PubMed HealthSearch

Biomedical subjects

A H Davies

Publications and source records attributed to A H Davies.

At least 19 recordsLinked to original sources

Early reoperation after major vascular surgery: a four-year prospective analysis.

Between 1 January 1985 and 31 December 1988, 1176 major vascular operations were performed on 1040 patients by the Oxford Regional Vascular Service, of which 136 (12 per cent) were reoperations within 30 days of the initial procedure (110 patients). Sixty-seven (49 per cent) of the reoperations were attempted revascularizations, 43 (32 per cent) were amputations, and surgery for bleeding accounted for 18 (13 per cent). Of the first reoperations 71 (65 per cent) were successful, but among the remaining 39 patients, 17 underwent 26 further reoperations, 15 of which were reoperations for revascularization. The 30-day mortality rate for patients undergoing one reoperation was 13 per cent; this rose to 35 per cent if more than one reoperation was performed. Early reoperation after major vascular surgery is common and carries a high operative mortality. This should be borne in mind when obtaining the informed consent of the patient.

Adolescent

Subcutaneous rectal stump closure after emergency subtotal colectomy.

Subtotal colectomy with preservation of the rectum is now the procedure of choice for patients with severe colitis requiring emergency surgery. The use of subcutaneous 'rectal closure' when the retained distal bowel is placed at the caudal end of the abdominal incision in the subcutaneous or fascial layer is studied. An anal catheter may be placed to drain the rectum. Thirty-two patients (14 men, 18 women) of mean age 33 (range 17-77) years with severe inflammatory bowel disease (29 ulcerative colitis, one Crohn's disease, one indeterminate colitis, one Campylobacter colitis) underwent emergency colectomy with subcutaneous rectal stump closure. Twenty-three stumps were closed with staples, four sutured and five by both staples and sutures. Complications developed in seven patients (22 per cent), of which two required surgical intervention. One significant wound infection was treated successfully with a course of antibiotics. Three minor wound infections did not require specific treatment. The rectal stump was always readily located at the time of restorative surgery. This technique is recommended as a simple and safe alternative to an open mucus fistula provided that surgeons adhere to standard surgical principles; in particular the distal bowel should not be brought out into the wound under tension.

Adolescent

Duplex ultrasonography and pulse-generated run-off in selecting claudicants for femoropopliteal angioplasty.

Non-invasive assessment of lower limb vasculature may avoid unnecessary angiography in claudicants. Colour duplex ultrasonography of the femoral and popliteal arteries was performed to assess patency and the presence of any stenoses, and pulse-generated run-off (PGR) was used to assess the distal vasculature. In 65 legs colour duplex scanning was successful, compared with angiography, in identifying the site and type of disease in the femoropopliteal segment and 23 lesions were correctly identified as suitable for angioplasty. More patent distal vessels were demonstrated by PGR than by angiography; no vessels patent on angiography were missed by PGR. The estimated cost of diagnostic angiography was 330 pounds per test compared with 52 pounds for non-invasive assessment. By using duplex examination as a screening test, a potential saving of 8062 pounds could have been made in this series. Duplex ultrasonography offers a non-invasive and cost-effective alternative to diagnostic angiography for clinically suspected infrainguinal arterial disease presenting as claudication. PGR was not of clinical value in assessing suitability for angioplasty.

Aged

Iliofemoral versus femorofemoral bypass: a 6-year audit.

Iliofemoral and femorofemoral crossover bypass operations performed over a 6-year period were reviewed. A total of 226 patients underwent 231 operations from 1984 to 1990. Seventy-two patients had 75 iliofemoral grafts and 154 patients had 156 femorofemoral grafts. The early mortality rate was 6 per cent for the iliofemoral group and 1.3 per cent for femorofemoral reconstruction. There was a higher reoperation rate in the iliofemoral group (31 versus 16.0 per cent). The cumulative patency rate at 6 years was 75 per cent for iliofemoral bypass and 92 per cent for the femorofemoral procedure (P < 0.01), while the survival rates for the same period were 55 and 74 per cent respectively (P < 0.01). Hospital stay was significantly shorter for patients undergoing femorofemoral bypass (P < 0.05).

Adult

Vein compliance: a preoperative indicator of vein morphology and of veins at risk of vascular graft stenosis.

