Biomedical subjects
Publications and source records attributed to N A Scott.
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In order to assess the current pattern of malaria presenting to the Aberdeen Infection Unit a retrospective casenote review was undertaken of 110 patients admitted with that diagnosis between 1st January 1992 and 31st August 1999. Oil-related work was the reason for travel in 48 (43.6%) of the UK residents, holiday in 35 (31.8%), backpacking in 8 (7.3%) and other work in 5 (4.5%). Sixty-five patients (59.1%) had PL falciparum malaria (pure or mixed), 25 (22.7%) had PL vivax, 6 (5.4%) PL ovale and 3 (2.7%) PL malariae infection. No prophylaxis had been taken by 66% of the 47 UK-based oil workers and by 36% of the other 48 UK residents who had returned from Africa. There is a need for better education of oil workers and holidaymakers travelling to areas endemic for malaria. We are now setting up a travel advisory service in our Unit to address the problem.
Between 1983 and 1997, a total of 16 patients were referred to a tertiary Intestinal Failure Unit (IFU) following surgery elsewhere for complications of radiation enteritis. Eleven were female with a mean age of 43 years (range 21-71 years) and the most common primary site of malignancy was genitourinary (n = 13). Patients had undergone an average of two laparotomies (range 1-7 laparotomies) for complications of radiation enteritis prior to transfer to the IFU. On admission, the principal problem in eight patients was persisting intestinal fistulation, four patients had continuing intestinal obstruction and four had the short bowel syndrome after extensive intestinal resection. Only one patient had evidence of residual malignancy; this patient with short bowel syndrome was allowed home without invasive therapy. Of the remaining 15 patients, 12 required an abdominal surgical procedure, while three were discharged without further surgery after training for home parenteral nutrition (HPN). Following abdominal surgery, five patients died in hospital, but the remaining seven patients went home alive--including two further patients on HPN. Overall, of the 15 patients referred with intestinal failure after surgery for complications of radiation enteritis and actively treated, one-third died in hospital and a further third required institution of HPN before being able to be discharged home.
Two cases of fistulation into the seminal vesicles are described. One related to Crohn's disease and the other following surgery for carcinoma of the rectum. Both cases were diagnosed by CT sinography. This technique is described and is recommended when attempting to demonstrate the internal communications of difficult perineal fistulae when standard techniques of fistulography fail.
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BACKGROUND: Recent recommendations for the reorganization of cancer services emphasize the importance of a 'minimal acceptable volume of work'. The influence of both hospital and surgical workload has been examined using a population-based series of patients with colorectal cancer. METHODS: Nine hundred and twenty-seven patients with primary colorectal cancer diagnosed during the period 1 January to 30 June 1993 were identified from the North Western Regional Cancer Registry. Case notes were reviewed for information on patient age and sex, histological diagnosis, disease stage, degree of tumour differentiation, mode of admission, identity of operating surgeon, timing of operative procedure, and use of radiotherapy and/or chemotherapy. A multivariate Cox proportional hazards model was then constructed to examine, simultaneously, the effects of patient-, disease- and health service-related variables on survival. RESULTS: Age, tumour stage and differentiation, and mode of admission were revealed as significant independent prognostic variables. After adjusting for these variables, neither operator grade (consultant versus junior), consultant workload nor hospital throughput were identified as independently influencing patient survival. CONCLUSION: The results of this study do not support an association between volume of work and patient outcome.
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Adrenergic stimulation of parotid secretion was investigated in anaesthetised brushtail possums to ascertain fluid secretion rates and salivary composition. Because neither alpha- nor beta-adrenergic stimulation evoked saliva output, infusion of the adrenergic agonists was superimposed on a pre-existing bethanechol-stimulated flow. Isoprenaline infusion (2.4 nmol min-1) increased salivary amylase activity, [protein]; [HCO3]; [PO4] and [Ca], and amylase/Ca and protein/Ca ratios; reduced [Cl]; [K] and osmolality; but did not alter H+ activity; [urea]; [Na]; [Mg]; amylase/protein or saliva/plasma urea ratios. These data are consistent with isoprenaline stimulating acinar secretion of protein, Ca and PO4 but not the ion transport necessary for primary fluid formation at the endpieces and modifying transport of monovalent ions in the excurrent ducts. Consequently, the possum parotid has beta-adrenergic receptors in both the endpieces and excurrent ducts. Phenylephrine infusions at 2.4 and 24 nmol min-1 were without effect whereas phenylephrine at 240 nmol min-1 caused changes in salivary composition which paralleled those for isoprenaline administration but were generally of lesser magnitude. Thus, the possum parotid has few or no alpha-adrenergic receptors and the salivary response elicited was the result of cross-reaction of phenylephrine with beta-adrenergic receptors.
