 12 months to 10.5 years were recruited, with complete follow-up for 48. A vesicular rash with a single lesion occurred in one child (2.1% (95% CI: 0, 11.1%)), 10 days following vaccination. Local reactions, including erythema, swelling and tenderness, were reported in eight children (16.7%). A flare-up of moderate-severe generalized eczema was reported in one child (2.1%) during the first week following varicella vaccine.

CONCLUSIONS

Vesicular rash and local reactions following varicella vaccination were no more common or severe in children with moderate-severe eczema than that reported in the published literature in children without eczema. Eczema in the 42 days following vaccination did not appear to increase in severity.

The diagnosis and management of Kawasaki disease

Kawasaki disease (KD) is a systemic vasculitis of childhood with a predilection for the coronary arteries. It is the predominant cause of paediatric acquired heart disease in developed countries. The aetiology of KD remains unknown and consequently there is no diagnostic test. The diagnosis is made using a constellation of clinical criteria that in isolation have poor sensitivity and specificity. Early treatment prevents overt coronary artery damage in the majority of children. The long-term effects of childhood KD on later cardiovascular health remain unknown. A recent study showed that treatment of KD in Australia is suboptimal, with late diagnosis occurring in approximately half of the cases and an unacceptably high incidence of acute cardiac involvement. These guidelines highlight the difficulties in the diagnosis of KD and offer some clues that may assist early recognition of this important paediatric disease. They also detail current treatment recommendations and the evidence on which they are based. Increased awareness of the epidemiology and spectrum of the clinical presentation of KD is essential for early recognition and optimal management.

RN and RPN decision making across settings

Nursing decision making was a focus of the Province-Wide Nursing Project (PWNP), a 3-year project to promote best nursing practice. In much of the growing literature on nursing decision making, it is assumed that there are differences in the way RNs and RPNs make decisions. However, there is little scientific evidence to support this assumption. The RN and RPN decision making across settings questionnaire was completed by nurses employed in the 23 agencies of the 4 Participating Complexes taking part in the project. The survey questions were subjected to factor analysis and reduced to five factors. Results revealed measurable differences between the way that RNs and RPNs made decisions. Both RNs and RPNs reported making decisions frequently and experiencing little difficulty in making them. However, there were statistically significant differences in the frequency with which RNs and RPNs perceived they made decisions and the difficulty they found in making them. To plan effective health care, it is important to take account of the strengths of different health care workers. There is a need for further research to investigate the reasons behind the differences revealed in these findings.

Use of electronic devices in pain management

Far from being a recent phenomenon, electroanalgesia has been a feature of medicine for thousands of years. Perhaps it is now time that we let history teach us a lesson and look again at how the use of electronic devices in pain management may benefit our cash-strapped NHS.

The organizational environment and evidence-based nursing

The Province-Wide Nursing Project (PWNP) was designed to remove some of the structural barriers that can impede the ability of nurses in selected health care settings to assess, implement and evaluate best nursing practice. Literature on capacity building and research utilization suggests that the organization is the most important factor in promoting best nursing practice. Therefore, managers and nursing leaders need to encourage the creation of optimum work environments. A survey undertaken by the PWNP Research Centre team assessed the extent to which the 23 agencies in the 4 Participating Complexes provided supportive environments for evidence-based practice. The Characteristics of Agencies in Participating Complexes: Demographics and Resources questionnaire investigated the resources available to help nurses improve their standards of practice in agencies participating in the project. Larger agencies, especially those associated with academic centres, had considerably more resources than agencies in smaller towns. Participation in the Province-Wide Nursing Project enabled agencies to develop strategies to improve the use of evidence in nursing practice.

Outbreak of extended spectrum beta lactamase producing Klebsiella pneumoniae in a neonatal unit

An outbreak of extended spectrum beta lactamase producing Klebsiella pneumoniae (ESBLKp) in a neonatal unit was controlled using simple measures. Normally, the control of such infections can be time consuming and expensive. Seven cases of septicaemia resulted in two deaths. ESBLKp isolates were subtyped by pulsed field gel electrophoresis, and four of the five isolates typed were identical. Control of the outbreak was achieved by altered empiric antibiotic treatment for late onset sepsis and prevention of cross infection by strict attention to hand washing. Widespread colonisation of babies in the unit was presumed, so initial surveillance cultures were not performed. No further episodes of sepsis occurred.

Should peri-operative infra-inguinal graft duplex scans be routinely performed?

BACKGROUND

The ability of duplex ultrasound graft surveillance to detect graft stenosis is well documented. However, the optimal time to commence duplex ultrasound graft surveillance is not clear.

METHODS

An early duplex ultrasound study was performed on 90 infra-inguinal bypass grafts within 2 weeks of surgery. Further duplex scans were performed at intervals after surgery of 1 month, 3 months, 6 months, 1 year and then annually. An ankle/brachial systolic pressure index (ABI) was performed before the infra-inguinal bypass and then 24 h after the surgery. The ABI was also routinely measured at the time of each graft duplex examination.

