Oropharyngeal histoplasmosis: a report of 10 cases.

A wide differential diagnosis must be entertained in patients with unusual oral and pharyngeal ulcerations. A mucosal biopsy is essential. We retrospectively reviewed 10 cases from the Infectious Diseases Division at Mayo Clinic Rochester (MN, USA), in which the diagnosis proved to be Histoplasma capsulatum infection. Between 1995 and 2016, 10 patients were diagnosed with oropharyngeal histoplasmosis. Common presenting symptoms included weight loss, weakness and oropharyngeal pain with ulcerations. Despite specialty evaluation at other facilities, diagnostic delay occurred in six patients due to lack of biopsy or fungal staining. Yeast forms consistent with H. capsulatum were identified in the biopsy specimens of all our patients. Treatment included intravenous amphotericin B and prolonged courses of azoles. Oral histoplasmosis occurred in both immunocompetent and immunosuppressed patients, and was a manifestation of disseminated infection. Severe pain involving all areas of the mouth was typical. Diagnostic delay may be avoided by early biopsy using fungal stains.

Thermal ablation in the management of superficial thrombophlebitis.

INTRODUCTION: In superficial thrombophlebitis (ST), saphenous high ligation and stripping may be indicated. Endovenous thermal ablation (ETA) was hitherto not reported for ST management. We treated three ST patients using ETA and describe one in more detail. REPORT: An 81 year-old man with ST at the medial lower leg and a refluxing GSV underwent ETA of the GSV. Since thrombi were present, the GSV was punctured at the inguinal crease and the laser catheter introduced caudad in order to prevent embolism. DISCUSSION: In ST, ETA might prevent thrombus expansion and embolism. However, this approach requires further optimisation and scrutiny.

Treatment of varicose veins with minimally invasive methods: is conventional surgery still a "gold standard"?

AIM: To assess the current role of thermal ablation in the treatment of saphenous reflux in comparison to more conventional methods. METHOD: Some pertinent publications are presented as well as the author's experience with thermal ablation using ClosureFast. RESULTS: Over the last decade several techniques for thermal ablation of saphenous reflux have been developed. There is some evidence--although scarce--that thermal ablation was from the start not inferior to standard surgery (high ligation and stripping). In addition, more recent thermal ablation techniques appear to have milder side effects than the pioneers. CONCLUSION: Thermal ablation of saphenous reflux has quickly assumed an important role in the treatment of varicose veins and the parameters of thermal ablation may further be optimised. Therefore, we believe that high ligation and stripping of refluxing saphenous veins will widely be displaced by thermal ablation.

Erysipelothrix rhusiopathiae bloodstream infection - A 22-year experience at Mayo Clinic, Minnesota.

Erysipelothrix rhusiopathiae is a facultatively anaerobic Gram-positive bacillus found mostly in swine, fish and sheep. E. rhusiopathiae classically causes cutaneous eruptions in butchers, fish handlers and veterinarians. Based solely on case reports, 90% of E. rhusiopathiae bloodstream infections (BSI) have been associated with infective endocarditis (IE). To assess the true frequency of IE in E. rhusiopathiae BSI as well as other clinical associations, we performed a retrospective cohort analysis of E. rhusiopathiae BSI at Mayo Clinic. This is a single-centre, retrospective study conducted between 1/1/1994 and 20/6/2016 at Mayo Clinic in Rochester, MN. Medical records were reviewed for demographics, E. rhusiopathiae BSI, anti-microbial susceptibilities, incidence of IE, patient comorbidities, intensive care unit (ICU) admission and duration of antibiotics. Five cases of E. rhusiopathiae BSI were identified. Risk factors included animal exposures, immunosuppression, diabetes and kidney disease. All cases involved penicillin-sensitive strains and high-grade BSI. Four cases showed no signs of IE on transesophageal echocardiogram. All patients recovered fully with intravenous antibiotics. Our retrospective review illustrates that E. rhusiopathiae can cause invasive BSI in the absence of IE and that the previously reported 90% association between BSI and IE may be overestimated due to reporting bias. E. rhusiopathiae should be suspected in any patient with Gram-positive bacilli in blood cultures and the aforementioned risk factors. A limitation of our study was the low sample size, and future studies may involve multicentre collaborations and the use of polymerase chain reaction (PCR) or serologic testing to increase the number of diagnoses..

The macrolides: erythromycin, clarithromycin, and azithromycin.

