Treatment of infrarenal aortic stenosis by stent placement: a 6-year experience

There is a significant re-stenosis rate with percutaneous treatment of stenoses of the infrarenal abdominal aorta with balloon angioplasty. Since 1990 the authors have primarily treated local infrarenal aortic stenoses with metallic endoluminal stents. The authors' experience with 12 consecutive patients (nine women and three men, aged from 30 to 72 years (mean age = 57 years)) is presented. Follow-up is available in 11 cases over 7-78 months (mean 32 months). The procedure was technically successful in all patients. Of the 11 patients with follow-up available, claudication was cured (n = 7) or significantly improved (n = 4). Those with persisting claudication had concurrent distal arterial disease. Periprocedural complications occurred in five cases, with two significant complications. One case required iliac angioplasty for embolized aortic atherosclerotic plaque, and one case required surgical thrombectomy and vein patch for iliac thrombosis complicating iliac dissection, without long-term sequelae in either case. One patient has had recurrent symptomatic aortic stenosis occurring 6 years after initial stenting, which responded to further stent insertion. Primary patency of 91% and secondary assisted patency of 100% has been achieved. Primary treatment of infrarenal aortic stenosis with endoluminal stenting results in high patency rates, with low morbidity and relatively low complication rates.     

Radiation exposure of the families of outpatients treated with radioiodine (iodine-131) for hyperthyroidism.

Patients who receive radioiodine (iodine-131) treatment for hyperthyroidism (195-800 MBq) emit radiation and represent a potential hazard to other individuals. Critical groups amongst the public are fellow travellers on the patient's journey home from hospital and members of the patient's family, particularly young children. The dose which members of the public are allowed to receive as a result of a patient's treatment has been reduced in Europe following recently revised recommendations from ICRP. The annual public dose limit is 1 mSv, though adult members of the patient's family are allowed to receive higher doses, with the proviso that a limit of 5 mSv should not be exceeded over 5 years. Unless the doses received during out-patient administration of radioiodine can be demonstrated to comply with these new limits, hospitalisation of patients will be necessary. The radiation doses received by family members (35 adults and 87 children) of patients treated with radioiodine at five UK hospitals were measured using thermoluminescent dosimeters mounted in wrist bands. Families were given advice (according to current practice) from their treatment centre about limiting close contact with the patient for a period of time after treatment. Doses measured over 3-6 weeks were adjusted to give an estimate of values which might have been expected if the dosimeters had been worn indefinitely. Thirty-five passengers accompanying patients home after treatment also recorded the dose received during the journey using electronic (digital) personal dosimeters. For the "adjusted" doses to infinity, 97% of adults complied with a 5-mSv dose limit (range:0.2-5.8 mSv) and 89% of children with a 1-mSv limit (range: 0.2-7.2 mSv). However 6 of 17 children aged 3 years or less had an adjusted dose which exceeded this 1 mSv limit. The dose received by adults during travel was small in comparison with the total dose received. The median travel dose was 0.03 mSv for 1 h travel (range: 2 microSv-0.52 mSv for 1 h of travel time). These data suggest that hyperthyroid patients can continue to be treated with radioiodine on an out-patient basis, if given appropriate radiation protection advice. However, particular consideration needs to be given to children aged 3 years or younger. Admission to hospital is not warranted on radiation protection grounds.     

A survey of the current clinical practice of psychiatrists and accident and emergency specialists in the United Kingdom concerning vitamin supplementation for chronic alcohol misusers

Although it is well known that B-vitamin deficiencies directly affecting the brain are common in alcohol misuse, no concise guidelines on the use of vitamin supplements in alcohol misusers currently exist in the UK. The purpose of this study was to assess current practice and opinion among UK physicians. Questionnaires were completed by a total of 427 physicians comprising Accident and Emergency (A&E) specialists and psychiatrists, with a response rate of 25%. The main findings were that vitamin deficiency was perceived as being uncommon amongst alcohol misusers (<25%) and there was no consensus as to which B vitamins are beneficial in treatment or the best method of administration of B-vitamin supplementation. The majority of psychiatrists favoured oral administration for prophylaxis against the Wernicke-Korsakoff syndrome in chronic alcohol misusers and parenteral therapy in patients with signs of Wernicke-Korsakoff syndrome. Whilst only just over half the A&E specialists expressed a preference, most favoured parenteral therapy in both cases. Most respondents did not currently have a unit policy/protocol on the management of vitamin supplementation in chronic alcohol misusers. Overall, the findings suggest that there is wide variation in current practice and highlight the need for guidelines in this area.     

Models of commissioning health services in the British National Health Service: a literature review.

The commissioning of health services is an under-researched area and yet it is critical to the way services meet health needs and to the quality of care. Recent emphasis in the United Kingdom and elsewhere has been on a 'primary care led National Health Service', particularly on locality commissioning through primary care groups. However, there are other models of commissioning using 'programmes of care' (focused on diseases or patient groups rather than geography) which may offer greater benefits. There is little research comparing the benefits and costs of these models, and most are not even clearly enough described to be replicated. There will always be a political dimension to models of commissioning, dependent, for example, on the balance of power in the decision-making process. None the less, a broader knowledge of possible models and a willingness to evaluate rigorously are needed if commissioning of health services is to result in better patient care.     

Antibiotic resistance in nosocomial isolates in Scotland

In this first multi-centre study in Scotland, 1028 consecutive Gram-negative and staphylococci strains were obtained from four major teaching hospitals. E. coli was the most common organism among both intensive care units (ICUs) (39%) and non-ICU strains (46.6%). The prevalence of antibiotic resistance among E. coli was always higher in isolates from ICUs than non-ICUs: ceftazidime (14.1%, 7.2%), ceftriaxone (12.7%, 6.1%), cefotaxime (15.5%, 8.7%), cefuroxime (28.8%, 20.8%), amoxicillin plus clavulanic acid (52.2%, 38.8%) and gentamicin (7.0%, 2.8%). The highest incidences of resistance were identified among Enterobacter/Citrobacter spp. from ICUs; 43.8%, 41.7%, 45.8%, 54.2%, 87.5% and 10.4% of these organisms were resistant to ceftazidime, ceftriaxone, cefotaxime, cefuroxime, amoxicillin plus clavulanic acid and gentamicin, respectively.