RESULTS

Six graft thromboses (6.7%) were demonstrated on the first graft duplex within 2 weeks of the surgery. The 24-hour postoperative resting ABI were less than 0.5 in all six cases. Significant graft stenoses (> 50%) or native artery diseases were detected in six cases (6.7%) on the first graft scan (proximal anastomosis stenosis, 1: mid-graft stenosis, 3; peroneal artery stenosis, 1; popliteal artery occlusion, 1). The resting ABI was less than 0.5 in one of these cases. Vein patch angioplasty was performed on graft stenosis in two cases following the first duplex scan. In 78 cases with either normal or minimal graft/native artery stenosis (< 50%), the resting ABI were less than 0.5 in only two cases (2.6%). The first graft duplex ultrasound examinations were technically difficult or gave a poor image in 21 cases (23.3%). During the subsequent graft duplex follow-up, seven graft thromboses were demonstrated at an average of 5.9 months after surgery (1-12 months). Significant stenosis (> 50%) was demonstrated in 10 additional cases at an average of 8.5 months after surgery (1-12 months).

CONCLUSIONS

The data of the present study do not support routine peri-operative graft duplex scanning in addition to a 1-month graft duplex scan. Early postoperative resting ABI should be routinely performed. If the resting ABI is less than 0.5, an immediate duplex scan should be carried out to assess graft integrity. A long-term non-invasive graft surveillance programme is important in the detection of graft stenosis.

Recurrent varicose veins after short saphenous vein surgery: a duplex ultrasound study

Recurrent venous reflux in the popliteal fossa of patients with recurrent varicose veins following short saphenous vein surgery was assessed in 70 limbs using a duplex scanner. Incompetence of the short saphenous vein was found to be the main source (61%) of venous reflux in the popliteal fossa (43/70). The recurrence or persistence of the short saphenous vein was subdivided into four types: an intact saphenopopliteal junction, as well as an intact short saphenous vein in 20 limbs (type I): varicosities in the popliteal fossa communicating with a short saphenous vein stump in 11 limbs (type II); a residual short saphenous vein communicating with the popliteal vein via a tortuous recurrent vein in eight limbs (type III); and a segment of residual short saphenous vein with no communication with the popliteal vein in four limbs (type IV). Incompetence of a gastrocnemius vein was involved in 24 cases (34%), an incompetent popliteal area vein in one (1.4%), popliteal vein incompetence in 15 (21%), and popliteal fossa varicosities communicating with the long saphenous system in two (3%). Of 12 limbs tested pre- and postoperatively, a high termination of the short saphenous vein was demonstrated in four of seven residual incompetent short saphenous veins. Duplex scanning is recommended to assess recurrent venous reflux in the popliteal fossa. It can be used to determine the level of an incompetent saphenopopliteal junction and the level of the termination of any other incompetent vein in the management of varicose veins recurring after a short saphenous vein operation.

Combined semiclosed iliac endarterectomy and distal arterial reconstruction for multilevel arterial disease

Semiclosed iliac endarterectomy in combination with an infrainguinal vascular reconstruction has been used over the past decade in the treatment of lower-limb ischaemia. Although the early results of this combination of operations were known, the durability of the external iliac endarterectomy had not been assessed and so an effort was made to review all surviving patients by duplex scanning. Between 1985 and 1993, 48 patients (51 limbs) underwent combined semiclosed iliac endarterectomy and infrainguinal vascular reconstruction for iliac and femoropopliteal occlusive disease. Some 49% of operations were performed for limb salvage. An iliofemoral bypass graft was required twice because of failure of the endarterectomy. A variety of distal arterial reconstructions was employed. One patient required a major amputation and there were two deaths. Mean (s.d.) ankle/brachial indices (ABI) rose from 0.54 (0.14) to 0.85 (0.25) after surgery. Some 85% of the patients who underwent operation for claudication became symptom free; 83% of patients who underwent operation for limb-threatening ischaemia became symptom free or improved to mild claudication during an average of 29 months follow-up. During the follow-up period five patients underwent a further procedure because of restenoses of the external iliac artery. A duplex scanning study was performed in 22 of the 51 limbs an average of 36 months after surgery. External iliac artery stenotic lesions were found in the area of the endarterectomy in three patients. Endarterectomy of the external iliac artery from the groin is an alternative for some patients with iliac arterial disease. In a patient scheduled for an infrainguinal bypass, when an unexpectedly greater degree of athermoma is found at operation in the common femoral and external iliac arteries, this operation may be performed. The durability of the operation as assessed by follow-up duplex scan is quite acceptable.

