Impact of the COVID-19 pandemic on interventional radiology services across the world.

AIM: To review data on the impact of the COVID-19 pandemic on interventional radiology (IR) services. MATERIALS AND METHODS: A systematic review of the available studies was performed according to the PRISMA guidelines. RESULTS: A total of 14 studies met the inclusion criteria. IR caseload reduced between 16.8-80%, with elective activity affected more than emergency work. Trainees also experienced a 11-51.9% reduction in case volumes and many were redeployed to critical care. IR departments re-organised operations and personnel, and many continued to offer 24/7 services and support critical care areas through redeployment of staff. The majority of studies report no significant issues with the availability of personal protective equipment and that local or national governing body or radiology society guidelines were followed. CONCLUSION: The COVID-19 pandemic reduced case volumes and training opportunities. IR departments showed flexibility in service delivery. The lessons learned offer novel insights into how services and training can be reorganised to ensure that IR continues to thrive.

Utilisation and outcomes following the introduction of an interventional radiology day unit.

AIM: To assess the utilisation of an interventional radiology day unit (RDU), the rates of on-time discharges, the financial performance of the unit, and finally, the patient satisfaction rates. MATERIALS AND METHODS: Data regarding the unit utilisation, discharge times, and complications were retrospectively collected for the first 2 years of operation of the unit (1 April 2013 to 1 January 2015). In addition, monitoring the activity going through the RDU and applying a contribution margin to the freed-up beds measured the financial performance. The data were provided by the finance department of the hospital. Satisfaction survey questionnaires were sent randomly by post to 100 patients who had been previously admitted to the RDU. RESULTS: During the study period, 3019 patients were admitted to the RDU, comprising 1426 during the first year and 1513 during the second. On average, 5.6 patients were discharged from the RDU on every working day during the first year and 7.1 patients during the second (21% increase in the discharge rate). Given the 8-hour working time configuration of the unit, a realistic 80% utilisation rate of the RDU's seven beds could free a total of 1400 inpatient bed days over a full year. The cost of delivering these episodes of care was reduced by approximately 50%. From the financial data, it was estimated that the RDU managed to achieve a total of £393,000 in savings for the Trust for the financial year 2013-2014. The return rate of the patient satisfaction survey was 40%. All patients were satisfied with their overall RDU experience. CONCLUSION: The RDU has brought significant benefits for patients and the Trust without compromises in safety or quality.

Advances in MRI for the evaluation of carotid atherosclerosis.

Carotid artery atherosclerosis is an important source of mortality and morbidity in the Western world with significant socioeconomic implications. The quest for the early identification of the vulnerable carotid plaque is already in its third decade and traditional measures, such as the sonographic degree of stenosis, are not selective enough to distinguish those who would really benefit from a carotid endarterectomy. MRI of the carotid plaque enables the visualization of plaque composition and specific plaque components that have been linked to a higher risk of subsequent embolic events. Blood suppressed T1 and T2 weighted and proton density-weighted fast spin echo, gradient echo and time-of-flight sequences are typically used to quantify plaque components such as lipid-rich necrotic core, intraplaque haemorrhage, calcification and surface defects including erosion, disruption and ulceration. The purpose of this article is to review the most important recent advances in MRI technology to enable better diagnostic carotid imaging.

Interim results on abolishing reflux alongside a randomized clinical trial on laser ablation with phlebectomies versus foam sclerotherapy.

