An introduction to quality of life analysis: the new outcome measure in vascular surgery.
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Health Care Rationing↗
Biomedical subjects
R C Kester
Publications and source records attributed to R C Kester.
Exercise-induced neutrophil activation in claudicants: a physiological or pathological response to exhaustive exercise?
OBJECTIVES: To assess the effect of exhaustive exercise on neutrophil activation and degranulation in claudicants and controls. We investigated the hypothesis that neutrophil activation and degranulation are normal responses to exhaustive exercise in healthy patients. DESIGN: This was a controlled experimental two-group study. MATERIALS: Exercise was performed using a fixed workload treadmill test. Neutrophil activation was assessed by flow cytometry of whole blood labelled with anti-CD11b mouse IgG, and neutrophil degranulation in terms of plasma elastase measured by enzyme-linked immunosorbent assay. METHODS: Twenty-eight claudicants with stage 1 chronic leg ischaemia, and 22 healthy controls were recruited. Blood and urine samples were collected before and after treadmill exercise. Claudicants exercised to their maximum walking distance, and controls at a higher "fatigue" workload for a maximum of 20 min. RESULTS: Exercise produced a brief but significant neutrophilia in both groups. Neutrophil CD11b expression increased significantly after exercise only in the claudicants, and was associated with a significant rise in plasma neutrophil elastase. These indices remained unchanged in the control group at all time points despite exercise at a fatigue level. CONCLUSION: The inflammatory response associated with exercise in claudicants is not simply a physiological response to exhaustive exercise.
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Percutaneous transluminal angioplasty for intermittent claudication: evidence on which to base the medicine.
OBJECTIVES: This study aims to assess the impact of PTA on the quality of life (QoL) of claudicants and to analyse which patients and which arterial lesions derive the most benefit. DESIGN: A prospective observational study. MATERIALS: One hundred and seventeen claudicants undergoing PTA were studied; 35 patients had bilateral disease, whilst 82 had unilateral disease and underwent PTA to a solitary iliac lesion, solitary superficial femoral or a iliac lesion above a diseased superficial femoral artery in 24, 39 and 19 cases, respectively. METHODS: Patients completed the Short Form 36 (SF36) and EuroQol (EQ) QoL assessment instruments prior to and at 1, 3, 6, and 12 months following intervention. The SF36 produces a QoL profile, whilst the EQ produces two QoL indices. RESULTS: Claudication has a deleterious effect on QoL, especially in patients with multi-segment disease. PTA results in an immediate and lasting improvement in the QoL of claudicants. Unilateral claudicants undergoing PTA to a solitary iliac lesion demonstrate the most marked QoL benefits and 12 months post PTA report a QoL approaching that of an age-matched population. Patients with bilateral claudication undergoing unilateral PTA and unilateral claudicants undergoing PTA to a solitary SFA lesion demonstrate some QoL benefits, but at 12 months post PTA do not approach the QoL scores of an age-matched population. Unilateral claudicants undergoing iliac PTA above a diseased SFA demonstrate minimal QoL changes. CONCLUSIONS: These results should influence decision making in the management of claudication and it may be possible to prioritise PTA waiting lists to ensure patients with greatest potential benefit are treated with most urgency.
Adult↗
Reduced total antioxidant capacity predicts ischaemia-reperfusion injury after femorodistal bypass.
BACKGROUND: Antioxidant defence systems are essential to protect the body from harmful free radicals released following ischaemia-reperfusion. The aim of this study was to examine the total antioxidant capacity (TAC) of patients with chronic critical leg ischaemia undergoing femorodistal bypass and to correlate this with lipid peroxidation, changes in capillary permeability and clinical outcome. METHODS: Twenty-five patients, 15 men and ten women of median age 71 (range 62-79) years, and 15 matched controls were studied. Blood was taken before operation and after reperfusion, with assays performed for malondialdehyde (a product of lipid peroxidation) and total antioxidant capacity. Changes in capillary permeability were measured by changes in the urinary albumin:creatinine ratio (ACR) following reperfusion of the ischaemic leg and expressed as a percentage increase from the preoperative value. Clinical outcome in terms of the systemic inflammatory response syndrome (SIRS) was recorded. RESULTS: Vascular patients who developed clinical evidence of a systemic inflammatory reaction following revascularization had a significantly reduced TAC compared with the controls (490 versus 860 mumol/l; P < 0.01, Mann-Whitney U test). These patients also demonstrated an increase in lipid peroxidation (0.5 versus 0.25 mumol/l, P < 0.05) and vascular permeability, as measured by the percentage increase in ACR (365 versus 130 per cent, P < 0.01). CONCLUSION: Vascular patients with a lower TAC developed increased capillary permeability as a result of ischaemia-reperfusion, which progressed to SIRS. TAC may provide a test to identify 'at risk' patients. It may be possible to augment their defence with exogenous antioxidants.