A total of 112 surgical patients took part in telephone follow-up, conducted by non-medical staff, after discharge home. Successful telephone follow-up was achieved in 93% of patients at 6 weeks, 91% at 3 months and 79% at 12 months. Telephone follow-up by non-medical staff is a practical method of assessing patient outcome after surgery. Wider use of this technique would free up time in the surgical clinics, without compromising audits of outcome and purchaser demands for evidence of efficacy.
This study determined whether 24 h access to current surgical literature via a personal computer CD-ROM was of relevance to the junior surgeon managing acute surgical referrals. Over a 2 month period, a total of 53 acute surgical referrals were assessed and initially managed by a single basic surgical trainee. The Medline database was searched using Silver Platter software for current surgical literature regarding aetiology and management after the initial patient assessment. Of the 53 searches made (mean search time 7 min 22 s), 20 (38%) were judged to have produced information that increased basic surgical trainee knowledge and a further 9 (17%) changed patient management. By contrast, 24 (45%) of searches did not reveal helpful information. The availability of a surgical database that provides the trainee with abstracts of the current literature is valuable both for the educational development of the surgeon and improvement of patient care.
Heparin is an effective agent in the treatment of unstable angina and myocardial infarction. The clinical utility of heparin is limited by bleeding complications. This study was performed to determine whether static delivery of heparin could effectively inhibit further platelet deposition. Thrombogenic graft segments were incorporated into chronic arteriovenous shunts in pigs. Autologous platelets were labeled with 111Indium. Platelet deposition was quantitated with gamma camera imaging. The grafts were exposed to blood flow for 15 min in order to induce platelet deposition on the thrombogenic surface. Heparin was delivered locally either by direct exposure or with a double balloon catheter. After a 15 minute exposure period, the heparin solution was removed and subsequent platelet deposition was monitored for 90 minutes. Heparin, administered with the double balloon catheter in doses as low as 12.5 U, effectively inhibited further platelet deposition. An intravenous injection of 100 U of heparin, the highest dose use for local delivery, did not perturb bleeding time or the activated partial thromboplastin time. In conclusion, platelet deposition can be inhibited with static local delivery of heparin at doses that are not associated with systemic bleeding.
BACKGROUND: Ionizing radiation has been shown to reduce vascular lesion formation after balloon overstretch injury of pig coronary arteries. The present series of experiments examines the mechanism by which this occurs. METHODS AND RESULTS: Balloon injury was performed on porcine coronary arteries, followed immediately by ionizing radiation using either a source train of 90Sr/Y or 192Ir seeds designed to deliver 14 or 28 Gy at a depth of 2 mm from the source. The animals were killed 3, 7, or 14 days after injury. Bromodeoxyuridine was administered 24 hours before euthanasia to label proliferating cells. Cell proliferation was significantly reduced on day 3 in the adventitia and media of the irradiated vessels compared with controls. Two weeks after injury, there were fewer alpha-actin-positive myofibroblasts in the adventitia of the irradiated vessels than in nonirradiated controls, and morphometric analysis indicated that the vessel perimeter of the irradiated vessels was significantly larger than in controls. Together, these results suggest a positive effect of intravascular irradiation on vascular remodeling. Apoptosis was estimated by terminal transferase dUTP-biotin nick-end labeling (TUNEL) 3 and 7 days after injury. TUNEL-labeled cells were found primarily in the adventitia at the medial tear, but no differences were detected between irradiated and control vessels. CONCLUSIONS: These studies suggest that intracoronary radiation primarily inhibits the first wave of cell proliferation in the vessel wall and demonstrates a favorable effect on late remodeling by preventing adventitial fibrosis at the injury site.
The feasibility of breeding spring-calving, single-suckled beef cows without the use of natural service was investigated over two breeding seasons by using repeated oestrus synchrony and fixed-time artificial insemination (AI). Initially, cows were oestrus-synchronised with subcutaneous norgestomet implants inserted for 10 days, with an injection of prostaglandin before the implants were removed. The cows were inseminated once 56 hours after the implants were removed, and 12 days later they were re-treated with norgestomet implants to allow a second synchronised service. Twenty-one days after the first synchronised AI, milk samples were taken for progesterone assay and the norgestomet implants were removed. The cows received a second service 56 hours later if the 21-day milk progesterone assay suggested that they were not pregnant. All the cows receiving a second service were retreated with norgestomet implants to allow a third synchronised service as necessary. Pregnancy was later confirmed by rectal palpation. In the first year, 48 cows entered the programme and the pregnancy rates to the first, second and third synchronised services were 56, 69 and 40 per cent, respectively, with 17 per cent of cows barren at the end of the breeding period. In the second year, 69 cows entered the programme and the pregnancy rates were 58, 48 and 33 per cent to the successive services with 20 per cent of cows barren at the end of the breeding period. The accuracy of milk progesterone assay for pregnancy diagnosis was 84 per cent and 87 per cent in the first and second years, respectively.