AIM: The early results of a randomised clinical trial comparing local anaesthesia endovenous laser ablation (EVLA) with concurrent phlebectomies versus ultrasound-guided foam sclerotherapy (UGFS) into the great saphenous vein (GSV) revealed that laser was more expensive but the results on abolition of reflux were similar. The interim results at 15 month follow-up are reported. METHODS: Evaluations included ultrasound, the venous clinical severity score (VCSS), the Aberdeen varicose vein questionnaire (AVVQ) and the saphenous treatment score (STS). The global absence of reflux defined technical success. Adjuvant sclerotherapy to areas of reflux was administered on patient choice. RESULTS: Occlusion of the GSV was more effective with EVLA at 42/44 (95.5%) versus 31/46 (67.4%) for UGFS. However both techniques were equally effective at abolishing global venous reflux. The number of legs (N.=100) with total reflux abolition, above-knee, below-knee or combined reflux and loss to follow-up was 18, 6, 12, 8, 6 with EVLA and 20, 8, 11, 7, 4 with UGFS, respectively. The VCSS, AVVQ and STS reduced compared to baseline (P<0.0005), but there was no statistical difference between the groups. The AVVQ remained unchanged between 3-15 months (P=0.601). Also during this time, 19/46(41%) UGFS versus 9/44(20%) EVLA legs received adjuvant treatment (2.1 times increase). However, overall, adjuvant foam was given 4.7 times more frequently in the UGFS patients. CONCLUSION: EVLA and UGFS are equally effective at abolishing global venous reflux with overall success of 41% and 43%, respectively. The high reflux rate was not related to deterioration in quality of life indicating that this reflux was largely asymptomatic.

Availability of supervised exercise programs and the role of structured home-based exercise in peripheral arterial disease.

OBJECTIVES: The effectiveness of supervised exercise programs (SEPs) for the management of peripheral arterial disease (PAD) can be hampered by low accessibility and poor compliance. The current international availability and use of SEPs was evaluated and the evidence on alternative approaches such as structured, home-based exercise programs (HEPs) was reviewed. METHODS-MATERIALS: International survey on SEP availability among vascular surgeons using an online questionnaire. A systematic review on structured-HEPs effectiveness was also performed. RESULTS: A total of 378 responses were collected from 43 countries, with the majority (95%) from Europe. Only 30.4% of the participants had access to SEPs and within this group there was significant heterogeneity on the way SEPs were implemented. This systematic review identified 12 studies on the effectiveness of HEPs. In 3 studies SEPs were superior to HEPs in improving functional capacity or equivalent in improving quality of life (QoL). HEPs significantly improved most of the functional capacity and QoL markers when compared to the "go home and walk" advice and baseline measurements. CONCLUSIONS: SEPs remain an underutilized tool despite recommendations. Structured HEPs may be effective and can be useful alternatives when SEPs are not available. Further research is warranted to establish cost-effectiveness.

Multi-drug-resistant gram-negative bacterial infection in surgical patients hospitalized in the ICU: a cohort study.

We sought to identify risk factors for postoperative infections, caused by multi-drug-resistant gram-negative bacteria (MDR-GNB) in surgical patients. This was a retrospective cohort study among patients hospitalized in the intensive care unit (ICU) for more than 5 days, following general surgical operations. Comparison of patients who developed infection caused by MDR-GNB with the remainder of the cohort showed that every minute of operative time, use of special treatments during hospitalization (antineoplastic, immunosuppressive or immunomodulating therapies), every day of metronidazole, and every day of carbapenems use, increased patients' odds to acquire an infection caused by MDR-GNB by 0.7%, 8.9 times, 9%, and 9%, respectively [OR (95% CI): 1.007 (1.003-1.011), p = 0.001; 8.9 (1.8-17.3), p = 0.004; 1.09 (1.04-1.18), p = 0.039; 1.09 (1.01-1.18), p = 0.023, respectively]. The above were adjusted in the multivariable analysis for the confounder of time distribution of infections caused by MDR-GNB. Finally, the secondary comparison, with patients that did not develop any infection, showed that patients who had received antibiotics, within 3 months prior to admission, had 3.8 times higher odds to acquire an infection caused by MDR-GNB [OR (95% CI): 3.8 (1.07-13.2), p = 0.002]. This study depicts certain, potentially modifiable, risk factors for postoperative infections in patients hospitalized in the ICU for more than 5 days.

Introduction to the biomechanics of carotid plaque pathogenesis and rupture: review of the clinical evidence.

