A “precauÇÃo padrÃo” como forma de prevenÇÃo de infecÇÃo cruzada
Vascular II0247 The Consequences of Socio-Economic status on outcomes from Amputation R. Gohil*, R. Barnes, I.C. Chetter Hull York Medical School, University of Hull, Hull & E Yorkshire Hospitals Trust, Hull, UK Aims: Currently 5,000 leg amputations occur annually in England and Wales and have a 50% mortality rate at 2 years. We aimed to analyse the effect of socioeconomic deprivation on amputation outcome. Methods: All patients undergoing major lower limb amputation from January 2005 to December 2009 were identified from a prospectively maintained vascular database. Patient’s postcodes were used to determine socioeconomic status using the ACORN classification system (1 highest group to 5 lowest). It is based on census data and integrates information on age, sex and marital status, occupation, education, home ownership, health, perceived crime and local neighbourhood issues. Non parametric analysis of data was performed using SPSS version 19. Results: We identified 354 patients (218 men; 65.5%), median age 68 (IQR 58-78) years. 47 (14.8%) patients were ACORN grade 1, 4 (1.3%) were grade 2, 65 (20.4%) were grade 3, 56(17.6%) were grade 4 and 146 (45.9%) were grade 5. Significant differences were noted for the cardiovascular risk factors; hyper-cholesterolaemia (p=0.034), diabetes (p=0.020), smoking status (p=0.006). No significant differences were noted between classes for gender, type of admission (emergency or elective) or mortality (peri- operative or 1 year death rate) or blood test (haemoglobin, white cells, urea, creatinine, sodium and potassium). Conclusions: Socio-economic status of amputees does not have an effect on mortality. However, their status does have an impact on their cardiovascular risk factors, therefore aggressive modification remains imperative.
Vascular II0341 Long-term outcomes in men screened for Abdominal Aortic Aneurysm: a prospective cohort study J. Duncan*1, K. Harrild2, L. Iversen2, A. Lee2, D. Godden3 1Raigmore Hospital, Inverness, UK, 2University of Aberdeen, Aberdeen, UK, 3Centre for Rural Health, Inverness, UK Aims: To determine whether there is there a relationship between aortic diameter and morbidity and mortality in men screened for abdominal aortic aneurysm. Methods: Between April 2001 and March 2004, 8146 men aged 65-74 years living in Highland and the Western Isles were screened and completed a general health questionnaire. Long term outcomes were obtained by data linkage to national records of hospital admissions and mortality. Time to an event of interest was compared using crude and adjusted Cox proportional hazards regression models. Results: At screening 414 (5.1%) men had an aneurysm (aortic diameter >29mm), 669 (8.2%) had an aorta 25-29mm in diameter and 7,063 (86.7%) an aorta less than 25 mm. Median (IQR) follow-up was 7.4 (6.9, 8.2) years. The mortality risk in men with an aneurysm or with an aorta 25-29mm, was significantly higher than men with an aorta < 25mm. The increased mortality risk in the 25-29mm group disappeared when variables such as smoking and known heart disease were adjusted for. Risk of hospital admission for cardiovascular, respiratory, abdominal wall and peritoneal disease, were significantly higher in men with aneurysm and men with aortas 25- 29mm in diameter. Most of these relationships remained after correction for confounding variables. In men with aortas 25-29mm in diameter, risk of hospital admission with AAA was significantly higher than in men with aorta <25mm, (adjusted HR 6.7 99% CI 3.4,13.2) Conclusions: Men with AAA and those with aortic diameter 25-29mm have an increased risk of mortality and subsequent hospital admissions compared to men with an aorta <25mm. Studies should consider whether risk factor control and rescreening should be offered to these men. Vascular II0359 Relationship between ABPi and Free-Living Daily Physical Activity C.L. Clarke*1, C.G. Ryan2, M. Granat1, R.J. Holdsworth1 