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BACKGROUND The benefits of best medical therapy (BMT) for secondary prevention of cardiovascular events in patients with peripheral arterial disease are well established. Guidelines recommend prescription of BMT should consist of anti-platelet, statins and angiotensin-converting enzyme inhibitor or angiotensin receptor blocking therapy, with evidence this regimen reduces cardiovascular mortality following vascular surgery and improves vascular bypass graft patency. This multicentre study examines the BMT prescription on discharge after infrainguinal bypass (IIB) in Australia and New Zealand (ANZ). Primary outcome measure was discharge prescription of three BMT pharmacological agents, defined for study purposes as an anti-platelet/anti-coagulant, a lipid-lowering agent, and an anti-hypertensive medication if hypertension was diagnosed. METHODS This study retrospectively examined discharge prescriptions and summaries of all patients discharged following IIB in five ANZ hospitals, between January 2015 and April 2018. RESULTS A total of 688 admissions for IIB were included (76.9% male; mean age 67.8 ± 12.0). A total of 72.4% of procedures were for chronic limb ischaemia, compared to acute limb ischaemia (12.6%), and aneurysmal disease (15%). The primary outcome of adherence with complete BMT prescription occurred in 66.9% of admissions. Anti-thrombotic agents were most frequently prescribed (96.4%), followed by anti-lipidaemic agents (82.1%). Of the patients with documented hypertension, 43.8% were not prescribed an angiotensin-converting enzyme inhibitor/angiotensin receptor blocking, while 19.2% were discharged without any anti-hypertensive medications. CONCLUSION Almost one third of patients were not prescribed complete BMT following IIB. There is potential to improve the outcomes after IIB in ANZ through a focus on risk-factor control and BMT prescription.

The formation of an ilio-iliac arteriovenous fistula is a potentially lethal complication of common iliac artery aneurysm presentations. Whilst trauma predominantly accounts for the majority, spontaneous rupture of a common iliac artery aneurysm into an adjacent venous structure accounts for a small subset of patients. Urgent surgical intervention is warranted with the aim to restore arterial continuity and ideally, closure of the fistula. This case study describes the endovascular management of a spontaneous ilio-iliac arteriovenous fistula following rupture of a common iliac artery aneurysm into an adjacent vein.

Venous aneurysms are a rare vascular anomaly characterized by a solitary area of dilatation containing all three layers of the venous vessel wall. Described throughout the venous system, venous aneurysms can be classified as deep or superficial based on the vein involved. Although generally asymptomatic, superficial venous aneurysms can be associated with venous insufficiency or venous thromboembolism and are often confused for soft tissue masses or hernias. In young adults, venous aneurysms are often associated with Klippel-Trenaunay syndrome. In this report, we present a case of a primary superficial venous aneurysm in a patient with Klippel-Trenaunay syndrome mimicking a femoral hernia.

Fecal incontinence is a chronic and debilitating condition with significant health burden. Despite its clinical relevance, the prevalence of fecal incontinence remains inconsistently described.This study aimed to systematically review the literature regarding the prevalence of and factors associated with fecal incontinence among community-dwelling adults.A search of the PubMed, Embase, and Cochrane databases was performed.Studies that reported the prevalence of fecal incontinence and/or associated factors in a community-based (ie, unselected) adult population were included. Two independent assessors reviewed eligible articles.Relevant data were extracted from each study and presented in descriptive form. The main outcome measures included the prevalence of fecal incontinence (adjusted and/or unadjusted), stratified for age and sex if reported; factors associated (and not associated) with fecal incontinence; and study quality, assessed using predefined criteria.Of 3523 citations identified, 38 studies were included for review. The reported median prevalence of fecal incontinence was 7.7% (range, 2.0%-20.7%). Fecal incontinence equally affected both men (median, 8.1%; range, 2.3%-16.1%) and women (median, 8.9%; range, 2.0%-20.7%) and increased with age (15-34 years, 5.7%;90 years, 15.9%). The study populations and diagnostic criteria used were heterogeneous, precluding any meaningful pooling of prevalence estimates. Study quality assessment revealed 6 high-quality studies, of which only 3 were performed in a representative sample. The median prevalence of fecal incontinence was higher in these studies at 11.2% (range, 8.3%-13.2%). The factors most commonly reported to be associated with fecal incontinence included increasing age, diarrhea, and urinary incontinence.Heterogeneity of studies precluded meaningful pooling or meta-analysis of data.Fecal incontinence is a prevalent condition of equal sex distribution, affecting ≈1 in 8 community adults, and has identifiable associated factors. The paucity of high-quality prevalence studies emphasizes the need for future population-based studies that use standardized diagnostic criteria for fecal incontinence.

