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Biomedical subjects

J Kelman

Publications and source records attributed to J Kelman.

8 recordsLinked to original sources

Effective subsidies in developing countries.

During the last decades, significant subsidies have been allocated to government-owned water and sewerage enterprises in developing countries. However, water and sewerage coverage is still far from desirable and the poor are particularly affected by the shortage of these services. The truth is that a considerable part of these subsidies have been used up to build huge infrastructure works that would make some construction firms happy, while often decreasing the service costs for the richer. The costs associated of delivering water and sanitation services to the poor are significantly higher, as they often live in slums or irregular urban developments without urban infrastructure. It is possible, and desirable, to improve government's effectiveness through the use of appropriate economic incentives. The Brazilian River Basin Pollution Abatement Program, based on the "output-based aid" concept, is a good example of how this can be achieved. The Program is a success story that shows that the quality of expenditures on sanitation can be considerably improved if governments of developing countries refrain from contracting sanitation infrastructure works and start paying for results, not for promises.

Brazil↗

Training in infrainguinal bypass surgery for severe leg ischaemia.

BACKGROUND: Recent changes in surgical training in the UK mean that operative experience must be gained more efficiently. However, it is important to demonstrate that improved training opportunities are not associated with inferior patient outcomes. The aim was to examine changes in training in infrainguinal bypass surgery and to compare the outcomes of operations performed by consultants and trainees. METHODS: A prospectively gathered, computerized database of 1077 consecutive infrainguinal bypasses performed on 1003 patients for chronic severe leg ischaemia between 1 January 1983 and 31 December 1998 was analysed. RESULTS: Consultants performed 733 (68 per cent) infrainguinal bypasses to the following distal sites: 347 (47 per cent) above-knee popliteal artery, 257 (35 per cent) below-knee popliteal artery, 121 (17 per cent) to a crural artery and eight (1 per cent) other. Trainees performed 344 operations: 170 (49 per cent) were to the above-knee popliteal artery, 122 (35 per cent) to the below-knee popliteal artery, 48 (14 per cent) crural and four (1 per cent) other. The operative mortality rate was 27 (4 per cent) of 733 for consultants and 11 (3 per cent) of 344 for trainees (P > 0.05, chi2 test). There were no significant differences in patency or limb salvage at 36 months after operation between consultants and trainees, regardless of the site of distal anastomosis and the type of conduit used. CONCLUSION: With appropriate case selection and supervision, training in infrainguinal bypass grafting does not compromise early or long-term patient outcomes.

Blood Vessel Prosthesis Implantation↗

Vascular surgical society of great britain and ireland: duplex surveillance does not enhance infrainguinal prosthetic bypass graft patency

BACKGROUND: All patients discharged from this unit with a patent infrainguinal polytetrafluoroethylene (PTFE) bypass are entered into a graft surveillance programme. Previous internal audit had suggested that duplex surveillance was not worthwhile in this patient group. The aim of this study was to compare the fate of infrainguinal PTFE grafts before and after stopping duplex surveillance. METHODS: Between January 1986 and December 1994, 220 grafts (141 above-knee popliteal, 69 below-knee popliteal, ten tibial) were entered into the duplex surveillance programme. Between January 1995 and June 1996, 56 further grafts (29 above-knee popliteal, 21 below-knee popliteal, six tibial) were followed prospectively without duplex scans. RESULTS: During the first study interval, an 'abnormal' scan was reported in 66 of 220 grafts. For clinical reasons (no further reconstruction feasible), no intervention was undertaken in 56 patients. Of these, 34 grafts occluded and 17 amputations were performed. An intervention to maintain patency was performed in ten patients. In 154 patients with 'normal' scans, 53 grafts occluded and 21 amputations were performed. During the second study interval, 20 grafts occluded and 12 amputations were performed. In six patients, an attempt was made to re-establish patency and this was successful in two. Kaplan-Meier 36-month primary and secondary patency rates were 48 and 51 per cent respectively for the group that underwent duplex surveillance, and 58 and 60 per cent for the group that was followed without duplex imaging. CONCLUSION: Prospective duplex surveillance of infrainguinal PTFE bypass grafts does not enhance graft patency and cannot be justified.

Journal Article↗

Growth rate of infrarenal aortic aneurysms.

OBJECTIVE: To delineate the natural history of infrarenal aortic aneurysms with respect to growth rate. METHODS: A referral based series of 233 patients with abdominal aortic aneurysm was serially assessed by abdominal ultrasound. RESULTS: The mean age was 71 years and the median follow up 26 months (range 6-146). The mean growth rate of the series was 3.2mm/year. Division of the initial size into those less than 41 mm (128 patients), between 41-60 mm (92 patients) and those above 60 mm (13 patients) in AP diameter showed mean growth rates per year were 2.6 mm/year, 4.1 mm/year and 6.5 mm/year. Examination of the relationship between aneurysm size and subsequent growth rate over the whole study period revealed a rank correlation of 0.19 (p = 0.002). Aneurysms were also observed to expand at an erratic rate both in terms of time and size. CONCLUSIONS: When the initial decision is to observe the patient, serial ultrasound examinations facilitate later judgements on the balance of risks in relation to surgical treatment.

Adult↗

Duplex ultrasound surveillance of infrainguinal bypass grafts: auditing the process.

The effectiveness of an infrainguinal bypass graft surveillance programme using duplex scanning was assessed over a 2-year period. Of 220 infrainguinal bypass grafts (123 vein and 97 PTFE grafts; 114 to the above knee level, 94 below knee and 12 distal to popliteal artery) in 203 patients, 208 (94.5%) were available for follow-up surveillance. The protocol called for duplex scans at 6 weeks, 3, 6, 9 and 12 months. Fifty-seven grafts (27%) were found to have a V1/V2 ratio equal to or greater than 1.5 and in this group 25 grafts occluded. The median time between primary operation and positive duplex finding was 4 months. Thirty-nine grafts failed during follow-up (at time of analysis median follow-up was 12 months [range 2-83 months]). There were 18 interventions resulting from surveillance-detected stenoses. The median time between positive duplex finding and further investigation was 2 months. Further, there were significant differences in the site of abnormal findings between ePTFE and vein grafts. The value of a surveillance programme may be reduced if there are low rates of intervention and/or excessive delays in intervention following the demonstration of graft-related stenoses. Surveillance programmes and subsequent interventions need to be audited.

Adult↗

Above-knee femoropopliteal bypass grafts and the consequences of graft failure.

In all, 290 femoral to above-knee popliteal artery bypasses were performed between January 1983 and September 1991. PTFE grafts were used in 113 cases (39%) and vein grafts in 177 (61%) (reversed in 146 cases and in situ in 31). Patients were followed up for a median time of 20 months. The 2-, 4- and 6-year patency rates for vein and PTFE grafts were 70%, 62% and 57%, respectively, compared with 58%, 46% and 41% (no statistical difference in survival curves, P = 0.2). The 2-, 4- and 6-year limb salvage rates were 82%, 78% and 62% compared with 75%, 64% and 58% (no statistical difference in survival curves, P = 0.6). A total of 99 grafts occluded during follow-up (45 PTFE and 54 vein grafts). Major amputation was required in 63 limbs; below-knee in 37 limbs (59%), and above-knee in 26 limbs (41%). There was no statistical difference in the amputation level with respect to the graft type. Final healing at the below-knee level was achieved in 23 of 35 (66%) failed vein grafts and in 14 of 28 (50%) failed PTFE grafts.

Adult↗