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Biomedical subjects

R B Galland

Publications and source records attributed to R B Galland.

At least 37 records · Page 2Linked to original sources
PubMed2003

A 1 year prospective study of management and outcome of patients presenting with critical lower limb ischaemia.

OBJECTIVES: to determine management of patients with critical lower limb ischaemia (CLI) from first presentation to investigation and treatment. DESIGN: prospective study of critical ischaemia patients. METHODS: one-year prospective survey (May 2000-May 2001). Follow-up 3-15 months. RESULTS: some 873 arterial cases presented, 134 patients had CLI. Of the latter 49% were men, 30% diabetic, the median age was 81 years. Only 15 (24%) of 62 cases were referred to outpatients as urgent. Patients waited a median of 25 days (range 1-100) to be seen in outpatients, and had symptoms for a median of 8 weeks. Treatment was conservative for 70 patients, and 11 primary amputations, six secondary amputations, and 62 revascularisation procedures (34 operative, 28 percutaneous transluminal angioplasty) were performed. At follow-up (3-15 months, median 9 months), rates of major amputation and death were 12 and 27% respectively. Significantly more diabetics underwent major amputation (p < 0.02) than non diabetics. Patients presenting with ulceration or gangrene were at greater risk of death than those with rest pain alone (p < 0.01). CONCLUSION: patients with CLI often have symptoms for many weeks before being seen by a specialist, and 76% are referred as non-urgent cases. This compares with patients with suspected malignant disease in the U.K. who are required to be seen within 2 weeks.

Adult↗
PubMed2003

The current role of intra-arterial thrombolysis.

BACKGROUND: the role of intra arterial thrombolysis (IAT) in the management of peripheral vascular disease has come under scrutiny. This study aims to assess current usage and indications for IAT in the U.K. METHOD: the use of IAT was assessed at our own centre and a questionnaire was sent to all centres that provide data for the U.K. "Thrombolysis Study Group". RESULTS: there has been a steady decline in the use of IAT at our centre from a peak of 40 cases per annum to zero. Response was received from 22 of 24 centres (92%). Nineteen (86%) reported a decline in IAT use. Main reasons were concerns over lack of efficacy (74%) and complication rate (63%). Most centres would use IAT for acute limb ischaemia (86%). However, for acute thrombosis in specific indications the results varied; synthetic graft (82%), vein graft (54%), supra-inguinal graft (54%) and thrombosed popliteal artery aneurysm (54%). When asked what their commonest usage for IAT was, the results again varied; acute limb ischaemia (40%), graft thrombosis (40%), embolism post radiological intervention (12%), other (8%). CONCLUSION: there has been a significant decrease in IAT use. Concerns exist as to efficacy and complication rate. There is no clear consensus on indications.

Acute Disease↗
PubMed2003

Variation in general practitioner referral of patients with arterial disease.

AIM: To compare patterns of referral for arterial disease in two areas in the UK. METHODS: A postal questionnaire was used to survey general practitioner (GP) referral patterns for arterial disease. Questionnaires were sent to West Berkshire GPs in 1993 and 2000 and to Llantrisant GPs in 2000. RESULTS: A 70-year-old man with claudication at half a mile and an 80-year-old man with claudication at half a mile or 100 m were significantly more likely to be referred (P < 0.001) in West Berkshire in 2000 compared with 1993. This referral change also applied to an 80-year-old man with an aortic aneurysm who was more likely to be referred in 2000 (P < 0.01). Patients with gradual onset of rest pain were more likely to be referred urgently or as an emergency in 2000 (P < 0.05). When comparing the two areas in 2000, significant differences emerged in the likelihood of referring patients with intermittent claudication. Scepticism continues towards the value of AAA screening in West Berkshire with only about two-thirds of GPs thinking that it was of value. On the other hand in Llantrisant, 94% of GPs thought AAA screening was valuable (P < 0.001). There was a significant decrease in the number of GPs who felt that they would refer patients directly to a regional vascular centre in West Berkshire between the two time periods (P < 0.001). There was a difference in likelihood of referral to regional centres between the two areas in 2000 (33% versus 6%, P < 0.001). CONCLUSIONS: Vascular referral patterns change with time and vary from one area to another. This has implications for planning vascular services.