Aged↗
Comparison of POSSUM and the Portsmouth predictor equation for predicting death following vascular surgery.
BACKGROUND: The Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) scoring system has been proposed as an accurate predictor of death which takes account of case mix. It appears to overpredict death, and may have drawbacks which prevent accurate individual or subgroup analysis. An alternative system, the Portsmouth predictor equation for mortality (P-POSSUM) may have overcome these problems, but its apparent advantage could be related to inappropriate analysis of POSSUM predictions. METHODS: Some 312 patients having arterial procedures were studied. POSSUM and P-POSSUM scores were used to predict death and compared with actual outcomes. The observed:predicted (O:E) mortality ratios were calculated by two methods for each of the scoring systems. First the analysis devised by the inventors of POSSUM was used and second the method devised for P-POSSUM. RESULTS: The O:E ratio for POSSUM using its recommended 'exponential' method of analysis was 1.14, but it was 0.59 if the P-POSSUM 'linear' analysis was used. The O:E ratio for P-POSSUM using its correct method of analysis was 0.89, but it was 0.67 if the method of analysis devised for POSSUM was used. CONCLUSION: The O:E ratios for POSSUM and P-POSSUM were close to unity when the appropriate analysis was performed. Both POSSUM and P-POSSUM overpredicted death if the incorrect analysis was used.
Aged↗
Prospective analysis of quality of life in patients following infrainguinal reconstruction for chronic critical ischaemia.
BACKGROUND: The aims of this prospective study were to analyse the health-related quality of life (QOL) changes associated with infrainguinal arterial reconstruction for chronic critical limb ischaemia (CLI) and to assess the impact of graft patency and limb salvage. METHODS: Fifty-five consecutive patients, 28 women and 27 men of median age 71 (range 41-86) years, undergoing infrainguinal arterial reconstruction for CLI, consented to participate in the study. QOL was assessed using the Short Form 36 (SF36) health survey questionnaire, which was completed before and at 1, 3, 6 and 12 months following surgery. Graft patency was assessed by duplex imaging at the same postoperative intervals. RESULTS: CLI severely impaired QOL. Cumulative graft patency at 1, 3, 6 and 12 months after surgery was 82, 78, 76 and 64 per cent respectively. Reconstruction resulted in significant improvements in the SF36 domains Physical Functioning, Pain, Vitality and Social Functioning (P< 0.01). With a patent graft these improvements began soon after surgery and were maintained for the 12 months studied. Following irredeemable graft occlusion, patients who had secondary amputation also described some QOL improvements. CONCLUSION: A patent graft following infrainguinal arterial reconstruction for critical ischaemia results in an immediate and lasting improvement in health-related QOL.
Activities of Daily Living↗
The role of leukocytes in the pathogenesis of vibration-induced white finger.
Vibration white finger (VWF) is an occupational disorder associated with long-term exposure to hand-transmitted vibration. The condition exhibits features of secondary Raynaud's phenomenon. The etiology is unknown. The aim of this study was to examine the role of leukocyte rheology in the pathogenesis of VWF. Fifty-two male subjects divided into two groups were exposed to controlled acute hand-transmitted vibration. One group consisted of 29 workers who have all had occupational exposure to handheld vibration and all suffered from VWF (mean age 46.9 years, range 22-66). The second group consisted of 23 controls. Venous blood was analyzed from the dorsum of the hand before and after vibration to determine granulocyte deformability, granulocyte morphology, and white blood cell count with differential. There was a subpopulation of hard and poorly deformable granulocytes in the VWF group when compared with controls (p < 0.05). Acute hand-transmitted vibration had no in vitro effect on leukocyte rheology in either group. Leukocyte rheology may play a role in the pathogenesis of microvascular disease and tissue ischemia in VWF, although whether this is a cause or an effect of the disorder is not clear.
