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Biomedical subjects

R B Galland

Publications and source records attributed to R B Galland.

At least 73 records · Page 4Linked to original sources
PubMed1999

Surgical patients with methicillin resistant staphylococcus aureus infection: an analysis of outcome using P-POSSUM.

The significance of MRSA infection in surgical patients was studied using the P-POSSUM scoring system. All surgical patients undergoing operation between 1/10/96 and 30/09/97 were prospectively scored using P-POSSUM. A subset of these patients with MRSA infection was analysed using P-POSSUM predicted mortality. Physiological and operative severity scores were compared with non-MRSA surgical patients and length of hospital stay with P-POSSUM matched non-MRSA controls. Thirty of the 1,132 patients were MRSA positive and of these five died, giving a P-POSSUM observed/expected deaths ratio of 1.7 (not significant; 95% CI -0.24 to 0.10). The P-POSSUM physiology score of 30 MRSA positive patients, compared with the non-MRSA group (n = 1102), was significantly more severe (20.9 v/s 17.4; 95% CI 1.09 to 5.95) as was the operative severity score (15.6 v/s 9.2; 95% CI 4.40 to 8.42). The length of stay for surviving MRSA positive patients was significantly longer than P-POSSUM matched controls. MRSA infection in surgical patients does not increase mortality. However, patients who contract MRSA infection are more debilitated and have undergone a greater surgical insult.

Adult↗
PubMed1998

Accuracy of centrally recorded OPCS codes for vascular surgery in the United Kingdom.

AIM: Centrally recorded OPCS codes are based upon district returns. The aim of this study is to determine the accuracy of this system with regard to vascular surgery. METHODS: Prospectively recorded audit data for vascular and endovascular procedures were compared with those obtained from the Department of Health and Welsh Office. Five U.K. hospitals were involved in the study. Data were obtained for the twelve months, 1 April 1994-30 March 1995 (these being the most up to date figures available). RESULTS: The total number of arterial reconstructions based on audit data was 1082. Those recorded by the OPCS codes were 743. This represents a discrepancy of -31.3% (range for the five hospitals: -13.1% to -63.8%). When examining specific codes similar discrepancies were seen. For example, in one hospital 38 AAA repairs were carried out but only two were centrally recorded. However, examination of ICD9 codes (relating to hospital admissions) for that hospital showed that 38 patients with AAA were admitted. A similar wide variation was seen when examining iliac and superficial femoral artery endovascular procedures. Despite the discrepancies of audit and OPCS data, the codes for reconstructions did reflect relative workload of the different hospitals. CONCLUSION: This study shows that there is a marked underestimate of vascular workload when comparing central recorded data with that obtained from local audit. Marked variation is seen in the accuracy of data submitted from different hospitals.

Angioplasty, Balloon↗
PubMed1998

A survey of current attitudes of British and Irish vascular surgeons to venous sclerotherapy.

AIM: To determine current practice amongst vascular surgeons regarding venous sclerotherapy. METHOD: A postal questionnaire was sent to 350 members of the Vascular Surgical Society of Great Britain and Ireland. RESULTS: There were 218 replies (62%). Forty surgeons (18.3%) never injected varicose veins (VV) although six injected venous flares. Most surgeons (n = 168, 77.1%) reserved sclerotherapy for residual VV postoperatively. Primary varicose veins without proximal incompetence were injected by 152 (69.7%) and recurrent VV without proximal incompetence by 141 (64.7%). Sixteen surgeons only injected residual postoperative VV. Few surgeons injected VV in the presence of proximal incompetence. Where specified, 46% of respondents were injecting fewer VVs than in previous years. Only 5% were injecting more. By contrast, 44% were injecting more venous flares than previously (p < 0.001). Eight different sclerosants were used, the commonest being STD (146 surgeons) and Sclerovein (33). The median number of patients treated with sclerotherapy was 11-50 per year compared with 51-150 per year who were operated upon. The median time advised for compression was 2 weeks (range--a few minutes--2 months). Treatment was repeated at a median of 4 weeks (0-6 months). Thirty-two surgeons obtained written consent. All but eight respondents discussed potential complications, the commonest being staining and ulceration. Forty-six surgeons had patients who had experienced serious complications, the commonest being ulceration. There was one reported death from a pulmonary embolus. CONCLUSION: Sclerotherapy is being used less frequently for VV. Most surgeons use it for residual VV and for those without proximal incompetence.

Attitude of Health Personnel↗
PubMed1998

Early experience with stenting for iliac occlusive disease.

