A new vision for day surgery.

The premise that underlines this article (based on a presentation delivered at AfPP's Annual Congress in October 2006) is that all elective surgery performed in this country should be day surgery. This should eventually include patients undergoing hip replacements, radical prostatectomies, aortic aneurysm repair and hepatectomies, to name a few. All of these procedures we should perform, safely and well, under the British definition of day surgery as 'going home at the end of the day'.

L-arginine and S-nitrosoglutathione reduce embolization in humans.

Background: L-Arginine reduces platelet aggregation and adhesion in ex vivo studies, but there is no evidence as yet that it has a therapeutic effect on clinical end points. Doppler ultrasound can detect cerebral emboli noninvasively. Such embolic signals are common after carotid endarterectomy, and their frequency predicts risk of stroke recurrence.

Detection of distal emboli in patients with peripheral arterial stenosis before and after iliac angioplasty: a prospective study.

Purpose: Embolism is believed to be the major cause of end-organ damage after angioplasty and endoluminal procedures. Recently, Doppler ultrasound scanning has been used to detect asymptomatic cerebral emboli. We determined whether asymptomatic embolic signals (ES) could be detected distal to a significant iliac artery stenosis of >60% both before and soon after iliac percutaneous transluminal angioplasty (PTA).

S-nitrosoglutathione reduces the rate of embolization in humans.

Background: Antiplatelet agents presently used in the secondary prevention of cardiovascular disease fail to prevent the majority of cases of recurrent stroke and systemic embolization. An evaluation of the efficacy of new agents is hampered by a lack of in vivo models in humans. Asymptomatic cerebral embolic signals (ES) may be detected with the use of transcranial Doppler ultrasonography.

Undergraduate teaching in a day surgery unit: a 2-year evaluation.

Medical schools are having to adapt their teaching in response to the reduction in inpatient availability and the increase in outpatient and community care. A surgical course for first clinical-year undergraduate medical students was established in the day surgery unit at King's College School of Medicine and Dentistry in 1995. It was considered desirable because of the shift to day-case surgery, and proved feasible to run (Seabrook et al.

Technical report: Combined carotid bifurcation endarterectomy and intra-operative transluminal angioplasty of a proximal common carotid artery stenosis: an alternative to extrathoracic bypass.

A method of management of a dual stenoses affecting the proximal common carotid artery and the internal carotid artery, the tandem lesion, is described in two cases. The combination of a surgical endarterectomy of the internal carotid artery narrowing and percutaneous balloon dilatation of the more proximal common carotid artery narrowing, via the arteriotomy site, with clamping of the internal carotid artery was successfully employed to avoid an extrathoracic bypass procedure.

Teaching and learning in day surgery units: a UK survey.

Recent increases in day case surgery offer new opportunities for medical student learning, whilst the reduction in surgical beds and length of hospital stays has reduced opportunities in traditional inpatient settings. To establish the extent and nature of undergraduate medical education in day surgery units in the UK, the authors undertook a postal questionnaire survey. Of the 227 units which replied, 45% are used for teaching.

Basic fibroblast growth factor upregulates the expression of vascular endothelial growth factor in vascular smooth muscle cells. Synergistic interaction with hypoxia.

Background: Vascular endothelial growth factor (VEGF) is a hypoxia-inducible direct angiogenic factor. Upregulation of VEGF is thought to mediate many of the angiogenic effects of growth factors that are not direct endothelial cell mitogens. Like VEGF, basic fibroblast growth factor (bFGF) is considered to induce angiogenesis by a direct effect on endothelial cells.

Response of digital arteries to endothelium dependent and independent vasodilators in patients with Raynaud's phenomenon.

The cause of the digital artery spasm seen in Raynaud's phenomenon (RP) is unclear. A dysfunction of endothelium-dependent vasodilation might contribute to the development of this spasm. We studied the digital artery responses to endothelium-dependent and independent vasodilators in eight Raynaud's phenomenon patients and eight sex-matched controls.

The influence of the adventitia on the presence of smooth muscle cells and macrophages in the arterial intima.

Objective: To test the hypothesis that atherosclerosis may be initiated by hypoperfusion or thrombotic occlusion of the adventitial vasa vasonum.

Design: In a new model of atherogenesis, an early atherosclerotic lesion may be initiated by removal of the adventitia from the carotid artery of the New Zealand White rabbit, wherein lie the vasa vasorum.

Setting: Animal laboratory, University Department of Surgery and Medicine.

Hypoxia and platelet-derived growth factor-BB synergistically upregulate the expression of vascular endothelial growth factor in vascular smooth muscle cells.

Vascular endothelial growth factor (VEGF) mRNA expression was analysed in rabbit vascular smooth muscle cells following exposure to hypoxia and platelet-derived growth factor-BB (PDGF-BB). Hypoxia potently upregulated VEGF mRNA steady-state levels in a time- and concentration-dependent manner reaching a maximum level (approximately 30-fold increase) after 12-24 h at 0% 0(2). In contrast, PDGF-BB caused a modest increase in VEGF expression.

False aneurysm of the carotid artery.

Vascular injury following penetrating neck trauma may be present despite a lack of clinical signs. Management of wounds deep to platysma should include a high level of suspicion and thorough investigation to exclude these 'silent' vascular injuries. This may prevent serious late complications.

Raynaud's phenomenon and cold stress testing: a new approach.

