Deep vein thrombosis and pulmonary embolus associated with a ruptured popliteal aneurysm – a cautionary note

Popliteal artery aneurysms representing 80% of peripheral artery aneurysms rarely rupture (a reported incidence of 0.1–2.8 %) and second commonest in frequency after aorto-iliac aneurysms. They usually present with pain, swelling, occlusion or distal embolisation and can cause diagnostic difficulties. We report a 78 year old man who was previously admitted to hospital with a pulmonary embolus secondary to deep venous thrombosis. He was heparinized then warfarinised and was readmitted with a ruptured popliteal aneurysm leading to a large pseudo aneurysm formation. The pulmonary embolus had been due to popliteal vein thrombosis and propagation of the clot. A thorough review of literature identified only one previously reported case of ruptured popliteal artery aneurysm and subsequent large pseudo aneurysm formation. We feel it is important to exclude a popliteal aneurysm in a patient with DVT. This may be more common than the published literature suggests.     

Decision analysis model of incisional hernia after open abdominal surgery

Background The incidence rate of incisional hernias after open surgery has been reported to be higher than that of port site hernias after laparoscopic surgery. No studies have compared the costs for the health care system in treating those two types of hernia. Methods A systematic review was conducted to obtain the baseline data, and a decision analysis model was created to simulate the occurrence and recurrence of incisional and port site hernias. Results The overall risk of having incisional hernias was eight-times higher than that of having port site hernias (7.4% vs 0.9%). A cost savings of ￡93 per patient can be generated for the health care system in the UK. Similar results were obtained for Germany, Italy and France. Conclusions The additional treatment costs for incisional hernia should be taken into account when the costs of a surgery performed by open approach are compared with by laparoscopy.     

Short-term patient-reported outcomes after different exercise-based cardiac rehabilitation programmes.

BACKGROUND: An objective of exercise-based cardiac rehabilitation is improvement in patient-reported outcomes such as health-related quality of life as well as anxiety and depressive symptoms. There are no direct comparisons of the effectiveness of inpatient and outpatient exercise-based cardiac rehabilitation programmes on patient-reported outcomes. METHODS: In this non-randomized study we collected patient-reported outcomes data with the MacNew Heart Disease health-related quality of life questionnaire and the Hospital Anxiety and Depression Scale at baseline, 1 month and again 3 months after admission to exercise-based cardiac rehabilitation in a cohort of 216 consecutive patients enrolled either in a 4-week inpatient exercise-based cardiac rehabilitation (n=62) or a 3-month outpatient exercise-based cardiac rehabilitation (n=87) and in a usual care group (n=67) to document the natural course in patient-reported outcome variables without exercise-based cardiac rehabilitation. RESULTS: Although MacNew health-related quality of life scores improved more with inpatient than outpatient exercise-based cardiac rehabilitation by month 1, the improvement was still significant in both groups at month 3 and also in the usual care group when compared to baseline. The health-related quality of life scores in the inpatient group, however, decreased between month 1 and 3 whereas they continued to improve in the outpatient group. The significant reduction in both anxiety and depressive symptoms in both exercise-based cardiac rehabilitation groups by month 1 was maintained at month 3 only with outpatient exercise-based cardiac rehabilitation. No significant changes over the 3 months were observed in the usual care group. CONCLUSION: Significant improvements of 1-month patient-reported outcomes are achieved in patients attending inpatient as well as outpatient exercise-based cardiac rehabilitation when compared with no exercise-based cardiac rehabilitation. In contrast to inpatient exercise-based cardiac rehabilitation, however, outpatient exercise-based cardiac rehabilitation leads to a further improvement of patient-reported outcomes. These results suggest that, if patients have to be admitted for inpatient exercise-based cardiac rehabilitation, this programme should be followed by an outpatient exercise-based cardiac rehabilitation to further improve and stabilize these patient-reported outcome variables.     

BS15PFACILITATING NATIONAL CONSISTENCY IN BREAST CANCER DATA COLLECTION

In Australia there is currently no consistent approach to collecting breast cancer specific data. The National Health Data Dictionary (NHDD) recommends a core set of generic data items for clinical cancer registration. However this list does not include the more detailed items required by specific tumour streams. The NBCC has developed a supplementary set of Breast Specific Data Items and definitions to serve as a guide for specialist breast cancer data collection in Australia. A multidisciplinary Working Group comprising clinical and consumer representation, including three breast surgeons, identified 16 breast specific data items for collection. The items are designed to align with items collected through the RACS National Breast Cancer Audit and leading cancer centres. A range of items from patient data (menopausal status), diagnostic data (HER2 status, sentinel lymph node), treatment (surgical margin clearance and involvement), and breast reconstruction are included. The data items are recommended as best practice for breast cancer specific data collection and aim to facilitate national consistency in defining, recording, and monitoring information about patients with breast cancer. This national approach will contribute to improved patient outcomes by informing planning, quality improvement and evaluation strategies for cancer services. The items are currently being piloted in two sites in NSW and will be available nationally in late 2007.     

Exercise training for claudication.

Exercise advice is a well established component of the conservative management of intermittent claudication. Supervised programmes of exercise remain relatively uncommon and are provided mainly in secondary care. This review outlines the evidence for the effectiveness of different exercise regimens and the relative benefits of exercise therapy, where comparisons have been made with medical therapy, angioplasty and surgery.     

Implantatwahl bei trochanteren Femurfrakturen

Intramedullary implants have decisive advantages in the treatment of femoral fractures in the vicinity of the hip joint: a torque that leads to a less pronounced varus position, implantation in the course of the relevant forces, and primary stability in the case of both stable and unstable fractures. Because of the constant developments in the implants available and the frequent failure to differentiate between stable and unstable fractures, some of the recommendations in the literature seem to contradict each other. However, precise analysis of the literature data show that stable fractures can be adequately treated with any technique, while unstable fractures fall in the domain of nailing systems. Since it is not possible to distinguish unequivocally between stable and unstable fractures, all trochanteric and subtrochanteric femoral fractures should be treated with a cephalomedullary nailing system.     

Nontransplantation of Livers from Deceased Donors Who Are Able to Donate Another Solid Organ: How Often and Why It Happens

Deceased donor factors associated with poor graft outcome are well known, but how often these factors lead to livers left untransplanted is poorly defined. A nested, case-control study was conducted using the United Network for Organ Sharing (UNOS) database from 1987 to 2005. Only those donating >/=1 solid organ were included. Primary outcome was livers not transplanted (LNT, cases) versus transplanted (LT, controls). Primary variables for multivariate analysis were donor age and obesity. Covariates included donation after cardiac death (DCD), cerebral vascular accident death, viral serologies, cancer, ALT and bilirubin. There were 23 373 (26%) LNT's from 91 362 donors who donated at least one organ. Percent LNT fell over time (1987-1990: 48%; 1991-1995: 29%; 1996-2000: 21%; 2000-2005: 16%; p < 0.01). Increased age (odds ratio: 4.2, 95% confidence interval 3.6-4.9, p < 0.01) and obesity (2.1, 1.9-2.3, p < 0.01) were significantly associated with LNT across all time periods. Other significant factors included DCD and elevated ALT. For 2001-2005, population attributable risk indicate that age >40, abnormal ALT and obesity account for 32.6%, 25.3% and 9.2% of untransplanted livers, respectively. Use of expanded criteria livers has pushed LNT lower in spite of an aging and heavier donor population. Nevertheless, age and obesity still account for a significant portion of untransplanted livers.