The management of patients with asymptomatic carotid disease is currently under debate and new methods are warranted for better risk stratification. The role of the biomechanical properties of the atherosclerotic arterial wall together with the effect of different stress types in plaque destabilisation has only been recently investigated. PubMed and Scopus databases were reviewed. There is preliminary clinical evidence demonstrating that the analysis of the combined effect of the various types of biomechanical stress acting on the carotid plaque may help us to identify the vulnerable plaque. At present, MRI and two-dimensional ultrasound are combined with fluid-structure interaction techniques to produce maps of the stress variation within the carotid wall, with increased cost and complexity. Stress wall analysis can be a useful tool for carotid plaque evaluation; however, further research and a multidisciplinary approach are deemed as necessary for further development in this direction.

Probiotic bacteria and biosurfactants for nosocomial infection control: a hypothesis.

The adaptation of strict hygienic practices by healthcare personnel as well as the implementation of appropriate cleaning and disinfection measures form the basis of infection control policies. However, nosocomial infections constitute a considerable problem even in hospitals with meticulous infection control programmes. This should prompt biomedical researchers to evaluate the efficacy and safety of novel infection control measures. There is preliminary evidence that probiotic type micro-organisms may antagonise the growth of nosocomial pathogens on inanimate surfaces. We therefore propose the hypothesis that environmental probiotic organisms may represent a safe and effective intervention for infection control purposes. We suggest that probiotics or their products (biosurfactants), could be applied to patient care equipment, such as tubes or catheters, with the aim of decreasing colonisation of sites by nosocomial pathogens. This could potentially impede a central step in the pathogenesis of nosocomial infections.

Meta-analysis: ertapenem for complicated intra-abdominal infections.

BACKGROUND: Ertapenem is a new member of the carbapenem class of antibiotics, with a favourable pharmacokinetic profile, but a narrower spectrum of antimicrobial activity, compared with older representatives of this class. AIM: To evaluate the effectiveness and safety of ertapenem for treatment of complicated intra-abdominal infections. METHODS: We performed a meta-analysis of randomized-controlled trials identified in PubMed, Cochrane and Scopus that compared ertapenem with other antimicrobial regimens, in patients of all ages, with complicated intra-abdominal infections. The primary outcomes evaluated were clinical success (cure or improvement) in the modified intention-to-treat population and clinical adverse events. RESULTS: Six randomized-controlled trials involving patients with complicated intra-abdominal infections, mainly of mild-to-moderate severity (three with a double-blind design; one performed in children) that compared ertapenem treatment (once daily) against piperacillin/tazobactam, ceftriaxone plus metronidazole and ticarcillin/clavulanic acid (in three, two and one randomized-controlled trials respectively) were included. No difference was found between adult patients with complicated intra-abdominal infections treated with ertapenem vs. comparators, regarding clinical success (five randomized-controlled trials, 2002 patients, fixed-effect model, odds ratio: 1.11, 95% confidence interval (CI): 0.89-1.39); clinical adverse events (four randomized-controlled trials, 1530 patients, fixed-effect model, OR: 0.86, 95% CI: 0.61-1.20); microbiological success; mortality and withdrawals because of adverse events. Ertapenem was associated with more laboratory adverse events (four randomized-controlled trials, 1530 patients, fixed-effect model, OR: 1.73, 95% CI: 1.14-2.61), but none was reported as serious. CONCLUSION: This meta-analysis provides additional evidence that ertapenem can be used as effectively and safely, as other recommended antimicrobial regimens, for the treatment of complicated intra-abdominal infections, particularly of mild-to-moderate severity.

Heteroresistance: a concern of increasing clinical significance?

Recent studies have focused on issues related to heteroresistance, including its definition, methods of detection and frequency. Most such studies have reported data concerning infections caused by Staphylococcus aureus, but the clinical significance of heteroresistance is unclear. Six studies have described infections caused by S. aureus strains that were heteroresistant to vancomycin, with two suggesting an association between the emergence of heteroresistance and treatment failure or mortality, and four suggesting no such association. Further studies are required to evaluate the clinical implications of heteroresistance in an era in which rates of antimicrobial resistance are increasing alarmingly worldwide.