A paper for debate: Vein versus PTFE for critical limb ischaemia - an unfair comparison?

Introduction:There is a widely held view that vein grafts for infrainguinal arterial reconstruction perform much better than prosthetic conduits, the best of which seems to be PTFE. Many randomised studies have been conducted which confirm this opinion, but is the difference as large as it is thought to be? One interesting feature of published trials is that the results for obligatory PTFE (when no vein is available) were much worse than the results for randomised PTFE grafts. The only way to explain this is that these groups of patients were not similar, and there are probably other factors which contribute to the difference in results when vein and PTFE grafts are compared.Materials and Method:A consecutive series of 109 femoro-infrapopliteal grafts undertaken for critical limb ischaemia was analysed to see the difference between vein and PTFE with vein cuff grafts.Results:Vein grafts were superior to PTFE grafts when the whole cohort was included (p=0.0038); however, there was no significant difference when the patients were stratified for inflow and runoff status.Conclusions:The difference between vein and PTFE has probably been exaggerated in the past, due to differences in risk factors and in the extent of arterial disease between the two groups of patients. The advantage of vein becomes more significant with time

Q-switched neodymium-doped phosphate glass fibre lasers

The operation of a short-pulse, Q-switched, neodymium-doped fiber laser operating at 1.054µm is described experimentally and theoretically. The laser is efficiently pumped with a single-stripe AlGaAs laser diode and emits &gt;1kW pulses. It is seen that due to high gain, short pulses with high energy extraction efficiency can be obtained. The feature of broad emission lines associated with rare-earth-doped glasses is exploited to demonstrate tunable, Q-switched operation over a 40 nm tuning range. <br/

Gastric intramucosal pH predicts outcome after surgery for ruptured abdominal aortic aneurysm

Objective:The mortality associated with repair of ruptured abdominal aortic aneurysms (RAAA) remains obstinately high and many deaths result from multiple organ failure which is likely to be related to splanchnic ischaemia. The aim of this study is to investigate the importance of splanchnic ischaemia in determining outcome from RAAA by comparing gastric intramucosal pH with other methods of assessing the adequacy of splanchnic oxygenation.Design and setting:Prospective cohort of patients following surgery for RAAA admitted to the Intensive Care Unit of Guy's Hospital, London.Outcome measures:Gastric intramucosal pH (pHim) and global haemodynamic, oxygen transport and metabolic variables were measured on admission, at 12 h and at 24 h after admission. Results were compared between survivors and non-survivors and Receiver Operating Characteristic (ROC) curves were constructed to assess the ability of each measurement to predict outcome.Results:The median 24 h APACHE II was 18 and the ICU mortality 45.5%. Gastric pHim was significantly higher in survivors than non-survivors at 24 h (7.42 vs. 7.24, p < 0.01). In survivors who had a low intramucosal pH (pHim) on admission there was a significant improvement over the first 24 h (7.26 to 7.40, p < 0.05), whereas in patients who subsequently died, and had a normal pHim on admission, there was a significant fall in pHim (7.35 to 7.16, p < 0.05). ROC curves showed that gastric pHim was the most sensitive measurement for predicting outcome in these patients.Conclusions:Gastric intramucosal pH is the most reliable indicator of adequacy of tissue oxygenation in patients with RAAA, suggesting that splanchnic ischaemia may have played an important role in determining survival

A scoring system to predict the outcome of long femorodistal arterial bypass grafts to single calf or pedal vessels

Objectives:The aim of this study was to develop a scoring system to predict the outcome of long femorocrural and femoropedal bypass grafts performed for critical limb ischaemia.Setting:Teaching hospital.Methods:An analysis of 109 consecutive femorodistal bypass grafts performed for critical lower limb ischaemia between June 1991 to December 1994. Factors shown to affect the outcome were: inflow, number of patent calf vessels, graft material, straight flow to the foot and patent pedal vessels. These variables were weighted according to their relative significance (multivariate Cox regression) and a scoring system (ranging from 0 to 10) was developed.Results:Patients with a preoperative score of 0–4 (n = 35) showed a secondary patency of 36% at 1 month, 12% at 3 months and 0% at 10 months (Cum SE = 6.90/0.0). Secondary patency rates for the 46 patients with score 5–7 were 88.7% at 3 months, 56.3% at 12, and 45.1% at 2 and 3 years (Cum SE = 9.82), while the respective values for the 28 patients with score 8–10 were 92.7%, 88.5% and 81.7% (Cum SE = 8.08). The difference was highly significant (p = 0.000) in all tests of equality. In addition, the median total hospital cost was £12 600 for the group 0–4 compared with £8100 (group 5–7) and £4400 (group 8–10) (p = 0.0085).Conclusions:This preoperative scoring system appears to correlate well with the outcome of distal revascularisation to single calf or pedal vessels. If applied to patient selection, it could significantly reduce the total hospital cost per leg saved. A prospective testing of its predictive ability is needed and is in progress