Aged↗
PubMed2003

Nineteenth century amputations at the Royal Berkshire Hospital, Reading.

AIM: To describe 19th century amputations carried out at the Royal Berkshire Hospital, Reading. METHODS: A retrospective analysis of hospital archives. RESULTS: Details of 276 amputations were analysed. The majority (86%) were in men and boys. The median age was 33 years. The ratio of leg:arm amputation was 2:1. Trauma accounted for 58% of amputations. Of 52 arm amputations, 42 were due to trauma, compared with 37 of 110 leg amputations (P < 0.001). Mortality was higher following amputation for trauma than for disease (P < 0.01). Mortality following leg amputation was 16% compared with 3.8% after arm amputation (P < 0.05). Death rate following compound fracture was 23%. CONCLUSIONS: Compared with today, the population undergoing amputation and the indications for amputation in the 19th century differ significantly. However, it is apparent that in those patients who were selected to undergo amputation acceptable survival figures could be achieved.

Amputation, Surgical↗
PubMed2003

Abdominal aortic aneurysms and concomitant coronary artery disease. Is routine dipyridamole thallium scintigraphy still justified?

There is a high prevalence of coronary artery disease in patients with peripheral vascular disease (PVD). Following elective abdominal aortic aneurysm (AAA) repair the commonest cause for perioperative death is cardiac-related. Patients at high risk of developing perioperative adverse cardiac events can be identified. Means of identification include clinical history and examination with or without the calculation of a scoring index, stress testing and measurement of ejection fractions. The use of dipyridamole thallium scanning (DTS) in patients with PVD results in about 1/3 of patients having normal scans, 1/3 showing reversible and 1/3 fixed defects. It has been generally accepted that fixed defects represent a completed myocardial infarction and patients are at no greater risk of developing perioperative cardiac complications than those patients with normal scans. However, delayed scans show that some of these "fixed" defects are in fact reversible. Evidence of a redistribution defect implies myocardial ischaemia. The debate centres on whether identification of such defects and their correction will improve perioperative mortality following AAA repair. There is no evidence that identification and correcting coronary artery disease in asymptomatic patients results either in improved operative mortality or long-term survival. "Routine" use of DTS or any other means of cardiac investigation cannot be justified. Patients who clinically fall into a "high risk" category perhaps should be investigated but a case could be made for simply optimising their medical treatment and not carrying out either coronary revascularisation or aneurysm repair.

Aortic Aneurysm, Abdominal↗
PubMed2002

Severity scores in surgery: what for and who needs them?

Scoring systems which try to quantify patient risk are becoming increasingly popular. They have been widely used in intensive care unit patients, trauma patients, and patients undergoing operation. Both general scores, such as APACHE and POSSUM, and specific scores, such as the Detsky Index for post-operative cardiac morbidity and mortality, have been defined. They can be used for comparative audit, to define treatment options, to predict long- and short-term outcome, and to define morbidity and mortality associated with a specific condition. Little evidence yet exists that it is possible to move patients from higher to lower risk groups and thus lower post-operative mortality. However, this may be achieved in time. All surgeons need to be involved in further refinements of scoring systems.

Anesthesiology↗
PubMed2002

Management of popliteal aneurysm.

BACKGROUND: The best management of patients with a popliteal aneurysm has yet to be established. This paper describes an experience of managing both patent and acutely thrombosed popliteal aneurysms. METHODS: A prospective study was carried out of all patients who presented with a popliteal aneurysm from January 1988 to December 2001. Since 1993 asymptomatic popliteal aneurysms less than 3 cm in diameter without distortion have been managed conservatively. Ultrasonography was repeated at 6-month intervals. These results were compared with conservative management of popliteal aneurysms greater than 3 cm in diameter in patients who declined or were unfit for operation, and with the outcome of patients who underwent elective bypass of a popliteal aneurysm. RESULTS: Fifty-eight patients (two women) presented with 92 popliteal aneurysms. Some 39 had a thrombosed aneurysm and these patients were significantly more likely to have bilateral aneurysms (P < 0.001). Of patent popliteal aneurysms managed conservatively, none below 3 cm in diameter thrombosed. The risk of postoperative complications was greater after repair of a thrombosed than a patent aneurysm (P < 0.005). Preoperative lysis for a thrombosed popliteal aneurysm was associated with more complications than operation and on-table lysis (P < 0.05). CONCLUSION: Careful monitoring of asymptomatic popliteal aneurysms less than 3 cm in diameter is safe. Preoperative lysis is associated with increased risks compared with operation alone in patients with a thrombosed popliteal aneurysm.

