Total posterior approach for femoropopliteal bypass

Standard approaches to the femoral and popliteal arteries are used in most extremity arterial reconstructions. In unusual circumstances, such as infection, reoperation, or variant anatomy, novel approaches to infrainguinal bypass may be useful, particularly in reoperative or infected cases. One such approach involves exposure of the femoral and popliteal arteries through posterolateral incisions with the patient prone. The major advantage of this exposure is the increased accessibility to the distal above-knee popliteal artery, which is not easily reached through either medial or lateral incisions. This approach also can be useful in cases of significant groin sepsis. The details of this exposure and its application in an illustrative case are presented.     

Don't lose sight of the importance of the individual in effective falls prevention interventions

Falls remain a major public health problem, despite strong growth in the research evidence of effective single and multifactorial interventions, particularly in the community setting. A number of aspects of falls prevention require individual tailoring, despite limitations being reported regarding some of these, including questions being raised regarding the role of falls risk screening and falls risk assessment. Being able to personalise an individual's specific risk and risk factors, increase their understanding of what interventions are likely to be effective, and exploring options of choice and preference, can all impact upon whether or not an individual undertakes and sustains participation in one or more recommendations, which will ultimately influence outcomes. On all of these fronts, the individual patient receiving appropriate and targeted interventions that are meaningful, feasible and that they are motivated to implement, remains central to effective translation of falls prevention research evidence into practice.     

Nicotine and cotinine stimulate secretion of basic fibroblast growth factor and affect expression of matrix metalloproteinases in cultured human smooth muscle cells

Purpose: We have recently shown that nicotine and its metabolite cotinine are mitogenic for smooth muscle cells in vitro. In the present study, we examined the effect of nicotine and cotinine on the production of growth factors and the expression of matrix metalloproteinases in smooth muscle cells.Methods: Smooth muscle cells were harvested from human arteries and grown in culture. Subconfluent cultures were incubated for 24 hours in M199 containing 0.1% fetal bovine serum with or without nicotine or cotinine at concentrations ranging from 10^-9mol/L to 10^-6mol/L. The supernatants and cell lysates were assayed by enzyme-linked immunosorbent assay for basic fibroblast growth factor (bFGF), tumor necrosis factor alpha (TNF-α), platelet-derived growth factor AB (PDGF-AB), and transforming growth factor beta (TGF-β). Matrix metalloproteinase expression was determined in subconfluent cultures incubated in albumin with or without nicotine or cotinine at 10^-8mol/L and 10^-7mol/L for 6, 12, 18, 24 and 36 hours. Northern blot analyses were performed with human cDNA probes for collagenase-1, stromelysin-1, gelatinase A, gelatinase B, and triose phosphate isomerase. Blots were quantified by phosphor-imaging techniques.Results: Both nicotine and cotinine stimulated the production and secretion of bFGF in a dose-dependent manner. PDGF, TNF-α, and TGF-β secretions were not significantly affected by nicotine or cotinine. Collagenase was up-regulated by nicotine at 18 and 24 hours (4.5-fold to 5.8-fold) and by cotinine at 18 hours (from 5.0-fold to 29-fold). Stromelysin-1 was up-regulated by nicotine and cotinine at 12 and 18 hours (1.5-fold to 7.0-fold). Gelatinase A generally peaked at 12 hours and was up-regulated by both agents (2.0-fold to 6.5-fold).Conclusion: Nicotine and cotinine enhanced the production of bFGF, a major mitogen for smooth muscle cells, and up-regulated the expression of several matrix metalloproteinases that are critical in cell migration. These data demonstrate mechanisms by which smoking may contribute to the development of intimal hyperplasia, atherosclerosis, and aneurysms. (J Vasc Surg 1996;24;927-35.)     

Observations on cerebral computed tomography in patients having carotid endarterectomy

A review was undertaken of all patients seen in our institution between January 1978 and March 1987 in whom a cerebral CT scan was obtained in association with elective carotid endarterectomy. Three hundred fifty-nine such patients were identified. In a subgroup of 89 patients who were neurologically normal after carotid endarterectomy, scans were performed at least 48 hours after surgery to quantitate the incidence of silent postoperative infarction. These scans were interpreted by one neuroradiologist. Preoperative cerebral CT scans showed ipsilateral infarction in 146 of 359 patients (40.6%). Ipsilateral infarction was most common in patients with stroke (76%) but was also seen in 32.8% of patients with transient ischemic attacks, in 9 of 40 patients (22.5%) with nonhemispheric symptoms, and in 9 of 45 patients (20%) with asymptomatic hemodynamically significant carotid stenosis. The postoperative stroke rate was not significantly increased by the presence of infarct on preoperative cerebral CT scan (2.6% vs 1.9%). New infarcts were seen on cerebral CT scanning after carotid endarterectomy in 2 of 89 patients with no detectable neurologic abnormality (2.3%). This study demonstrates a high frequency of ipsilateral infarction in patients having elective carotid endarterectomy, even in those patients with clinical symptom complexes thought by many physicians to be relatively benign (i.e., transient cerebral ischemia, nonhemispheric ischemia, and asymptomatic carotid stenoses).(ABSTRACT TRUNCATED AT 250 WORDS)