No abstract

Jehovah's Witnesses do not permit the use of allogeneic blood products. An increasing number of patients are refusing blood transfusion for non-religious reasons. In addition, blood stores are decreasing, and costs are increasing. Transfusion avoidance strategies are, therefore, desirable.Bloodless surgery refers to the co-ordinated peri-operative care of patients aiming to avoid blood transfusion, and improve patient outcomes. These principles are likely to gain popularity, and become standard practice for all patients.This review offers a practical approach to the surgical management of Jehovah's Witnesses, and an introduction to the principles of bloodless surgery that can be applied to the management of all patients.

Conclusion:Transfection of calcitonin gene-related peptide inhibits inflammatory mediator expression, macrophage infiltration, and neointimal hyperplasia in experimental vein graft disease.Summary: The mechanisms of intimal hyperplasia are complex, and include interactions with inflammatory cells, inflammatory mediators, and smooth muscle cells. In particular, macrophages appear necessary for the initiation of intimal hyperplasia. Calcitonin gene-related peptide (CGRP) is a biologically active amino peptide, 37 amino acids in length. Studies have shown that CGRP can inhibit inflammatory cells and expression of inflammatory mediators such as tumor necrosis factor (TNF)-␣ and NCP-1 that appear important in intimal hyperplasia (Li W, et al, Am J Cell Physiol 2006;291:C456-65). CGRP can also inhibit hyperplasia of vascular smooth muscle and protect endothelial cell function (Deng W, et al, Life Sci 2006;78:1830-8 and Ye F, et al, Vasc Pharm 2007;46:238-46). The authors sought to evaluate the effects of CGRP expressed by an adeno-associated virus vector (AAV2) gene transfer on macrophage infiltration and inflammatory mediators of vein graft disease in a rabbit model. The hypothesis was that the transfected CGRP gene could inhibit macrophage infiltration and expression of inflammatory mediators and thus suppress intimal hyperplasia.Rabbit jugular vein grafts were incubated ex vivo in a solution of adeno-associated virus vectors containing the CGRP gene (AAV2/ 1.CGRP) or Escherichia coli B-galactosidase (LacZ), or a saline solution. These grafts were then interposed in the carotid artery. CGRP gene expression was identified by a reverse transcription polymerase chain reaction (PCR) and LacZ gene expression was identified by X-gal staining. At 4 weeks, intima/media ratios were determined, and macrophages were identified with CD68 antibody immunochemistry. Inflammatory mediators were measured with real-time PCR. CGRP and LacZ gene expression were positive at 4 weeks postoperatively. The intima/media ratio was significantly inhibited in the AAV2/1.CGRP group. Also significantly inhibited in the AAV2/1.CGRP group were monocyte chemoattractant protein-1, TNF-␣, inducible nitric oxide synthase, and matrix metalloproteinase-9. Macrophage infiltration was also inhibited.Comment: The authors' experiment supported their hypothesis. The report is brief and does not delineate specific patterns of gene expression and thus does not allow precise determination of mechanism. However, the end result-very effective inhibition of intimal hyperplasia-is interesting. Vascular and cardiovascular surgeons remember the recent disappointments of the PREVENT 3 and PREVENT 4 trials, where novel therapy directed at the genetic level failed to suppress intimal hyperplasia. With respect to inhibiting intimal hyperplasia, the chiasm between promising basic bench research and clinical relevance in humans remains wide. This is interesting work, but given the history of this field, any optimism should be tempered with caution.

Both the AVVQ and SQOR-V questionnaire are sensitive and responsive disease-specific questionnaires, which correlate with generic and clinical outcomes to some extent. Anatomical and hemodynamic measurements correlated poorly with functional outcomes both preoperatively and following interventions.

and the incidence in different groups compared. RESULTSOf 935 groin explorations, EACT was identified in 25 (2.7%); there were no cases in girls. The incidence was 0.7% at inguinal herniotomy (IH), 4.1% at ligation of the patent processus vaginalis for communicating hydrocele ( P = 0.03 vs IH), and 3.3% at exploration for undescended testes ( P = 0.02 vs IH). In boys with undescended testes the incidence of EACT was similar in different age groups (0-7 years, 3.3%; 8-15 years 3.2%, P = 0.96). CONCLUSIONSThe overall incidence of EACT at groin exploration was 2.7%, with none detected in girls. There was no evidence of involution of EACT with increasing age. The incidence of EACT varied with the underlying diagnosis, but the reason for this is unknown.

Failures in patient safety are common during complex arterial procedures. Few failures were severe, although minor failures during critical stages and accumulation of multiple minor failures may potentially be important. Failures occurred especially during the endovascular phase and were often related to equipment or communication aspects. Interventions to improve procedural safety and quality of care should primarily target these specific areas.

Severe AKI is common following successful repair of rAAA. In this large case series of high-risk patients, OSR was associated with significantly higher rates of severe AKI compared with EVAR, despite the increased dose of contrast involved in EVAR and the older age of these patients. In turn, severe AKI was associated with higher mortality rates.

Only a minority of patients referred with varicose veins were aware of endovenous treatments or felt adequately informed to express a treatment preference prior to consultation. Over half of patients expressed a preference for local anaesthetic therapy and a preference for a single visit treatment, although most would be strongly influenced by the opinion of their vascular surgeon and not influenced by media advertising.