Compliance measurements of 53 long saphenous veins before femorodistal bypass have been performed using a duplex scanner with venous occlusion for distension. These have been compared with the histological features of the veins. There was significantly more moderate or severe focal hyperplasia and circular muscle hypertrophy in distal long saphenous vein than in its proximal counterpart (P < 0.01 and P < 0.05 respectively). The mean (95 per cent confidence interval) compliance of distal vein with moderate or severe hyperplasia was 0.16 (0.13-0.19) compared with 0.29 (0.22-0.36) for that with no, minimal or mild hyperplasia (P = 0.001). The mean compliance of distal vein with moderate or severe muscle hypertrophy was 0.19 (0.17-0.21) and of vein with no, minimal or mild hypertrophy 0.25 (0.21-0.29) (P = 0.14). The mean lowest compliance in seven patients who developed stenosis was 0.10 (0.07-0.13) compared with 0.21 (0.16-0.26) in the rest (P < 0.001). Preoperative measurement of vein compliance can be used to identify vein with marked pre-existing intimal hyperplasia and as a predictor of future graft stenosis.

Compliance

Praxilene (naftidrofuryl oxalate) as an alternative for the augmentation of femoro-distal bypass blood flow.

In 30 patients undergoing femoro-distal bypass the effect of papaverine and praxilene on blood flow in the graft was measured. The mean resting flow was 129 ml min-1 (range: 91-167) and after papaverine was 202 ml min-1 (142-262) and after praxilene was 205 ml min-1 (143-267). Praxilene has a similar effect to papaverine in the augmentation of blood flow, and further investigation is needed to see if long-term praxilene administration might improve graft survival.

Adult

Amputation level is not adversely affected by previous femorodistal bypass surgery.

Data was reviewed on patients presenting with lower limb-threatening ischaemia to a single vascular unit between September 1984 and December 1990. Three hundred and thirty patients underwent either femoro-popliteal or femoro-infrapopliteal reconstructive surgery and 316 primary amputations were performed on 281 patients. Sixty-three secondary amputations were performed following a femoro-distal bypass failure. The below-knee amputation to above-knee amputation ratio (BKA/AKA) was 1.0 in the primary amputation group to 0.91 in the secondary amputation group. A direct comparison cannot be made as the patients represent two separate clinical groups. The ratio of reconstructive operations to primary amputations more than doubled between the first and second halves of the study. The BKA:AKA ratio in the secondary amputation group and the total number of secondary amputations remained relatively constant. This study supports the view that previous femoro-distal surgery does not adversely affect the overall outcome of amputation.

Aged

The effect of diabetes mellitus on the outcome of angioplasty for lower limb ischaemia.

Angioplasty is an important tool in the armamentarium of the clinician dealing with atherosclerotic disease. Diabetic patients with occlusive disease pose special problems. Four hundred and twenty-five lesions were dilated in 370 patients. No difference in site was found when comparing the diabetic and non-diabetic groups (p less than 0.001), but a significant difference in indication for treatment was observed. Cumulative patency at 5 years for iliac lesions in non-diabetic patients was 61.2% and in diabetic patients was 35.6% (p less than 0.05), for superficial femoral and popliteal artery lesions in non-diabetic patients it was 49.7% and in diabetic patients it was 38.8% (NS). The need for subsequent surgical intervention (p less than 0.01) and risk of death (p less than 0.001) are both significantly greater in the diabetic group. This study shows that angioplasty is a technique that can be used with success in diabetic patients and if the indications for interventions are compared, diabetic patients do not worse.

Angioplasty, Balloon

Three pathways of Epstein-Barr virus gene activation from EBNA1-positive latency in B lymphocytes.

Previous studies on Epstein-Barr virus (EBV)-positive B-cell lines have identified two distinct forms of virus latency. Lymphoblastoid cell lines generated by virus-induced transformation of normal B cells in vitro, express the full spectrum of six EBNAs and three latent membrane proteins (LMP1, LMP2A, and LMP2B); furthermore, these lines often contain a small fraction of cells spontaneously entering the lytic cycle. In contrast, Burkitt's lymphoma-derived cell lines retaining the tumor biopsy cell phenotype express only one of the latent proteins, the nuclear antigen EBNA1; such cells do not enter the lytic cycle spontaneously but may be induced to do so by treatment with such agents as tetradecanoyl phorbol acetate and anti-immunoglobulin. The present study set out to determine whether activation of full virus latent-gene expression was a necessary accompaniment to induction of the lytic cycle in Burkitt's lymphoma lines. Detailed analysis of Burkitt's lymphoma lines responding to anti-immunoglobulin treatment revealed three response pathways of EBV gene activation from EBNA1-positive latency. A first, rapid response pathway involves direct entry of cells into the lytic cycle without broadening of the pattern of latent gene expression; thereafter, the three "latent" LMPs are expressed as early lytic cycle antigens. A second, delayed response pathway in another cell subpopulation involves the activation of full latent gene expression and conversion to a lymphoblastoidlike cell phenotype. A third response pathway in yet another subpopulation involves the selective activation of LMPs, with no induction of the lytic cycle and with EBNA expression still restricted to EBNA1; this type of latent infection in B lymphocytes has hitherto not been described. Interestingly, the EBNA1+ LMP+ cells displayed some but not all of the phenotypic changes normally induced by LMP1 expression in a B-cell environment. These studies highlight the existence of four different types of EBV infection in B cells, including three distinct forms of latency, which we now term latency I, latency II, and latency III.