Aged↗
PubMed2001

Early results of retrograde transpopliteal angioplasty of iliofemoral lesions.

PURPOSE: To assess whether the retrograde transpopliteal approach is a safe, practical and effective alternative to femoral puncture for percutaneous transluminal angioplasty (PTA). METHODS: Forty PTAs in 38 patients were evaluated. Intentional subintimal recanalization was performed in 13 limbs. Ultrasound evaluation of the popliteal fossa was carried out 30 min and 24 hr postprocedurally in the first 10 patients to exclude local complications. All patients had a follow-up of at least 6 weeks. RESULTS: The indication for PTA was critical ischemia in seven limbs and disabling claudication in the remainder. Stenoses (single or multiple) were present in 24 and occlusion in 15. The superficial femoral artery (SFA) was the commonest segment affected (36) followed by common femoral artery (CFA) in four and iliac artery in four. Technical success was achieved in 38 of 39 limbs where angioplasty was carried out. In one limb no lesion was found. Immediate complications were distal embolization in two and thrombosis in one. None of these required immediate surgery. There were no puncture site hematomas or popliteal arteriovenous fistulae. Symptomatic patency at 6 weeks was 85%. Further reconstructive surgery was required in three limbs and amputation in two. CONCLUSION: The transpopliteal approach has a high technical success rate and a low complication rate with a potential to develop into an outpatient procedure. It should be considered for flush SFA occlusions or iliac disease with tandem CFA/SFA disease where the contralateral femoral approach is often technically difficult.

Aged↗
PubMed2001

Stenting for localised arterial stenoses in the aorto-iliac segment.

OBJECTIVE: to determine complications and patency following angioplasty (PTA) and stenting of aorto-iliac stenoses. SETTING: District General Hospital in U.K. DESIGN: prospective observational study. PATIENTS AND METHODS: between December 1994 and June 2000, 50 patients (38 men), median age 64 (41-89) years underwent aorto-iliac stenting. A total of 61 stents were placed. Indications were intermittent claudication in 38 and rest pain, ulceration or gangrene in 12. Sites stented were aorta 11, common iliac artery 32, external iliac artery 14, common and external iliac arteries two. Bilateral iliac procedures were carried out in nine. Two stents were used to correct residual stenoses after aortic stenting. Some 11 recurrent stenoses were treated. The other reasons for stenting were residual stenoses greater than 30% after PTA, tight calcified stenoses or when a stenosed iliac artery was being used as a donor prior to crossover or femoropopliteal bypass. RESULTS: two immediate technical failures occurred due to malposition. Residual stenoses were corrected by PTA. Two further patients sustained minor complications. None of the aortic stents occluded through two required secondary procedures. Primary-assisted patency was thus 100% at three years. Primary patency following iliac stenting for claudication and critical ischaemia were 97% and 86% at three years respectively. CONCLUSION: PTA and stenting of aorto-iliac stenoses can be safely achieved with durable results.

Adult↗
PubMed2001

Methicillin resistant Staphylococcus aureus in patients undergoing major amputation.

OBJECTIVES: To examine the impact of MRSA infection on patients undergoing major amputation. SETTING: District General Hospital. METHODS: Patients having had major amputation and positive MRSA cultures January 1995-December 1999 were included. Outcome was compared with a randomly chosen group of patients having major amputation but no positive MRSA culture from the same time period. RESULTS: overall 21% of patients undergoing amputation were MRSA positive. Some 28 patients (30 amputations) with MRSA positive cultures were compared with 44 patients (54 amputations) who did not have positive cultures for MRSA. MRSA was isolated from the wound in 17 of 30 amputations. More patients in the control group had a below knee amputation (38 of 54 compared with 12 of 30, p<0.02). Mortality in MRSA positive patients was higher than controls, (12 of 28, 43%, versus 4 of 44, 9%, p<0.01). Primary healing was achieved in only 4 of 17 (24%) amputations where MRSA was isolated from the wound. This compared with 31 of 54 (57%) controls (p<0.05). Delayed healing due to chronic infection was also more likely in MRSA positive patients (p<0.01). CONCLUSION: In view of the high morbidity and mortality in patients with MRSA positive isolates specific antibiotic prophylaxis against MRSA should be considered in patients undergoing major amputation.