Quantum dot emission from site-controlled ngan/gan micropyramid arrays

InxGa1−xN quantum dots have been fabricated by the selective growth of GaN micropyramid arrays topped with InGaN/GaN quantum wells. The spatially, spectrally, and time-resolved emission properties of these structures were measured using cathodoluminescence hyperspectral imaging and low-temperature microphotoluminescence spectroscopy. The presence of InGaN quantum dots was confirmed directly by the observation of sharp peaks in the emission spectrum at the pyramid apices. These luminescence peaks exhibit decay lifetimes of approximately 0.5 ns, with linewidths down to 650 me

Percutaneous angioplasty for infrainguinal graft-related stenoses

Objective:To assess the success of percutaneous transluminal angioplasty (PTA) in treating infrainguinal graft-related stenoses.Design:Retrospective analysis of stenoses undergoing PTA over 6 years.Materials:Fifty-seven stenoses in 42 grafts.Methods:Site, length and type of stenoses recorded. Follow-up till discharge, graft occlusion or death.Results:PTA was successful in 48/57 stenoses in 36 grafts (G), with a poor result in seven. Further PTA was required in seven stenoses (7 G). One graft occluded at PTA and one stenosis was inaccessible. Overall graft (G) patency (median 13 months) was 82% (1 year patency 84%). Of 48 successful PTAs (37 G), 36 remained patent (28 G), eight (4 G) occluded and four were lost to follow-up (4 G). Fourteen of thirty-six stenoses which remained patent required further intervention (seven PTA, six jump grafts, one vein patch). The four occlusions were associated with small veins (two), multiple stenoses (one) and a PTFE graft which occluded 10 days following PTA. Of the seven PTAs with a poor angiographic result, five remained patent, three after further intervention.Conclusion:PTA is the best treatment for localised stenoses. Stenoses >2 cm or multiple (three or more) stenoses are best treated surgically. Follow-up is essential, as 20% require further intervention

Developments towards practical free-space quantum cryptography

We describe a free space quantum cryptography system which is designed to allow continuous unattended key exchanges for periods of several days, and over ranges of a few kilometres. The system uses a four-laser faint-pulse transmission system running at a pulse rate of 10MHz to generate the required four alternative polarization states. The receiver module similarly automatically selects a measurement basis and performs polarization measurements with four avalanche photodiodes. The controlling software can implement the full key exchange including sifting, error correction, and privacy amplification required to generate a secure key

Vacuum polarization in the spacetime of charged nonlinear black hole

Building on general formulas obtained from the approximate renormalized effective action, the approximate stress-energy tensor of the quantized massive scalar field with arbitrary curvature coupling in the spacetime of charged black hole being a solution of coupled equations of nonlinear electrodynamics and general relativity is constructed and analysed. It is shown that in a few limiting cases, the analytical expressions relating obtained tensor to the general renormalized stress-energy tensor evaluated in the geometry of the Reissner-Nordstr\"{o}m black hole could be derived. A detailed numerical analysis with special emphasis put on the minimal coupling is presented and the results are compared with those obtained earlier for the conformally coupled field. Some novel features of the renormalized stress-energy tensor are discussed

Intraoperative high resolution duplex imaging during carotid endarterectomy: Which abnormalities require surgical correction?

Objectives:This study evaluates high resolution, duplex ultrasound imaging for quality control of carotid endarterectomy in order to determine which technical factors were linked to residual stenosis and to define duplex criteria for reexploration.Design, material and methods:A consecutive series of 100 patients undergoing carotid endarterectomy were evaluated. Duplex imaging was performed prior to wound closure and repeated at 6–8 weeks postoperatively. Stenoses were classified as non-significant, moderate or severe based on duplex criteria. Intimal flaps, shelves, kinks, clamp damage and fronds were identified by ultrasound imaging.Results:Five moderate stenoses were noted in the proximal endarterectomy site (PES), and at follow-up three had resolved. Adherent fronds were detected in 83% of vessels and resolved in all but three cases. At the distal endarterectomy site there were 10 severe and 12 moderate stenoses. Intimal flaps were associated with an increased incidence of residual stenosis (p = 0.010).Conclusions:We conclude that severe stenoses with an intimal flap should be corrected immediately. Further data is required to establish the significance of kinks. Residual intimal flaps in the PES appear to remodel. The role of completion duplex may lie in the modification of surgical technique to eradicate anatomical and haemodynamic imperfections