There are a number of methods of evaluating digital blood flow in the vascular laboratory but none fulfills the criteria of providing a quick and reproducible diagnostic test for Raynaud's phenomenon. We present our experience with the use of high frequency ultrasound to provide direct real time imaging of the digital arteries. Using this method and a standardised cold challenge test, consisting of exposure of the hand to a temperature of 10 degrees C for 5 minutes, it is possible to distinguish patients with Raynaud's phenomenon from normal controls on the basis of extent of digital artery closure.

The adventitia and atherogenesis: removal initiates intimal proliferation in the rabbit which regresses on generation of a 'neoadventitia'.

Removal of the carotid artery adventitia from rabbits induced the formation of an intimal hyperplastic lesion. In rabbits fed a normal diet, the lesion (measured as the intimal:medial ratio) was maximal by day 14 (0.456 +/- 0.

Arterial intimal hyperplasia after occlusion of the adventitial vasa vasorum in the pig.

Oxygenation of the arterial wall is provided by diffusion of oxygen outward from the main vessel lumen and inward from the adventitial vasa vasorum. In a group of four Yucatan miniature pigs the oxygenation profiles across the superficial femoral arteries were recorded by polarographic oxygen microelectrodes. The profiles obtained suggested a relatively poorly oxygenated media (a trough value of approximately 25% that of the intimal oxygenation) with a progressive rise in oxygenation toward the intimal and adventitial surfaces.

The vasa vasorum of the rabbit carotid artery.

The anatomy of the vasa vasorum of the carotid arteries was assessed by light and electron microscopy in a series of 25 New Zealand White male rabbits. The low viscosity acrylic resin, LR White, was used to cast the microvasculature. The carotid artery was found to have an endothelial monolayer placed directly upon a broad fenestrated internal elastic lamina.

Quantitative studies of transfer in vivo of low density, Sf 12-60, and Sf 60-400 lipoproteins between plasma and arterial intima in humans.

To assess the potential of various plasma lipoprotein classes to contribute to the lipid content of the arterial intima, influx and efflux of these plasma lipoprotein fractions into and from the intima of human carotid arteries were measured in vivo. While low density lipoprotein (LDL) is known to transfer from plasma into the arterial wall, there is less information on the atherogenic potential of lipoproteins of intermediate density (Sf 12-60) or of very low density (Sf 60-400). Aliquots of the same lipoprotein (LDL, Sf 12-60 lipoprotein particles, or Sf 60-400 lipoprotein particles) iodinated with iodine-125 and iodine-131 were injected intravenously 18-29 hours and 3-6 hours, respectively, before elective surgical removal of atheromatous arterial tissue, and the intimal clearance of lipoproteins, lipoprotein influx, and fractional loss of newly entered lipoproteins were calculated.

Digital artery calibre measurement--a new technique of assessing Raynaud's phenomenon.

This study evaluated the use of a high frequency A-mode ultrasound scanner (CUTECH DM70) for monitoring the digital artery vasospasm of Raynaud's Phenomenon (RP). The technique was evaluated on 12 RP patients and 12 age and sex matched controls. The diameter of a single digital artery was measured in these subjects over a range of finger temperatures between 14-35 degrees C.

Falsely raised ankle/brachial pressure index: a method to determine tibial artery compressibility.

The ankle/brachial index (abPI) may be falsely raised, notably in diabetes, due to the relative incompressibility of the tibial artery. This paper presents a method of determining tibial artery compressibility by deriving abPIs with the patient supine and with legs raised in increments up to 0.55 m (ankle to heart).

Ultrasound imaging of digital arteries.

This study assessed the use of high frequency ultrasound (CUTECH DM70) in the measurement of digital artery diameters. The accuracy of the technique was assessed using a model. Four silicone tubes of different diameters were embedded in opaque agar.

Modified plasma-derived lipoproteins in human atherosclerotic plaques.

Low density lipoproteins extracted from surgical specimens of human atherosclerotic plaques (A-LDL) showed altered electrophoretic mobility indicating a greater negative charge than that of plasma LDL (P-LDL). A-LDL but not P-LDL showed high affinity binding/degradation by human monocyte-derived macrophages; this was inhibited by acetylated LDL but not by native P-LDL. Following injection of 125I-labelled autologous P-LDL prior to reconstructive arterial surgery, polyacrylamide and agarose gel electrophoresis of A-LDL extracted from arterial intima showed that the A-LDL and its apolipoprotein B moiety were derived from P-LDL; the electrophoretic mobility of the product A-LDL was greater than that of native P-LDL.

[Thromboembolic disease and congenital venous abnormalities].

A pulmonary embolus and a bilateral thrombosis of the internal carotid artery caused the sudden death of two young adults with a congenital venous abnormality. The study of 49 patients suffering from a Klippel-Trenaunay syndrome showed that 11 out of 49 patients, or 22.5 p.

A method for quantifying lipoprotein flux rates between plasma and arterial intima in vivo.

A new method is proposed for measuring in vivo the rates of transfer of plasma lipoprotein into and out of arterial intima in man. The technique requires the injection of a lipoprotein which can be labelled with two different tracers, followed by a single arterial sample during elective surgery. The feasibility of the method was tested by computer simulation and it was found that measurement uncertainties of the order of those likely in practice produced uncertainties of 7% SD in the calculated influx and 16% SD in the calculated efflux rates.

Peri-aortic fibrosis: progression and regression.

The natural history and aetiology of peri-aortic fibrosis is unknown. In one of our patients in whom steroid treatment had successfully controlled the progression of the disease' cessation of treatment was associated with recurrence of the fibrosis, progressive ureteric obstruction and dilatation of the aorta. In another patient, graft replacement of the aorta was associated with regression of the fibrosis but in a third patient replacement of the aorta did not prevent progression to complete ureteric obstruction.