Intracranial circulation: pulse-sequence considerations in three- dimensional (volume) MR angiography

The technique and feasibility of magnetic resonance (MR) angiography of intracranial vessels were studied in 35 healthy volunteers. Variations in image orientation, repetition time (TR), and flip angle were evaluated to determine their effects on flow-related enhancement. Gradient modifications--including echo time (TE), motion compensation, bandwidth, and field of view--were also studied in an effort to reduce motion-induced phase shifts. Results indicated that a FISP (fast imaging with steady precession) sequence with a TR of 50 msec, TE of 15 msec, velocity compensation in the read and section-select directions, acceleration compensation in the read direction, anisotropic volume, and a 1.25-mm partition thickness produced three-dimensional angiographic MR images that were accurate and reproducible in the depiction of the major intracranial vessels. Difficulties with field of view, persistent signal void secondary to higher-order motion, and spatial resolution remain major problems requiring additional study.     

GS02LATERAL LAPAROSCOPIC SPLENECTOMY: THE AUCKLAND CITY HOSPITAL EXPERIENCE

Purpose To review the experience with laparoscopic splenectomy, to determine it’s efficacy for treating immune thrombocytopaenic purpura (ITP) and to highlight key technical issues with the operation. Methodology All splenectomies performed between 1992 and 2005 were identified from the Otago Surgical Audit and the clinical notes reviewed, including the laboratory records for follow‐up data related to the haematologic cases. Results There were 289 splenectomies performed over the 13 year period. The indications were trauma (111, 38%), haematologic disease (93, 32%), incidental (40, 14%) splenic malignancy (39, 13%), and other (8, 3%). Of the 68 patients with ITP, 49 (72%) had a lateral laparoscopic splenectomy (LLS) with no conversions, a 5% complication rate and one mortality. Based on platelet counts and the requirement for maintenance steroids there was a complete response in 44 (68%) patients at >6 months, a partial response in 16 (24%) and no response in 5 (8%) patients. A short video presentation will highlight the key steps for the safe and efficient performance of the LLS, including patient and port positioning, the use of ultrasonic dissection, splenic pedicle stapling, and morcellation. The indications for hand‐port assisted laparoscopic and open splenectomy will be discussed. Conclusions The LLS is the preferred approach to splenectomy for all but massive splenomegaly and can be performed safely with careful attention to key technical issues.     

Pneumatic sequential-compression boots compared with aspirin prophylaxis of deep-vein thrombosis after total knee arthroplasty

This prospective, randomized study was undertaken to compare the effectiveness of pneumatic sequential-compression boots with that of aspirin in preventing deep-vein thrombosis after total knee arthroplasty. Patients were randomly assigned to one of two prophylactic regimens: compression boots or aspirin. One hundred and nineteen patients completed the study. Seventy-two patients had unilateral arthroplasty and forty-seven, one-stage bilateral arthroplasty. In the unilateral group, the incidence of deep-vein thrombosis was 22 per cent for the patients who used compression boots compared with 47 per cent for those who received aspirin (p less than 0.03). In the bilateral group, the incidence of deep-vein thrombosis was 48 per cent for the patients who used compression boots compared with 68 per cent for those who received aspirin (p less than 0.20). The results confirm the effectiveness of compression boots in the treatment of patients who have had unilateral total knee arthroplasty. Despite the use of compression boots, however, patients who had bilateral arthroplasty were at greater risk for the development of deep-vein thrombosis.     

Survivorship of cemented knee replacements

The survivorship method of analysis has been used to compare the failure rate and overall success of 1,430 cemented primary total knee arthroplasties performed at The Hospital for Special Surgery over a 15-year period. There were 224 total condylar prostheses with a polyethylene tibia, 289 of the posterior stabilised type with an all polyethylene tibia, and 917 posterior stabilised with a metal-backed tibial component. There were 12 failures in the total condylar series, giving an average annual failure rate of 0.65% and a 15-year success rate of 90.56%. The posterior stabilised prosthesis with a polyethylene tibia showed an average annual failure rate of 0.27% and a 10-year success rate of 97.34%, and this prosthesis with a metal-backed tibial component gave an annual failure rate of 0.19% and a seven-year success rate of 98.75%. The overall survival rate was not influenced by sex or age, diagnosis or the percentage of ideal body weight. No metal-backed tibial components have yet needed revision for loosening. It seems that infection will be the major cause of failure.     