Adult↗
Five years' experience of PAS Port intravenous access system in adult cystic fibrosis.
An implantable venous access system provides a reliable and painless entry site for intravenous treatment. This study reports the authors' experience with such a system in adult patients with cystic fibrosis. Sixty five (87%) of 75 PAS Ports were placed successfully in 57 patients with cystic fibrosis. Because of early difficulties in advancing the catheter in patients whose veins had been traumatized by repeated courses of intravenous antibiotics, a technique was developed whereby venous entry was gained by direct subclavian puncture. This catheter insertion method was used in 53 (82%) attempts and the catheter was then passed by subcutaneous tunnelling to the port site on the ventral aspect of the upper arm. Fifty seven (88%) insertions were successful under local anaesthetic. The major early and late complications were iatrogenic pneumothorax (six cases) and infection (five cases), respectively. Late complications were more common when there was coexisting disease, e.g. diabetes mellitus, or an acute severe respiratory exacerbation, or when the Port was used for parenteral feeding. In conclusion, the PAS Port can be inserted safely by direct subclavian puncture. It was well tolerated and universally liked by the patients.
Adult↗
Randomized, double-blind, placebo-controlled study evaluating the efficacy and safety of AS-013, a prostaglandin E1 prodrug, in patients with intermittent claudication.
BACKGROUND: Intermittent claudication due to peripheral arterial occlusive disease (PAOD) is a common cause of pain and disability in the middle-aged. Clinical trials of the potent vasodilator prostaglandin E1 have been disappointing. This is the first report of a controlled clinical trial of AS-0:3, a novel prodrug of prostaglandin E1 incorporated into lipid microspheres that has been developed to improve delivery of the active compound to blood vessel walls. METHODS AND RESULTS: Eighty patients with stenosis or occlusion, symptoms of intermittent claudication, and maximum walking distance of > or = 30 and < or = 300 m on a standard treadmill test were randomized to placebo or one of three dosage regimens of AS-013. Drug was administered by intravenous injection 5 d/wk for 4 weeks. Treadmill tests and other assessments were completed at weeks 0, 4, and 8. A statistically significant increase in maximum walking distance was observed at 4 weeks (for placebo: median, 4.5 m; interquartile range [IQR], 20; for active treatment: median, 28.0 m; IQR, 81; P < .01, Mann-Whitney test). A similar response was seen at 8 weeks (for placebo; median, -11.2 m; IQR, 35; for active treatment: median, 35 m; IQR, 68; P < .01, Mann-Whitney test). Dose-related improvements in pain-free walking distance and quality of life were observed. No serious safety issues were noted. CONCLUSIONS: These promising clinical data indicate that AS-013, a new prodrug of prostaglandin E1, could provide an effective and acceptable treatment for patients with intermittent claudication. Studies to investigate the optimal dosing regimen, duration of clinical benefit, and effects in more severe forms of peripheral arterial disease are warranted.
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Correlating clinical indicators of lower-limb ischaemia with quality of life.