1School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK, 2The School of Health and Social Care, Teeside University, Middlesbrough, UK, 3Vascular Department, Forth Valley Royal Hospital, Larbert, UK Aims: Previous studies have reported that a reduction in ABPi is related to a decline in overall daily physical activity. Such studies include only those patients with an ABPi at rest of ≤ 0.90. Measurement of the ABPi becomes nondiagnostic in some patient groups such as when vessels are incompressible due to calcification leading to falsely elevated readings. The management of peripheral arterial disease (PAD) is based on the patients’ symptoms therefore it may be more appropriate to have a global measure of activity in a free-living environment as a measure of disease severity. The ActivPALTM physical activity monitor is able to quantify postural activity over 7 days. This study investigates whether activity data correlates with ABPi measurement. Methods: Seventy-one patients with a history of PAD were recruited from a Vascular Out- Patient Clinic. There were 50 males and 21 females with a mean age of 66 years (65.62 ± 8.4). Resting ABPi and a six-minute walk test were undertaken prior to wearing an ActivPALTM continuously for 7 days. Results: The median ABPi from the lowest limb was 0.74 (IQ range 0.63 - 0.92). The median distance walked in six minutes was 284 metres (IQ range 218-329). The median total walking time over 7 days was 9.1 hours (IQ range 7.1-12.1) and the median number of steps taken 39,407 (IQ range 29,472-53,145). There was no correlation between ABPi and the six-minute walk test nor total 7-day walking time and total steps taken. The six-minute walk test did correlate with 7-day total walking time and steps taken (Spearmans rank r=0.261, p=0.03; r=0.304, p=0.01 respectively). Conclusions: Given that the amount of exercise taken over a 7-day period is likely to reflect disease severity, these results expose the limitations of ABPi as a means of assessment of PAD and in particular as an assessment of disease severity.
Vascular II0458 Efficacy of topical local anaesthesia to reduce peri-operative pain for endovenous laser therapy of varicose veins: a double-blind randomised controlled trial S. Saha*, A. Tiwari, C. Hunns, J. Refson, A. Abidia Princess Alexandra Hospital, Harlow, Essex, UK Aims: Tumescent local anaesthesia via multiple injections in the peri-venous space leads to intra and post-operative pain during endovenous laser treatment (EVLT). We considered whether application of topical local anaesthesia (LA) reduces pain caused by these injections. Methods: All eligible patients undergoing local anaesthetic EVLT were recruited and randomised to either an application of topical local anaesthesia or water-based gel i.e. placebo to the thigh. Patients were classified using CEAP score and all filled in the Aberdeen varicose vein severity score (AVSS) questionnaire. Visual analogue pain scores were recorded immediately post-operative, prior to discharge and at 6 weeks. Analysis was performed using un-paired Students t-test to assess for statistically significant differences in the means. Results: 52 patients underwent the procedure. In 8 patients the data was incomplete. In the remaining 44 patients (24 local anaesthesia, 20 placebo), there was no statistical difference in mean ages (placebo=52yr, range=24-81yr; LA=52yr, range=23-76yr) or gender distribution. The severity of varicose veins assessed pre-operatively by the clinician (CEAP classification score, median=2 in both groups) and patient (AVSS, median placebo=19.8, LA=15.7) were similar. There was no statistical difference in pain scores between the placebo and topical local anaesthetic group immediately post-operatively (23.35 Vs 19.75, P=0.436), pre-discharge (20.90 Vs 13.75, P=0.681) or at 6 weeks (14.95 Vs 7.64, P =0.629). Conclusions: There is no benefit of using topical local anaesthesia for endovenous laser therapy of varicose vein to reduce patient experience of peri-operative pain.