Outcome of patients with symptomless carotid bruits: a prospective study

Knowledge of the natural history of symptomless carotid artery disease is important in determining the best preventative treatment for symptom-free patients. To document the progression of carotid artery disease and the clinical course of a symptomless population, 336 patients with symptom-free carotid bruits were prospectively followed up initially with oculoplethysmography and subsequently with duplex scanning. During a mean follow-up of 4.87 years, eight patients (2.4%) suffered a stroke. Thirty-seven (11.0%) experienced transient ischaemic attacks (TIAS). The cumulative event rate (TIA plus stroke) was 13.4% (45/336). The annual event rates were 0.48% for stroke, 2.26% for TIA and 2.75% for all ischaemic events. In a subgroup of 69 high-grade carotid stenoses (80-99%), 31 carotid endarterectomies were performed before the development of a TIA or stroke and 21 after the development of symptoms, while 17 lesions were followed-up non-operatively. The total event rate (TIA and stroke) was significantly greater in the non-operated compared with the operated arteries (51.0% versus 6.4% at 5 years, P=0.0034). However, most of the events which occurred in the non-operated group were TIAs (85.7%) rather than stroke. There was no difference In the death rate of the two groups (P>0.05). Review of serial duplex studies performed on 540 carotid arteries revealed that 382 arteries (70.7%) remained unchanged and 158 (29.3%) showed disease progression. Forty-four of the 540 arteries became symptomatic (TIA or stroke). In 29 of the 44, the event occurred without any change in diameter of the artery, while in 15 there was a change of at least one category greater stenosis. In 39 patients, the stenosis was at least 40% and in five the stenosis was under 40%. Nine events occurred in the patients with severe contralateral carotid stenoses (>60%). The incidence of TIA (32.2%), stroke (6.8%) and death (18.6%) was higher in patients with internal carotid artery stenoses in excess of 80% than in those with lesions between 0 and 79% stenosis (P<0.0001, P= 0.0367 and P=0.0236, respectively). In this study the incidence of cerebrovascular events was higher in patients with high-grade internal carotid artery disease, and the preservation of neurological status in patients with symptomless high-grade carotid artery stenosis was improved by carotid endarterectomy, although the overall mortality remained unchanged.

Duplex ultrasound assessment of the venous status of the swollen leg

Between January 1991 and December 1993, duplex ultrasound characterization of venous disease in leg swelling was studied in 214 patients (261 limbs; 167 unilateral and 47 bilateral). All patients were examined with a duplex scanner, the superficial and deep venous systems were evaluated for the presence of thrombus and valvular incompetence. Of the 261 limbs, 29 (11.1%) had deep venous thrombosis, 14 (5.4%) had superficial venous thrombosis, 66 (25.3%) had deep venous incompetence (31/66 limbs also had superficial venous incompetence), 65 (24.9%) had incompetence in the superficial veins only, and five (1.9%) had deep venous obstruction resulting from a popliteal cyst or a popliteal vein ligation. Eighty-two limbs (31.4%) had no evidence of venous obstruction or incompetence at the areas evaluated. This study showed that venous obstruction and valvular incompetence had occurred in two-thirds of swollen legs examined. Some of the venous obstructions resulted from surgically treatable diseases such as a popliteal cyst, and some of the venous disorders involved the superficial venous system only. Complete venous evaluation with duplex imaging can be very helpful in the determination of the underlying cause of the swelling.

Recurrent varicose veins following high ligation of long saphenous vein: a duplex ultrasound study

Duplex scanning was used to study recurrent varicose veins in 244 limbs with previous high ligation of the long saphenous vein. The recurrent varicose veins were classified into two types according to the presence or absence of a residual long saphenous vein. Varicose veins with a residual long saphenous vein (type I) occurred in 168 limbs (68.9%). A residual long saphenous vein with an incompetent saphenofemoral junction was present in 125 limbs and one without any residual saphenofemoral junction in 43 limbs. Besides the presence of an incompetent long saphenous vein in this group, an incompetent short saphenous vein was detected in 26 limbs, incompetent perforating vein(s) in 45 limbs and incompetent deep veins in 26 limbs. Varicose veins without a residual long saphenous vein (type II) occurred in 76 limbs (31.1%). An incompetent short saphenous vein was demonstrated in 44 limbs, incompetent perforating vein(s) in 18 limbs and incompetent deep veins in 32 limbs. Of the total 244 limbs with recurrent varicose veins, long saphenous vein incompetence was involved in 168 (68.9%), short saphenous vein incompetence in 70 (28.7%), perforating vein incompetence in 63 (25.8%) and deep venous incompetence in 58 (23.8%). Although saphenofemoral junction incompetence was found to be the main source of recurrence, a segment of incompetent residual long saphenous vein, an incompetent short saphenous vein, perforating vein and deep venous system incompetence are other common sources of recurrence. A precise assessment to identify underlying venous incompetence is important for the management of recurrent varicose veins.