The objectives of the study were to analyse the impact of increasing lower-limb ischaemia upon quality of life and to assess the correlation between clinical indicators of lower-limb ischaemia and such quality. A prospective observational study of a consecutive series of 235 patients (144 men and 91 women; median age 68 (range 41-87) years presenting with varying degrees of lower-limb ischaemia graded according to ISCVS criteria was performed. Data was collected at interview before any intervention. Clinical indicators of lower-limb perfusion included: intermittent claudication and maximum walking distance on standardized treadmill testing; ankle:brachial pressure indices and isotope limb blood flow. Quality of life analysis was performed using the EuroQol (EQ) questionnaire. This is a standardized generic instrument for describing health-related quality of life and consists of a descriptive system of five dimensions, each measured on three levels. Thus, a profile and two single indices of quality of life were derived using different methods. Increasing lower-limb ischaemia results in a statistically significant deterioration in both global quality of life and in all EQ-measured quality of life dimensions (P < 0.01 Kruskal-Wallis, ANOVA). The correlation between clinical indicators and quality of life is statistically significant but not sufficiently close (correlation coefficients < 0.6) to assume that variations in clinical indicators result in reciprocal variations in quality of life. In conclusion, as might be expected, a significant correlation exists between clinical indicators of lower-limb ischaemia and health-related quality of life. However, the low correlation coefficients emphasize how tenuous the association is. Thus, a significant improvement in the clinical indicators of lower-limb ischaemia cannot be assumed to impart a similar benefit on quality of life. The latter concept must therefore be analysed independently.
Activities of Daily Living↗
Quality of life analysis in patients with lower limb ischaemia: suggestions for European standardisation.
INTRODUCTION AND OBJECTIVES: In this era of evidence-based medicine and limited resources we seem obliged, on clinical and economic grounds, to demonstrate that we improve not only patient survival but also the quality of patients' lives. This study aims to determine the impact of increasing lower limb ischaemia on quality of life (QOL) and which of three commonly used generic QOL instruments is the most valid, reliable, and responsive to change in patients with lower limb ischaemia. PATIENTS AND METHODS: Two hundred and thirty-five patients, 144 men and 91 women, median age 68 years (range 41-87 years) were graded according to ISCVS suggested reporting standards, i.e. 16 mild, 116 moderate and 25 severe claudicants; 33 patients had rest pain and 45 tissue loss. Patients completed Short Form 36 (SF36), EuroQol (EQ-5D) and Nottingham Health Profile (NHP) questionnaires at interview. Additional copies of questionnaires were posted to 80 patients prior to attendance. Correlation between the two sets of responses reflects test-retest reliability. Correlation between domains measured by the three instruments reflects convergent and divergent validity. Kruskal Wallis ANOVA detected QOL changes across the whole group. Spearman Rank was used to analyse validity and reliability. Responsiveness was analysed using the Mann-Whitney U-test. RESULTS: Increasing lower limb ischaemia confers significant (p < 0.05) deterioration in: SF36 measured: physical functioning, physical role, pain, general health, vitality, social functioning and mental health. EQ-5D measured: mobility, self-care, usual activities, pain and anxiety/depression. NHP measured: energy, pain, emotional reaction, sleep, social isolation and physical mobility. All three instruments are significantly reliable (rs > 0.7). The validity of SF36 and NHP (rs = 0.68-0.78) is superior to EQ-5D (rs = 0.37-0.7). SF36 & NHP are equally responsive to changes in physical activity and pain. SF36 and EQ-5D are most responsive to changes in social activity. SF36 is most responsive to changes in psychological status. CONCLUSIONS: QOL deteriorates markedly with increasing lower limb ischaemia. The SF36 would appear to be the most appropriate generic QOL analysis tool for these patients. We recommend its widespread adoption throughout Europe, thus providing a standardised tool for reporting generic QOL.
Activities of Daily Living↗
The regulation of neutrophil activation and adhesion during femorodistal bypass surgery.
OBJECTIVE: To determine the effect that revascularising chronic critically ischaemic legs has no neutrophil activation and adhesion. DESIGN: Prospective clinical study. SETTING: University Hospital. MATERIALS: Twenty-five patients, 16 men and nine women undergoing femorodistal surgery. CHIEF OUTCOME MEASURES: Venous blood assays for neutrophils expression of CD11b, neutrophil adhesion, and the plasma concentration of the shed endothelial adhesion receptor, soluble intracellular adhesion molecule 1 (sICAM-1). Urinary microalbuminaemia was measured and expressed as an albumin/creatinine ratio (ACR), as a marker of vascular permeability and plasma neutrophil elastase as evidence of neutrophil activation. Venous blood was taken preoperatively, during surgery and for the first 7 days postoperatively. MAIN RESULTS: Neutrophil CD11b expression fell following reperfusion of the limb (21.4 mcf to 9.7 mcf, p < 0.02 Mann Whitney U-test) as did neutrophil adhesion (preop. 75% adhesion, postop. 28% p < 0.01). However, the plasma elastase levels rose from 95 micrograms/l to 345 micrograms/l at 4 h and the ACR increased from 5.3 mg/ml to 304.2 mg/ml. The concentration of sICAM-1 fell following reperfusion (p < 0.04). CONCLUSION: The change in CD11b, sICAM-1 and adhesion may represent a normal immunological response to ischaemia/reperfusion.