Vascular II0543 6-year clinical and ultrasound (DUS) results of endovenous laser ablation (EVLA) for varicose veins (VV) due to great saphenous vein (GSV) reflux B. McAree*, D. Dellagrammaticas, M. Gough The General Infirmary at Leeds, Leeds, UK Aims: 5-year surgical results (RCT: GSV stripping) report 50% groin neovascular-isation and 46% recurrent VV. Newer endovenous therapies have been widely adopted but late efficacy is unknown. We report 6-year follow-up for GSV EVLA. Methods: 63 patients undergoing above-knee (AK) GSV EVLA (79 limbs, 57 years (IQR 48-70); 36 female; time since EVLA: 6.5 years [6.4-7.0]) have been reviewed (DUS, Aberdeen Varicose Vein Severity Score [AVVS]) in an on-going study Results: Median length treated was 34cm (31-37.5) using 64.3 J/cm (60.6-69.7). 21/63 (33%) reported recurrent VV in 35/79 (44.3%) treated limbs. 45/62 (72.6%) considered their treatment successful and 50/62 (80.6%) would have EVLA again. DUS revealed normal deep veins; SFJ reflux >1s in 25/79 limbs (31.6%); groin neovascularisation in 11/78 (14%); AK GSV occlusion in 29/79 (34%); a fully patent GSV (reflux>1s) in 3/79 (3.8%) and segmental AK GSV (reflux>1s) patency (median 10cm [5.5-18.5]) in 37/79 (46.9%). New sites of reflux were present in 31/79 limbs [perforators (14), below-knee (BK) GSV (9), anterior accessory GSV (6), accessory posterior GSV (1), pelvic veins (1)]. Overall BK GSV reflux was present in 57/79 (72.2%). At follow-up 34/79 (43%) limbs were CEAP grade 0 or 1, 40 (51%) grade 2 and 5 (6%) grade >2 confirming a persisting benefit (median 2 [1-2] versus 2 [2-2 pre-treatment]), p<0.001. AVVS scores were 5.74 (2.4-14.3) versus 11.7 (8.5-18.6) pre- treatment (p<0.001). Conclusions: At 6.5 years clinical recurrence and groin neovascularisation seem less common than after GSV stripping and improved CEAP/AVVS scores persist. Nevertheless detailed DUS revealed sites of superficial reflux in half of patients, 2/3rds of which would be amenable to further minimally invasive therapy. Further, adoption of recently established parameters for successful EVLA (ablation from lowest point of reflux [particularly BK GSV], higher laser energy density) could improve outcomes. Vascular II0653 Endovenous Radiofrequency Ablation of Varicose Veins without routine Phlebectomy gives good Patient Satisfaction A. Chan*, C. Smith, R. Goel, R.A. Salaman East Lancashire Hospitals NHS Trust, Lancashire, UK Aims: Over 37,000 procedures are carried every year in the UK to treat varicose veins. Nearly half of all successful litigation claims relating to vascular surgery are a result of varicose vein treatments. High patient satisfaction as well as good outcomes should therefore be achieved in this group. Methods: A prospective analysis of one surgeon’s varicose vein practice was analysed. Patients with symptomatic varicose veins were treated with endovenous radiofrequency ablation (VNUS ClosureFAST system) under local anaesthetic. No routine phlebectomy was performed concurrently. All patients were sent a questionnaire following the procedure designed to assess symptom improvement, quality of life (QoL) and overall satisfaction. Results: Between August 2009 and June 2010, 138 patients were included in our analysis, with a total of 190 limbs treated. Only 6% (8 patients) had concurrent phlebectomy. On follow up only 5% (7) had residual varices, of which 4% (6) opted to have outpatient sclerotherapy sessions. Overall patient satisfaction rates were high (> 70%). Patients returned to work on average after 5 days and had only 11 days with noticeable bruising and swelling. Symptomatically, there was significant improvement with aching, itching, swelling and eczema following surgery. QoL improved in the domains of analgesia, physical appearance, clothing restrictions and daily activities, but not physical support. Interestingly, it was noticed that patients who had a clinic follow-up appointment had higher satisfaction rates than those that did not. Conclusions: We show that VNUS performed without routine phlebectomy under local anaesthetic is a safe and effective way to treat varicose veins and results in high patient satisfaction.