OBJECTIVES: To review our experience of iliac artery stenting for occlusive disease. DESIGN: Prospective study of 50 consecutive patients with iliac occlusive disease, November 1993-November 1996. The indications for stenting were complete iliac occlusion (37) restenosis (four), donor site inflow for bypass grafting (four) and difficult stenoses (> 90% and/or > 5 cm) (five). The majority of patients (41) presented with intermittent claudication. RESULTS: All 13 stenoses were successfully stented. One occluded but the rest remain patent. There were no other complications. By contrast, it was not possible to place a stent across 10 of the 37 complete iliac occlusions. In this group there were nine major complications, including five patients who required early embolectomy (four femoral, one brachial) and one patient who developed a false aneurysm at the site of the stent. The "intention to treat" primary cumulative patency for iliac occlusions was 65% at 2 years but after excluding technical failures was 88%. CONCLUSIONS: There is a sharp learning curve and significant complication rate associated with stenting complete occlusions. However, following successful stenting patency rates are around 90% for both iliac stenoses and occlusions.

Aged↗
PubMed1998

The fate of patients undergoing surveillance of small abdominal aortic aneurysms.

OBJECTIVES: Increasing numbers of patients with small abdominal aortic aneurysms (AAA) are being diagnosed. The aim of this paper is to define the fate of those patients undergoing surveillance of small AAAs. SETTING: U.K. district general hospital. METHODS: A prospective study has been carried out of all patients undergoing surveillance. At the time of the first consultation the patient was assessed, a Detsky score calculated and the referral source noted. End points of the study were elective repair of the aneurysm, aneurysm rupture or death of the patient. RESULTS: Details of 267 patients were analysed. The referral source was general practitioner in 39%, patients with peripheral vascular disease in 32% and department of urology in 21%. None were referred from population screening. The cumulative 5-year risks of rupture, elective repair or non-AAA related deaths were 15%, 26% and 46% for all patients, 4%, 13% and 38% for patients initially presenting with AAA less than 4 cm diameter and 21%, 42% and 54% for patients presenting with an AAA 4-5.5 cm diameter. All but one of 11 patients whose aneurysm ruptured were unfit or had declined elective repair. There were 56 non-AAA related deaths, the majority due to cardiovascular causes. Those patients with low Detsky scores had a 5-year survival of 62%, those with high scores 44%. The age/sex matched survival or a normal population at 5 years in 80%. CONCLUSION: Overall the non-AAA related mortality was greater than the risks of rupture or elective repair. It is important to bear in mind the poor prognosis of this group of patients compared with a normal population when considering elective repair of small AAAs.

Actuarial Analysis↗
PubMed1998

Prospective evaluation of quality of life after conventional abdominal aortic aneurysm surgery.

OBJECTIVES: To evaluate the changes in quality of life following conventional abdominal aortic aneurysm repair. DESIGN: Prospective study. MATERIALS AND METHODS: Fifty-nine consecutive patients (50 men; nine women) in two surgical centres were investigated preoperatively, and at 6 weeks, 3 months and 6 months postoperatively. Quality of life was measured using the Short Form 36 (SF 36) questionnaire and the York Quality of Life questionnaire, from which the Rosser index was calculated. RESULTS: Rosser index assessment showed restoration of quality of life to preoperative levels by 3 months, and significant improvement at 6 months. Changes in the SF 36 revealed significant improvement in mental health, and physical role limitation at all times postoperatively. Social function worsened at 6 weeks but improved to preoperative levels by 3 and 6 months after surgery. CONCLUSIONS: Quality of life was improved after open aortic aneurysm repair. The time course of recovery shows a predominant improvement between 6 weeks and 3 months postoperatively.

Aged↗
PubMed1998

Minimally invasive superficial femoral artery endarterectomy: early experience with a modified technique.

OBJECTIVES: To describe our experience of a modified technique for carrying out remote endarterectomy for superficial femoral artery occlusive disease. METHODS: A 4-French arterial dilator is inserted using a Smart needle into the popliteal artery below the occlusion. A remote endarterectomy is carried out through an arteriotomy in the proximal superficial femoral artery. The atheroma is cut distal to the lower extent of disease using a Moll ring cutter. The lower flap of atheroma is secured with an intraluminal stent inserted from the arteriotomy in the superficial femoral artery. The arteriotomy is extended into the common femoral artery and closed with a vein patch. RESULTS: The procedure was completed in 21 of 26 limbs. In 18 cases the superficial femoral artery remained patent at 30 days. Of the 21 cases all but four stayed in hospital for one night. A successful femoropopliteal bypass was carried out in the five patients in whom the procedure was not completed. CONCLUSION: Insertion of the dilator into the popliteal artery distal to the occlusion before carrying out the remote endarterectomy has two advantages. Firstly, the stent insertion is carried out in the correct plane and prevents dissection of the distal cut atheroma when attempting to pass the guidewire from above. Secondly, the procedure can be carried out under simple image intensification without sophisticated radiological equipment. The early results are encouraging and further evaluation of the technique is justifiable.