Background Sacral neuromodulation (SNM) has emerged as a treatment option for faecal incontinence (FI). However, its objective effect on symptoms and anorectal function is inconsistently described. This study aimed to systematically review the impact of SNM on clinical symptoms and gastrointestinal physiology in patients with FI, including factors that may predict treatment outcome. Methods An electronic search of MEDLINE (1946–2014)/EMBASE database was performed in accordance with PRISMA guidelines. Articles that reported the relevant outcome measures following SNM were included. Clinical outcomes evaluated included: frequency of FI episodes, FI severity score and success rates. Its impact on anorectal and gastrointestinal physiology was also evaluated. Results Of 554 citations identified, data were extracted from 81 eligible studies. Meta-analysis of the data was precluded due to lack of a comparison group in most studies. After permanent SNM, ‘perfect’ continence was noted in 13–88% of patients. Most studies reported a reduction in weekly FI episodes (median difference of the mean −7.0 (range: −24.8 to −2.7)) and Wexner scores (median difference of the mean −9 (−14.9 to −6)). A trend towards improved resting and squeeze anal pressures and a reduction in rectal sensory volumes were noted. Studies failed to identify any consistent impact on other physiological parameters or clinicophysiological factors associated with success. Conclusion SNM improves clinical symptoms and reduces number of incontinence episodes and severity scores in patients with FI, in part by improving anorectal physiological function. However, intervention studies with standardized outcome measures and physiological techniques are required to robustly assess the physiological impact of SNM.

The sense of hearing is remarkable for its auditory dynamic range, which spans more than 10 12 in acoustic intensity. The mechanisms that enable the cochlea to transduce high sound levels without damage are of key interest, particularly with regard to the broad impact of industrial, military, and recreational auditory overstimulation on hearing disability. We show that ATP-gated ion channels assembled from P2X 2 receptor subunits in the cochlea are necessary for the development of temporary threshold shift (TTS), evident in auditory brainstem response recordings as sound levels rise. In mice null for the P2RX2 gene (encoding the P2X 2 receptor subunit), sustained 85-dB noise failed to elicit the TTS that wild-type (WT) mice developed. ATP released from the tissues of the cochlear partition with elevation of sound levels likely activates the broadly distributed P2X 2 receptors on epithelial cells lining the endolymphatic compartment. This purinergic signaling is supported by significantly greater noise-induced suppression of distortion product otoacoustic emissions derived from outer hair cell transduction and decreased suprathreshold auditory brainstem response input/output gain in WT mice compared with P2RX2- null mice. At higher sound levels (≥95 dB), additional processes dominated TTS, and P2RX2- null mice were more vulnerable than WT mice to permanent hearing loss due to hair cell synapse disruption. P2RX2- null mice lacked ATP-gated conductance across the cochlear partition, including loss of ATP-gated inward current in hair cells. These data indicate that a significant component of TTS represents P2X 2 receptor-dependent purinergic hearing adaptation that underpins the upper physiological range of hearing.

Essential thrombocythaemia (ET) is one of the severe rare clonal haematologic stem cell disorders that encompass myeloproliferative neoplasms. ET has a well-described association with peripheral arterial thrombosis, which presents a challenging clinical presentation. Further understanding into the underlying pathophysiology of thrombosis in ET has been made following the identification of the Janus Kinase 2 (JAK2) mutation, which is thought to confer a prothrombotic phenotype. Here we present a case of refractory arterial insufficiency associated with JAK2-positive ET.