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Allogeneic versus autologous blood during abdominal aortic aneurysm surgery.
OBJECTIVES: To determine if cell-salvaged autologous blood can serve as an alternative to homologous blood, and to examine the incidence of infected complications and length of postoperative stay. DESIGN: A prospective randomised study comprising autologous and homologous blood transfusions in patients undergoing elective infrarenal abdominal aortic surgery. METHODS: Fifty patients undergoing AAA surgery were prospectively randomised to homologous blood (n = 27), or autologous blood transfusion (n = 23), using a cell salvage autotransfusion device. RESULTS: The haemoglobin at the time of hospital discharge was similar for both groups (11.0 vs. 10.8 g/dl) with no difference in perioperative mortality. The length of stay was reduced in those patients who received autologous blood (9 days vs. 12 days, p < 0.05 Mann-Whitney U test). There were four infected cases in the autologous group and 12 in the homologous group (p = n.s., Fisher's exact probability test). However, patients who received 3-4 units of homologous blood had an increased risk of infection compared to those who received a similar amount of autologous blood (50% vs. 0%). CONCLUSIONS: Cell salvage autologous blood can safely replace, or at least decrease, exposure to homologous blood transfusion, with a reduction in the mean hospital stay.
Aged↗
The hemorheologic effects of hand-transmitted vibration.
Vibration white finger (VWF) is an ischemic condition of the hands that is associated with long-term exposure to hand-held vibration tools. The pathophysiology of VWF remains unknown. The aim of this study was to assess the hemorheologic effect of acute hand-transmitted vibration. This study investigated 52 men divided into two groups: VWF = 29, mean age 46.9 years (range twenty-two to sixty-six); Controls = 23, mean age 42.8 years (range twenty to sixty-four). Each subject gripped a vibrating handle for seven minutes thirty seconds at a vibration frequency of 120 Hz with an amplitude of displacement of 0.25 mm. Venous blood was analyzed before and after acute vibration to determine the hematocrit, the plasma hemoglobin concentration, plasma viscosity, and red cell deformability, expressed as red cell transit time (RCTT). At rest, there was no significant difference in RCTT, plasma viscosity, hematocrit, and plasma hemoglobin concentration between the VWF group and controls. Acute vibration did, however, significantly increase the red cell transit time in the VWF group but not in the control group. In both groups vibration resulted in a significant increase in plasma viscosity, hematocrit, and plasma hemoglobin concentration in hand venous blood. Moreover, in each group there was a highly significant correlation between the change in plasma viscosity and the change in the hemoglobin concentration and the hematocrit. The authors conclude that hand-transmitted vibration is associated with hemoconcentration.
Adult↗
Modulation of 5-HT receptor subtype-mediated behaviours by corticosterone.
Malfunction of the serotonergic system and dysregulation of the hypothalamo-pituitary-adrenocortical axis have been implicated in the pathophysiology of depression. Several studies provide evidence for reciprocal influences between glucocorticoids and 5-HT receptors. The effect of repeated treatment with a high dose of corticosterone (50 mg/kg s.c. twice daily for 4 days) on 5-HT receptor subtype-mediated behaviours was studied. It was found that in rats that were repeatedly treated with corticosterone the number of 2-chloro-6-(1-piperazinyl)pyrazine HCl (MK 212)-induced, 5-HT2C receptor-mediated penile erections were reduced, whereas both MK 212 and (+/-)-1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane (DOI)-induced 5-HT2A receptor-mediated head shakes were increased. The (+/-)-8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT)-induced lower lip retraction mediated by presynaptic 5-HT1A receptors was unchanged, whereas the open field activity induced by 8-OH-DPAT was enhanced in corticosterone pretreated rats. These changes in 5-HT receptor subtype-mediated behaviours were not seen after a single injection with corticosterone given 24 h or 5 days before. The results suggest that 5-HT2A, 5-HT2C and postsynaptic 5-HT1A receptor-mediated behaviour can be modulated by repeated treatment with a high dose of corticosterone.