Arteriosclerosis↗
PubMed1998

Mortality following elective infrarenal aortic reconstruction: a Joint Vascular Research Group study.

BACKGROUND: This study aimed to define the cause of death in patients undergoing elective infrarenal aortic reconstruction. METHODS: Members of the Joint Vascular Research Group who had collected details prospectively of patients undergoing elective aortic reconstruction provided information on those who died. RESULTS: Details of 3786 patients were obtained. Some 171 patients died (133 following abdominal aortic aneurysm (AAA) and 38 after aortofemoral bifurcation graft (AFBG) for occlusive disease). The mortality rate following AAA repair was 4.8 per cent, rising to 16 per cent if repair was combined with either renal or distal reconstruction (P < 0.001). Similar results were obtained with AFBG (3.4 and 11 per cent respectively, P < 0.001). The first major complication encountered was cardiac (39.8 per cent), followed by bleeding (20.5 per cent), respiratory (13.5), and gut (5.3 per cent), or limb ischaemia (6.4 per cent). Bleeding was commoner following reconstruction for aneurysm compared with that for occlusive disease (P < 0.05). Eighty-six patients (50.3 per cent) died from the first major complication. Of the remainder, 45 (53 per cent) developed multisystem organ failure (MSOF). The most commonly involved systems were cardiac, respiratory and renal. CONCLUSION: Cardiac problems were the major cause of death following infrarenal aortic reconstruction. MSOF is the 'final common pathway' in about half of the patients who survive the initial complication.

Aged↗
PubMed1998

Survey of changes in the provision of vascular surgical services in the Oxford Region over 5 years.

AIM: This study aimed to examine changes in the provision of vascular services in the Oxford region over 5 years. METHODS: A questionnaire was sent to all general surgeons in the region asking of their involvement in vascular surgery. Data were obtained from the Department of Health concerning vascular procedures and inpatient codes for each district in the Oxford Region from 1990-1991 to 1994-1995. Office of Population Censuses and Surveys (OPCS) data for abdominal aortic aneurysm repair and femoral artery reconstruction were validated against data collected prospectively for West Berkshire. RESULTS: Eighteen of 45 surgeons who replied to the questionnaire carried out elective and emergency arterial work. All were members of the Vascular Surgical Society of Great Britain and Ireland (VSS). All but one took part in the general surgical rota. Eight surgeons carried out emergency arterial surgery only; only two of these were members of the VSS. Of 19 surgeons undertaking no arterial surgery, 15 operated on primary and 11 on recurrent varicose veins. The number of arterial reconstructions rose from 20.8 per 100000 population to 28 per 100000 throughout the study. The greatest increase occurred in districts where a new vascular consultant had been appointed. Similar results were obtained with endovascular procedures. The number of major amputations remained fairly constant at approximately 11 per 100000 population. The number of inpatient episodes for arterial disease also rose, from 35.7 to 47.6 per 100000. In validating OPCS codes against prospectively collected data, discrepancies for individual years were noted but the annual trend was reflected fairly accurately by the codes. CONCLUSION: There has been an increase in vascular activity in the region, but variations still exist between different districts.

Amputation, Surgical↗
PubMed1998

Combined fascia and mesh closure of large incisional hernias.

Large incisional hernias of the abdominal wall represent substantial defects of supportive tissues. The repair of these requires the mobilization of fascia or the use of a prosthetic mesh. A method for closing large midline incisional hernias using both the fascia and a mesh was described in 1979. This repair was used for six midline hernias and four large incisional hernias in the right subcostal region. No wound complications and no recurrences (median follow-up 1 year 5 months) were seen. The combined fascia and mesh repair can be successfully used for large incisional hernias of the anterior abdominal wall in areas other than the midline.

Fasciotomy↗
PubMed1998

Protocol violation in deep vein thrombosis prophylaxis.

This study aimed to determine how closely deep vein thrombosis (DVT) prophylactic policies are adhered to in routine general surgical practice, to identify reasons for policy violations and to assess the effects of policy modification. Eight adult patients, sixty of whom had undergone an operation, under the care of six general surgeons, each with their own written DVT protocol, were studied on one weekday. Thirty patients (50%) did not receive DVT prophylaxis according to the policy of the relevant consultant. Most violations occurred for unacceptable reasons, mainly starting low-dose subcutaneous heparin or using thromboembolic stockings postoperatively. However, 43% of protocol violations occurred for acceptable clinical reasons. Following the initial study, a uniform departmental DVT prophylaxis policy was introduced. Nursing and medical staff were thoroughly appraised of the new policy. In a repeat study of 75 patients 1 year later, there were 15 protocol violations among 58 patients who had undergone an operation (27%). However, there were no violations for acceptable reasons. The number of unacceptable protocol violations in the two studies was similar (24/60 and 17/56). The number of patients at moderate or high DVT risk who received no preoperative prophylaxis was the same in both studies (8/48 in both audits). DVT protocol violations are common in routine general surgical practice. Policy modification and unification results in fewer violations, but made little impact on the level of thromboprophylactic care.