The value of duplex scanning in surveillance of infra-inguinal vein and synthetic grafts

The contribution of duplex scanning to improving early diagnosis of graft stenosis was evaluated in 195 patients after infrainguinal bypass procedures. Over a 31 month period. 406 duplex scans were obtained on 232 limbs with 191 vein and 41 polytetrafluoroethylene (PTFE) grafts. Peak systolic velocities > 200 cm/s with spectral broadening and lumen reduction on B-mode image were the criteria adopted for identification of a haemodynamically significant (> 50%) stenosis. Sixty-one stenoses were identified in 55 of the grafted limbs. Thirty-three of the 55 limbs had a subsequent angiogram. The angiogram showed graft occlusion in six limbs, graft stenosis in 18, and native artery stenosis in four. Twenty-one of the grafts had the angiogram within 1 month after the duplex had detected graft stenosis, and one (4.76%) became occluded in this interval. Seven had an angiogram more than 1 month after the duplex study, and five (71.4%) had become occluded. The angiographic study did not confirm a graft stenosis in five limbs. Three were submitted to operation and stenosis was confirmed. Seventeen graft thromboses were detected by duplex scanning. Graft thrombosis was demonstrated following a previous negative duplex scan in one of the 106 vein grafts (0.94%), and in four of 30 PTFE grafts (13.3%). Duplex scanning is effective in the detection of graft stenosis. The precise anatomical location is less accurate when in the region of an anastomosis. Early attention should be taken when duplex studies suggest critical stenosis because there is a high risk of occlusion. Polytetrafluoroethylene grafts tend to thrombose without a precursory focal stenosis.

An anatomic source of false venous reflux with continuous wave Doppler

BACKGROUND

The limitations of continuous wave (CW) Doppler have been recognized in the assessment of venous reflux since CW Doppler is not able to distinguish reflux signals from more than one vein. In our experience, some regions with venous reflux suggested by CW Doppler were noted to have no reflux in any individual vein during duplex studies.

OBJECTIVE

The aim of the study was to assess the anatomic source of the venous reflux suggested by CW Doppler but not confirmed by duplex ultrasound.

METHODS

Five hundred and fifty-one consecutive lower limbs with primary or recurrent varicose veins were examined with CW Doppler and subsequently by color-coded duplex ultrasound to assess the source of venous reflux.

RESULTS

The duplex ultrasound study revealed no reflux in 44 specific regions (8%) where reflux had been indicated by CW Doppler. Two types of anatomy were noted. Two or more superficial veins joined the deep venous system via a common junction in 25 cases. A descending vein joined the deep venous system in 19 cases.

CONCLUSION

A bidirectional Doppler signal in a region of venous junction without any incompetent veins can be misinterpreted as venous reflux. A careful examination of veins not only at the region of the junction, but also at some distance down the stem of the vein is important during CW Doppler or duplex assessment.

Strategies for joint appointments

The structure and policies governing joint appointments discussed above, are developed primarily through cooperation and collaboration between nursing service and education institutions. The joint appointee participates in the process of negotiation of salary, benefits and role responsibilities and exploration of the implications of the appointment for personal career development. Implementation and maintenance of the appointment requires the collaborative efforts of the joint appointee with both contracting agencies. Factors influencing the functioning of joint appointees have been identified and strategies to facilitate functioning presented. The joint appointee must be independent in thought and action yet adaptable to work within the boundaries of two social systems with differing values and expectations. Nursing management, peers and students can provide the support needed to overcome the frustrations and to achieve the rewards inherent in successful implementation of an exciting and innovative role.

Ruptured iliac aneurysms

Iliac aneurysms are uncommon as compared with aneurysms of the abdominal aorta. Rupture is the most serious complication of aneurysms of both vessels. Considerable attention has been focused on the management of ruptured abdomonal aortic aneurysms, but ruptured iliac aneurysms have received little notice. The problems in the management of ten ruptured iliac aneurysms, seen over the last five years, together with the rarity of other reports of this condition, have stimulated this review.

The management of popliteal aneurysms

Twenty-three patients with 34 popliteal aneurysms were treated between 1963 and 1974. Nearly half of the aneurysms were the site of thrombosis when they first presented, and of these nearly half required a major amputation. Surgical treatment of aneurysms in which the popliteal artery was patent was satisfactory; the only failure occurred when a Dacron graft became occluded after eight years. A small group of patients was observed for an average of one year, during which time the thrombus in one aneurysm embolized and one aneurysm became occluded, necessitating an amputation. The results of this series suggest that the prognosis for a limb with popliteal aneurysm depends on the patency of the popliteal artery at the time of the initial presentation, and lends support to the belief that popliteal arteries with aneurysms are best reconstructed before the onset of a serious complication.