8-Hydroxy-2-(di-n-propylamino)tetralin↗
The menstrual cycle and Raynaud's phenomenon.
Fluctuations in female sex hormones may be responsible for the high prevalence of Raynaud's phenomenon (RP) observed in premenopausal women. These hormones are known to act on central and peripheral thermoreceptors. In an attempt to establish whether cold sensitivity is altered during the menstrual cycle 50 premenopausal women were investigated. Of these, 26 had primary RP and 24 acted as controls. Each subject was exposed to environmental heating and cooling at three stages of the menstrual cycle to coincide with peaks and troughs in hormone levels. These stages were menstruation, periovulation, and during the midluteal phase. Finger hemodynamics was assessed by means of venous occlusion strain gauge plethysmography and fingertip temperature. Core temperature was assessed with an oral thermocouple. The results show that cold sensitivity was altered during the menstrual cycle in both groups with the fastest finger rewarming pattern during menstruation. Moreover, a significant difference was observed in core temperature between the two groups during the midluteal phase. As a group, subjects with RP failed to show a significant rise in core temperature following ovulation. The authors conclude that the menstrual cycle is associated with changes in the effect of cold on digital blood flow.
Adolescent↗
Audit of vascular surgical workload: use of data for service development.
The power of surgical audit lies in the ability to clearly record complications and to compare case mix from year to year and between centres in order to compare results. In addition, accurate data about surgical activity is vital for the development of new services. We have analysed 52 weeks of activity in a developing pure vascular surgical service and compared activity against the recommendations previously published for consultant surgical workload. During the 12-month period the mean number of admissions per week was 25.3 (95% CI, 23.43-27.29). Mean elective surgical activity was 18.2 h/week (95% CI, 16.5-19.9) and mean emergency workload 12.7 h (95% CI, 10.7-15.4). Mean intermediate equivalent value (IEV) operations per week was 37 (95% CI, 33.6-40.8) and of these 26.4 IEV (95% CI, 22.96-29.6) were complex major operations. Finally, the mean bed occupancy of vascular patients on the unit was 23.3 (95% CI, 21.15-24.97). The recommendations for surgical activity are 3.5 IEV/list. In our unit this would equate to 21 IEV/week compared with 37.2 in our practice. This data forms the basis of a powerful bid for increased consultant manpower and theatre resources. Surgical audit is time-consuming and should be consultant led, but the benefits are tangible and the data generated can be used to support bids for resource re-allocation.
Elective Surgical Procedures↗
Impaired thermoregulation in Raynaud's phenomenon.
UNLABELLED: In an attempt to examine the role of the thermoregulatory apparatus in the etiology of Raynaud's phenomenon (RP), the authors exposed 15 women with RP and 12 controls to central body cooling and central body warming. Subjects were placed in an environmental chamber at 25 degrees C. Their right hand was placed in an annex of the chamber, which was insulated from the main chamber and maintained at a constant temperature of 25 degrees C throughout the experiment. Blood flow was measured in the digits of the right hand by venous occlusion strain gauge plethysmography and skin thermometry. Body temperature was measured with an oral thermometer. The temperature of the chamber was then increased to 35 degrees C and then reduced to 13 degrees C for twenty-five minutes with measurements repeated. Following this period patients were rewarmed in an ambient temperature of 35 degrees C for twenty minutes. RESULTS: subjects with RP had significantly lower blood flow at all stages of the test; moreover, their digital rewarming response following central cooling was considerably prolonged when compared with controls. Body temperature was lower and dropped significantly more in the RP group following the cold challenge. The authors conclude that subjects with RP have an impaired thermoregulatory mechanism. This may partially explain cold sensitivity.
Adult↗