Adolescent↗
PubMed1998

Subfascial endoscopic perforator vein surgery (SEPS): current practice among British surgeons.

Subfascial endoscopic perforator vein surgery (SEPS) has recently caused considerable interest among British surgeons. There are no data indicating which, if any, patients benefit from SEPS. A series of 47 British surgeons, identified as having taken up SEPS, were sent a questionnaire asking about their current practice; 26 were returned completed (55% response rate). Of those surgeons replying, 22 (85%) had performed their first SEPS procedure within the previous 21 months, 18 (69%) within the previous 9 months. Most surgeons had performed five procedures (range 1-52). The most common indication for SEPS was venous ulceration with proven incompetent perforators (eight surgeons), but there was a wide diversity of other indications used to select patients for SEPS. Only nine surgeons had changed their indications for surgery with the advent of SEPS, yet their predicted number of SEPS procedures was far greater than the number of open procedures they currently performed. Out of 26 surgeons, 25 intend to continue performing SEPS. Prospective studies are needed to identify which patients might benefit from this new procedure.

Attitude of Health Personnel↗
PubMed1998

Feasibility of pre-admission nurse clerking of patients with vascular disease.

A prospective study has been undertaken to determine the feasibility of nurse-led pre-admission clerking of patients with vascular disease. A total of 249 of 300 patients with planned admissions attended the clinic; 91% of patients with varicose veins, 83% of patients about to undergo endovascular procedures and 24% of patients awaiting arterial reconstruction were seen in the clinic. Patients with arterial disease were significantly more likely to rely on other people to bring them to the clinic than those with varicose veins. As a result of their age and frailty and their presenting symptoms, patients with arterial disease are less likely to benefit from a pre-admission clinic than patients with either varicose veins or general surgical disorders.

Adult↗
PubMed1997

Quality of life changes after angioplasty for claudication: medium-term results affected by comorbid conditions.

Rapid improvements in walking distance and quality of life have been identified in patients with intermittent claudication following percutaneous transluminal angioplasty, but the medium-term results are less well defined. The aim of this study was to assess quality of life and walking distance in the medium term. Walking distance was assessed before percutaneous transluminal angioplasty and at 6 weeks and 1 year after the procedure using a previously validated questionnaire. At the same time, quality of life was assessed using a EuroQol questionnaire and a visual analogue scoring system. Twenty-four patients (12 men, 12 women, mean age 65 years) underwent successful percutaneous transluminal angioplasty (five iliac, 17 femoropopliteal, two both). Significant improvements in walking distance and quality of life were demonstrated following percutaneous transluminal angioplasty. These were maintained at 1 year, although perceived health state deteriorated. During the study period, six patients developed other serious comorbidities. Development of comorbid conditions may affect the medium-term outcome of quality of life studies in patients treated for intermittent claudication. Data from such studies should therefore be interpreted with care.

Aged↗
PubMed1997

A prospective survey of patients presenting with abdominal aortic aneurysm.

OBJECTIVES: To define the presentation and management of patients presenting with abdominal aortic aneurysm (AAA) DESIGN AND SETTING: A prospective survey was carried out of all patients presenting to hospitals within the Oxford region. MATERIALS AND METHODS: Data were collected by one surgeon in each hospital. Full details were collected onto data sheets. RESULTS: One hundred and ninety patients presented, 141 electively, 46 with ruptured AAA and three with acute AAAs. In 53 patients presenting electively the aneurysm was small and surveillance started. Fifty-six patients underwent an operation, three patients died. Of 46 patients with a ruptured aneurysm 24 (52%) died. In 11 no operation was carried out and all of these patients died within 24 h. Operative mortality was 13 of 35 patients (37%). More patients with a ruptured AAA were transferred to the teaching hospital compared with a district general hospital (p < 0.05). This was reflected in a lower operative mortality in the teaching hospital. CONCLUSIONS: The presentation of AAA in this study was approximately 15 per 100,000 population. Approximately one-third of patients presenting electively had small AAAs which required surveillance. A further third underwent an operation, the remaining patients being unfit. Approximately one-quarter of patients with a ruptured aneurysm did not undergo an operation. The operative mortality was 37%.

Acute Disease↗