Antigens, Viral

Transcranial Doppler measurement before and after carotid endarterectomy.

Carotid endarterectomy not only removes a source of emboli but significantly increases flow up the internal carotid artery (ICA). ICA flow and middle cerebral artery velocity (Vmca) measurements were made before, during and after endarterectomy in 40 consecutive patients. Mean ICA flow increased from 207 ml/min (95% confidence interval (CI) 136-259) to 388 ml/min (95% CI 348-428) (P < 0.001, Mann-Whitney U test) following endarterectomy. Despite this, Vmca did not rise significantly at the end of the procedure. By the first postoperative day Vmca rose to 55.3 cm/s (95% CI 47.6-62.4) (P < 0.025, ANOVA) only to fall preoperative values (46.0 cm/s (95% CI 40.0-52.1)) by 6 weeks. These results suggest that cerebral autoregulation takes time to adapt to the increased flow and pressure following endarterectomy, but has stabilized by 6 weeks.

Aged

Prevention of malalignment during non-reversed femorodistal bypass.

A simple technique is described using a Doppler flowmeter to prevent malalignment of a vein graft during femorodistal reconstruction. In 63 non-reversed vein bypass grafts, this technique has been used and no evidence of malalignment has been found on subsequent completion arteriography.

Anastomosis, Surgical

Ultrasonography in the acute abdomen.

In a prospective study 152 consecutive patients presenting with acute abdominal pain were assessed clinically and an ultrasonographic examination was performed immediately. Of these, 16 (11 per cent) patients would normally have had an immediate ultrasonographic scan requested; routine (within 24 h of admission) ultrasonographic examination would have been requested in a further 66 (43 per cent) patients. In 70 (46 per cent) patients an ultrasonographic examination would not have been requested. Ultrasonography altered the diagnosis in one patient from probable appendicitis to cholecystitis. Ultrasonography missed one abdominal aortic aneurysm and one empyema of the gallbladder. Ultrasonography had a sensitivity of 96 per cent, a specificity of 94 per cent, a positive predictive value of 96 per cent, a negative predictive value of 94 per cent and an accuracy of 95 per cent in diagnosing appendicitis. Exactly the same values were found for the clinical diagnosis of appendicitis. The study shows that routine immediate ultrasonographic examination of the acute abdomen is rarely helpful, with the possible exception of appendicitis. Where an urgent ultrasonographic scan is necessary on clinical grounds the expertise of a radiologist is probably required, whereas in specific areas, for example in the diagnosis of right iliac fossa pain, there may be a place for training the surgical trainee.

Abdomen, Acute

Surgical management of the thoracic outlet compression syndrome.

There is some disagreement about whether the first rib should be excised in the presence of a cervical rib for the relief of the thoracic outlet compression syndrome (TOCS). Over a 14-year period (1975-1988) 58 patients have undergone surgery for TOCS. Forty-four patients (76 per cent) had vascular symptoms, 28 (48 per cent) with a neurological component; 11 (19 per cent) had only neurological symptoms. Thirty-six patients (62 per cent) had the first rib excised; 19 (33 per cent) had a cervical rib excised; two (3 per cent) had a division of fibrous bands; and one patient had a large transverse process resected. Follow-up details were available on 53 patients (91 per cent). Overall 38 (72 per cent) were cured of their symptoms, 11 (21 per cent) had a significant improvement, and four (8 per cent) showed no improvement. There was no significant difference between the results following excision of a cervical rib or of a first rib in terms of relief of symptoms. In patients with TOCS who have a cervical rib, excision of the cervical rib alone without excision of the first rib would appear to be an appropriate treatment.

Adolescent