Vascular II0666 Statins enhance vein recanalisation and reduce vein wall inflammation following venous thrombosis S.P. Premaratne*, A. Patel, B. Modarai, A. Smith, M. Waltham Academic Department of Surgery, King’s College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, London, UK Aims: Statins (3-hydroxy-3-methylglutaryl co-enzyme-A reductase inhibitors) exhibit anti- inflammatory, pro-angiogenic and pro-fibrinolytic effects that may affect thrombus recanalisation and organisation. We evaluated the effects of Atorvastatin in a model of venous thrombus resolution. Methods: Venous thrombi were induced in the vena cava of BalbC mice by a combination of reduced flow and endothelial injury. One day after thrombus induction, mice were randomised to 3 groups (n=7/gp). Atorvastatin (30mg/kg or 3mg/kg) or vehicle (methyl-cellulose) was given daily for 7 days by gavage. On day 7 thrombi were harvested, formalin fixed and paraffin sections obtained at defined intervals. Vein recanalisation, thrombus volume and nucleated cell counts in the thrombus and vein wall were measured by image analysis of stained sections. Immuno-histochemical staining was carried out to estimate the percentage area of thrombus or vein wall containing macrophages (MAC-2) and neutrophils (NIMP-R14). Results: Vein recanalisation was greater following treatment with high dose Atorvastatin (0.50±0.13mm3) compared with low dose or vehicle (0.29±0.11mm3, 0.27±0.13mm3 respectively, P=0.002 ANOVA). Neovascular channel number within the thrombus was significantly higher in both treated groups (5.00±.44 [high dose]; 5.14±.5 [low dose], vs 3.14±.40 [vehicle], P=0.009). There was no difference in thrombus volume between the three groups. Thrombus nucleated cell count, MAC-2 and NIMP-R14 staining was similar for all three groups. Vein wall nucleated cell count was lower in treatment groups (637±74 [high dose]); 649±75 [low dose] vs control (1023±60, P=0.001). MAC-2 (0.41%±0.04, 0.45%±0.04) and NIMP-R14 (3.92%±0.38, 3.76%±0.48) staining was significantly lower in the vein wall of statin treated groups compared with vehicle (0.97%±0.05, P<0.001; 7.33%±0.36, P<0.001 respectively) Conclusions: Atorvastatin enhanced recanalisation and inhibited vein wall inflammation associated with wall fibrosis. The use of statins in combination with existing therapeutic regimens may help to maintain valve competence and reduce the incidence of post-thrombotic syndrome.
Vascular II0721 Multidisciplinary approach to vascular intervention in Takayasu arteritis A.H. Perera*1, T. Youngstein2, R.G.J. Gibbs1, J.H. Wolfe1, J.C. Mason2 1Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, 2Rheumatology Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK Aims: Takayasu arteritis (TA) is associated with considerable morbidity and premature mortality amongst young patients. Poor outcomes are attributed to lack of awareness of the condition and therefore delayed diagnosis, alongside sub-optimal medical treatment and inappropriate patient selection for vascular intervention. We report the outcome of surgical intervention performed on the largest series of TA patients in the UK. The principle aim is to raise awareness amongst the surgical community of the condition and to emphasise the necessity for multi-disciplinary management in specialist centres. Methods: Retrospective case note analysis was performed on TA patients referred to the Rheumatology, Vascular Surgery and Interventional Radiology departments of the Trust over a 10 year period between 2001 and 2011. Results: We report the largest series of patients with a diagnosis of TA in the UK or USA, where 92 patients were identified over a 10 year period. 28% of patients underwent open surgery and 17% underwent interventional radiology (angioplasty ± stenting) procedures. The overall failure rate of intervention was 19%, with 13% of surgical and 32% of interventional radiology procedures resulting in symptomatic re-stenosis or requiring re-intervention. In 7% of cases, evidence suggests intervention was carried out inappropriately or in the presence of active disease. Conclusions: An overall failure rate of 19% for vascular intervention is an improvement on many series and we believe that this reflects effective medical treatment and a multidisciplinary approach to decision making as regards the optimal timing and type of intervention. Currently, medical and surgical management of TA in the UK remains dispersed with many centres having one or two patients. The results of