Adult↗
PubMed2001

Patency following successful thrombolysis of occluded vascular grafts.

AIM: to determine patency after successful lysis of occluded bypass grafts. METHODS: data were collected from four centres with a wide experience of thrombolysis. Outcome following successful lysis was determined from prospectively collected data or case notes. Data from 75 patients, 53 men, were analysed. RESULTS: median age at time of lysis was 68 years (range 33-88). Median age of graft was 12 months (range 1-120). Patency at 12 months was 33% (95% conf. interval: 21-44%). There were no differences in patency depending on whether the graft was above or below the inguinal ligament or whether an additional procedure eg. percutaneous or vein patch angioplasty was carried out. However in those 48 cases when lysis was deemed complete, i.e. there was restoration of graft patency and at least one vessel run off patency at 12 months was 39% compared with 17% if lysis was incomplete (p=0.04). CONCLUSIONS: at the present time it is difficult to justify routine thrombolysis of occluded grafts when patency, based on intention to treat, is approximately 20% at one year. Following successful graft lysis the role of anticoagulation and careful graft surveillance require further investigation.

Adult↗
PubMed2001

Cover arrangements for consultants on leave: an analysis of job descriptions.

There is much ambiguity about consultant leave allowances and arrangements for cover in the National Health Service. We analysed job descriptions for 47 consultant posts advertised in mid-2000. 35 defined a duty rota but only 3 mentioned specific available leave (all different). In 32 there was no mention of cover for colleagues on leave. When a consultant is absent, colleagues tend to provide cover for emergency cases but not for elective admissions, which are managed largely by junior doctors. This arrangement is particularly hazardous in surgical specialties. If elective surgery is to continue when the consultant is absent, arrangements for leave and cover need to be more clearly defined.

Consultants↗
PubMed2001

Is a palpable short saphenous vein a useful clinical sign in varicose vein assessment?

The short saphenous vein (SSV) may be palpable in the popliteal fossa in patients with varicose veins. A prospective study has been carried out to determine the significance of this sign in the presence of primary varicose veins. The SSV was assessed by palpation of the popliteal fossa with the knee slightly flexed. Hand-held Doppler insonation (HHD) was also used in the out-patient clinic. All patients had SSV assessment by duplex scanning. One hundred and sixty legs were examined. In 68 the SSV was palpable; 39 (57%) of these had SSV reflux on duplex examination. When the SSV was not palpable (92 legs), only 1% (1 leg) refluxed on duplex scanning. SSV palpability had a 98% sensitivity, 75% specificity, 57% positive predictive value (PPV), and 99% negative predictive value (NPV). In comparison, HHD had 80% sensitivity, 87% specificity, 67% PPV and 93% NPV. The combined tests had 78% sensitivity, 73% specificity, 76% PPV and 100% NPV. Palpation of the SSV is a valuable part of clinical examination. If the SSV is not palpable, it is unlikely to reflux.

Adult↗
PubMed2001

Transmetatarsal amputation: an 8-year experience.

This study retrospectively reviews an 8-year consecutive series of transmetatarsal amputation (TMA) for forefoot ischaemia in diabetic and non-diabetic patients. Forty-one patients had TMA. Peri-operative mortality was 17% (7/41). A healed stump was achieved in 19 patients (46%) and 18 of these patients were independently mobile, or mobile with sticks. Non-diabetic patients (8/12) healed significantly better than diabetics (11/29). Median time to healing was 7 months (range 3-20 months). All non-healed survivors had a higher amputation (14 below-knee, 1 Syme's). A healed TMA gives good mobility, but prediction of who will heal after operation is unreliable. Time to healing is often lengthy, and failed healing results in higher amputation. These issues need to be fully discussed with the patient who is considered for TMA.

Adult↗