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Percutaneous treatment of saphenous vein graft (SVG) stenosis has been established as an alternative to repeat coronary artery bypass grafting. Intracoronary Palmaz-Schatz stent (PSS) and directional coronary atherectomy (DCA) have been suggested to provide better short- and long-term results than balloon angioplasty. Records of 840 patients with 931 SVG lesions treated with PSS (121 patients, 132 lesions), DCA (103 patients, 107 lesions), and balloon angioplasty (616 patients, 692 lesions) were reviewed. Inhospital and long-term outcome were compared among treated groups. The groups had similar clinical and angiographic baseline characteristics except for higher previously dilated grafts in the stent group and graft location among devices. Stent placement was angiographically successful in 99%, DCA in 95%, and balloon angioplasty in 93% of the lesions (p = 0.03). Quantitative angiography revealed a larger lumen diameter after procedure after PSS (3.2 mm) and DCA (3.1 mm) compared with 2.4 mm after balloon angioplasty (p = 0.0001). Angiographic complications (abrupt closure, severe dissections, or distal embolization) were evident in eight (6.1%) lesions after PSS placement, in 17 (15.9%) after DCA, and in 61 (8.8%) after balloon angioplasty. Serious in-hospital clinical complications (death, emergency coronary artery bypass grafting, or Q-wave myocardial infarction) were similar among devices. Survival rates were similar among the groups (p = 0.15). Repeat revascularization at follow-up was reported in 58 (60.4%) of patients after PSS, in 48 (51.1%) after DCA, and in 280 (49.4%) after balloon angioplasty. Correlates of additional revascularization at follow-up were older grafts, calcific lesions, previously dilated grafts, longer lesions, and patients with lower ejection fractions (odds ratio 1.06, 1.34, 1.43, 1.04, and 1.01, respectively). Correlates of mortality rate at follow-up were older patients, patients with lower ejection fractions, and distal embolization (odds ratio 1.04, 1.04, and 1.92, respectively). These data suggest that in patents with SVG stenosis the initial success and morbidity rates are similar when comparing PSS and DCA with balloon angioplasty. Although a larger lumen is obtained with PSS and DCA, patients who underwent balloon angioplasty had similar rates of cardiac events and requirements for additional procedures at follow-up.
BACKGROUND: High-output external duodenal fistula remains a challenging condition to treat. Despite advances in metabolic and nutritional care, mortality rates remain high. METHOD: Retrospective casenote review of patients managed on a specialised unit. RESULTS: Thirteen of 388 admissions (3.4%, 11 males, median age 51 years) had an external duodenal fistula. Management was by eradication of abdominal and systemic sepsis and maintenance of nutritional status by the administration of total parenteral nutrition. The majority of fistulas followed surgery for peptic ulcer disease. Eight of 13 fistulas closed spontaneously, and of those requiring operative closure, surgery was successful in 4 of 5 cases. There were 2 mortalities. CONCLUSION: High-output external duodenal fistula may be successfully managed in a specialised unit.
Nonmuscle myosin heavy chain-B isoform (NMMHC-B) is expressed by proliferating vascular smooth muscle cells (SMCs), and its expression in primary lesions has been proposed to be predictive of restenosis after atherectomy. The present study was designed to study the time-course expression of NMMHC-B after angioplasty of porcine coronary arteries by in situ hybridization and immunohistochemistry. Domestic juvenile swine underwent percutaneous transluminal coronary angioplasty (PTCA) of the left anterior descending and circumflex coronary arteries with standard clinical angioplasty catheters. To identify proliferating cells, 5'-bromo-2'-deoxyuridine (BrdU) was administered and detected by immunohistochemistry on serial sections. Vessels were examined at 3, 7, and 14 days after balloon angioplasty, and uninjured coronary vessels were used as controls. Normal arteries showed hybridization to 35S-labeled NMMHC-B riboprobes localized mainly in the medial layer. NMMHC-B expression in the adventitia was markedly increased 3 days after balloon angioplasty. Seven and 14 days after injury, NMMHC-B mRNA-containing cells were localized in the adventitia and neointima at the arterial injury site. Cell proliferation, as indicated by BrdU staining, colocalized with NMMHC-B mRNA expression 3 and 7 days after angioplasty. These data indicate that cells proliferating in the adventitia and neointima express NMMHC-B; however, its expression is not limited to the proliferative state, since NMMHC-B mRNA was also found in quiescent SMCs of normal coronary arteries and in nonproliferating adventitial and neointimal cells 14 days after angioplasty.