our review of vascular intervention in this cohort, while encouraging, suggest that patient outcomes can be improved by increased disease awareness, earlier diagnosis, optimal medical treatment and selective surgical intervention. We propose that TA patients should be referred early in the disease course to a tertiary referral centre with a specialist multidisciplinary team. Vascular II0801 Effect of infiltration of tumescent anaesthesia (TA) and patient positioning on distance between sapheno-femoral junction (SFJ) and laser fibre-tip during endo-venous laser ablation (EVLA) of Great Saphenous Vein (GSV). S. Rai*, M. Abdel-Hamid, R. Chan, R. Vohra University Hospital Birmingham NHS Trust, Birmingham, West Midlands, UK
Aims: The laser-fibre tip should not be too close or too far from the SFJ risking DVT and recurrence respectively. TA infiltration and head-down patient position may increase or decrease the distance selected pre-TA infiltration. We looked at the effects of TA infiltration and patient-positioning on this distance and the need for readjustment of laser-fibre prior to laser emission. Methods: For EVLA the laser- fibre was positioned in GSV at a ‘safe distance’ from SFJ. This distance was measured Pre-TA infiltration and Post-TA infiltration in head-up and head-down positions. If required, the laser tip was repositioned to avoid complications. Results: Over a 22-month period 375 legs had EVLA using an average 300 ml of TA. In 19 (5%) legs <2 mm (insignificant) difference was found between various positions. In 115 (31%) legs the safe distance decreased by 8 mm (range 3-18) mm; in 226 (60%) legs this distance increased by 12 mm (range 3-20mm). Repositioning of the laser fibre tip by 10 mm was deemed necessary in 72 legs: fibre pulled out in 40 (11%) and advanced in 32 (8.5%). No case of DVT was recorded; GSV occlusion-rate at 3 months was 99.6%. Conclusions: TA infiltration and Head-down patient position effect the 'safe distance' between the laser- fibre and SFJ during EVLA. Therefore to avoid complications the ‘safe distance’ should be rechecked post- TA infiltration.
Vascular II0806 Outcome of infrainguinal bypass grafting for critical limb ischaemia in patients aged over 80 N. Pal*, W. Knight, K. Akbari, C. Bownass, R.M. Pemberton Queen Alexandra Hospital, Portmouth, UK Aims: As a result of improved life expectancy more octogenarians and nonagenarians are being referred with critical limb ischaemia. We aimed to determine the outcome following infrainguinal bypass surgery for this patient group. Methods: Data from a prospectively collected database of infrainguinal bypass procedures were analysed, looking at demographics, indications, procedural information and outcomes, in patients over the age of 80 who underwent a bypass procedure for critical leg ischaemia. Results: Of 541 consecutive bypass procedures performed at our institution between April 2004 and December 2009, 117 were performed in patients aged over 80 years for critical limb ischaemia. Mean age at operation was 84 years (range 80-94yr, 54 male, 63 female) with 8 patients over the age of 90. 46% patients were diabetic and 13% were current smokers. Vein graft was used in 80% cases, and in 57% the distal anastomosis was a crural or pedal vessel. 30 day mortality was 4.2% (n=5). Overall survival at 1, 2 and 5 years was 70, 62 and 32 per cent respectively. Overall amputation free survival for the same intervals were 80, 76 and 71 per cent. Graft patency at 6 months and 1 year were 78 and 70 per cent respectively. Conclusions: Our results suggest that reasonable outcomes in terms of overall and amputation free survival can be achieved in patients over the age of 80 undergoing infrainguinal bypass surgery for critical limb ischaemia.
IMAGINE INTERNATIONAL ACADEMY OF NORTH TEXAS World -Class C oll ege Preparatory Edu cati on www.imaginenorthtexas.org STUDENT MEDICATION REGULATIONS The Imagine International Academy of North Texas recognizes that it will occasionally be necessary for a student to take medication at school. Parents should make every effort to schedule medication outside the school day. When admin
2005, 90 Min., 35 mm, Farbe colour , deutsche Unter-titel German subtitles Regie Director Erik SkjoldbjærgDrehbuch Screenplay Nikolaj Frobenius, Erik Skjold-bjærg, nach dem Bühnenstück von Henrik IbsenKamera Camera Harald PaalgardSchnitt Editing Jon Endre MørkMusik Music Jan GabarekRollen Cast Jørgen Langhelle (Tomas), Trine Wiggen(Katrine), Per Jansen (Morten), Sven Nordin (Pe