Poliomyelitis outbreak in Natal/KwaZulu, South Africa, 1987-1988. 1. Epidemiology.

An epidemic of type 1 poliomyelitis occurred in Natal/KwaZulu in the eastern part of South Africa between December 1987 and November 1988. 412 poliomyelitis cases were reported, of whom 74% were younger than 5 years. The case-fatality rate was 8%. It is suggested that massive floods, experienced in the area 2 months earlier, triggered the outbreak.     

Evaluation of specialists'' outreach clinics in general practice in England: process and acceptability to patients, specialists, and general practitioners.

OBJECTIVES: The wider study aimed to evaluate specialists' outreach clinics in relation to their costs, processes, and effectiveness, including patients' and professionals' attitudes. The data on processes and attitudes are presented here. DESIGN: Self administered questionnaires were drawn up for patients, their general practitioners (GPs) and specialists, and managers in the practice. Information was sought from hospital trusts. The study formed a pilot phase prior to a wider evaluation. SETTING: Nine outreach clinics in general practices in England, each with a hospital outpatient department as a control clinic were studied. SUBJECTS: The specialties included were ear, nose, and throat surgery; rheumatology; and gynaecology. The subjects were the patients who attended either the outreach clinics or hospital outpatients clinics during the study period, the outreach patients' GPs, the outreach patients' and outpatients' specialists, the managers in the practices, and the NHS trusts which employed the specialists. MAIN OUTCOME MEASURES: Process items included waiting lists, waiting times in clinics, number of follow up visits, investigations and procedures performed, treatment, health status, patients' and specialists' travelling times, and patients' and doctors' attitudes to, and satisfaction with, the clinic. RESULTS: There was no difference in the health status of patients in relation to the clinic site (ie, outreach and hospital outpatients' clinics) at baseline, and all but one of the specialists said there were no differences in casemix between their outreach and outpatients' clinics. Patients preferred, and were more satisfied with, care in specialists' outreach clinics in general practice, in comparison with outpatients' clinics. The outreach clinics were rated as more convenient than outpatients' clinics in relation to journey times; those outreach patients in work lost less time away from work than outpatients' clinic patients due to the clinic attendance. Length of time on the waiting list was significantly reduced for gynaecology patients; waiting times in clinics were lower for outreach patients than outpatients across all specialties. In addition, outreach patients were more likely to be first rather than follow up attenders; rheumatology outreach patients were more likely than hospital outpatients to receive therapy. GPs' referrals to hospital outpatients' clinics were greatly reduced by the availability of outreach clinics. Both specialists and GPs saw the main advantages of outreach clinics in relation to the greater convenience and better access to care for patients. Few of the specialists and GPs in the outreach practices held formal training and education sessions in the outreach clinic, although over half of the GPs felt that their skills/expertise had broadened as a result of the outreach clinic. CONCLUSIONS: The processes of care (waiting times, patient satisfaction, convenience to patients, follow up attendances) were better in outreach than in outpatients' clinics. However, waiting lists were only significantly reduced for gynaecology patients, despite both GPs and consultants reporting reduced waiting lists for patients as one of the main advantages of outreach. Whether these improvements merit the increased cost to the specialists (in terms of their increased travelling times and time spent away from their hospital base) and whether the development of what is, in effect, two standards of care between practices with and without outreach can be stemmed and the standard of care raised in all practices (eg, by sharing outreach clinics between GPs in an area) remain the subject of debate. As the data were based on the pilot study, the results should be viewed with some caution, although statistical power was adequate for comparisons of sites if not specialties.