In addition to erythromycin, macrolides now available in the United States include azithromycin and clarithromycin. These two new macrolides are more chemically stable and better tolerated than erythromycin, and they have a broader antimicrobial spectrum than erythromycin against Mycobacterium avium complex (MAC), Haemophilus influenzae, nontuberculous mycobacteria, and Chlamydia trachomatis. All three macrolides have excellent activity against the atypical respiratory pathogens (C. pneumoniae and Mycoplasma species) and the Legionella species. Azithromycin and clarithromycin have pharmacokinetics that allow shorter dosing schedules because of prolonged tissue levels. Both azithromycin and clarithromycin are active agents for MAC prophylaxis in patients with late-stage acquired immunodeficiency syndrome (AIDS), although azithromycin may be the preferable agent because of fewer drug-drug interactions. Clarithromycin is the most active MAC antimicrobial agent and should be part of any drug regimen for treating active MAC disease in patients with or without AIDS. Although both azithromycin and clarithromycin are well tolerated by children, azithromycin has the advantage of shorter treatment regimens and improved tolerance, potentially improving compliance in the treatment of respiratory tract and skin or soft tissue infections. Intravenously administered azithromycin has been approved for treatment of adults with mild to moderate community-acquired pneumonia or pelvic inflammatory diseases. An area of concern is the increasing macrolide resistance that is being reported with some of the common pathogens, particularly Streptococcus pneumoniae, group A streptococci, and H. influenzae. The emergence of macrolide resistance with these common pathogens may limit the clinical usefulness of this class of antimicrobial agents in the future.

A double-blind clinical trial of prophylactic cloxacillin in open fractures.

In 100 patients with first-, second-, and third-degree open fractures, a randomized, double-blind study was carried out to compare prophylactic cloxacillin and placebo. Prophylaxis was started preoperatively and continued for 10 days. The standard fracture treatment consisted of operative stabilization, mostly by means of plates or external fixators. In the cloxacillin group two infections were observed as compared to 12 in the control group. This difference was significant.

A new approach to in vivo testing of vascular grafts?

We present an novel approach to in vivo testing of vascular grafts. Seven grafts of two different materials, each with an inner diameter of 5 mm, were joined together to form a bundle, the ends of which were joined to connecting segments with an inner diameter of about 15 mm. The device was then implanted into the abdominal aorta of an experimental animal. After surgery, the animal was followed by CT scan at regular intervals to assess patency of each individual graft. The model features an increased number of grafts per animal with standardized anastomoses and hemodynamic conditions, but it needs modification to lower its thrombogenic potential.

[Popliteal anastomotic aneurysm as the origin of recurrent embolism]. / Popliteales Anastomosen-Aneurysma als Ausgangspunkt rezidivierender Embolien.

We report on a young patient who underwent numerous arterial interventions after injury to the right groin. After several years, a popliteal anastomotic aneurysm, unidentified at that time, began to cause recurrent peripheral emboli. The importance of an intensive search for the source of the emboli is demonstrated. Bland arteriography does not rule out the presence of an aneurysm and should prompt further investigation with duplex-sonography and/or MR-imaging. Aneurysms causing recurrent peripheral emboli are an absolute indication for surgery.

Successful treatment of an extended leg ulcer in systemic sclerosis.

We report the successful surgical treatment of a large and painful leg ulcer associated with systemic sclerosis (scleroderma). In addition, there was a long occlusion of the superficial femoral artery, and ankle systolic blood pressure was 80 mmHg (ankle-brachial-index 0.65). All conservative treatments including systemic antibiotics, nifedipine, intravenous iloprost, intravenous penicilline G and hyperbaric oxygen failed. Pain was intolerable and below-knee amputation was considered. In a first attempt to save the limb, the patient underwent femoropopliteal bypass surgery. Despite a successful outcome of the bypass operation and normalization of the ankle blood pressure, the large wound remained recalcitrant and extremely painful. A second attempt to save the limb consisted of complete debridement of all sclerotic tissue down to the fascia and split skin grafting. The graft took in over 90% of the surface and the remaining wound healed spontaneously. Large leg ulcers in systemic sclerosis can become limb threatening. Radical debridement combined with a split skin graft seems to be a promising way to avoid amputation.

[Bypass to the anterior interosseous artery of the arm: follow-up of 3 years]. / Bypass auf die A. interossea anterior am Arm: Follow-up von 3 Jahren.

Bypass to the anterior interosseous artery in the forearm: Follow-up at 3 years A 56 year-old, otherwise healthy woman suffered from acute ischaemia of her left arm one year after a fracture of the radius which had been treated with plaster fixation. Angiography demonstrated occlusions of the brachial, radial and ulnar arteries. Three surgical thrombectomies, local fibrinolysis and throacoscopic sympathectomy all failed to restore adequate blood supply to the forearm and hand. The patient continued to have pain on exercise and even at rest. After three months, an autologous vein bypass graft was implanted from the proximal brachial artery to the anterior interosseous artery. Thereafter, the patient became free of symptoms. At over three years, angiography was repeated and demonstrated a patent bypass. Furthermore, the lumen of the previously heavily diseased brachial artery had considerably improved in terms of diameter and regularity. These changes and possible mechanisms are discussed.

Inguinal mass as a late complication of hip arthroplasty. Differential diagnosis and treatment from a vascular surgical perspective.

We report on three patients with a symptomatic inguinal mass as a late complication of repetitive arthroplastic hip surgery. In one case, there was a false aneurysm and in two cases a so-called "synovial cyst". A synovial cyst is usually an enlarged iliopsoas bursa in communication with the capsule of the hip joint. Hypersecretion in arthritic joints may cause expansion of this bursa. Compression of the common femoral and external iliac veins may lead to outflow obstruction and leg swelling. The most important diagnostic tools are plain films of the hip joint and ultrasound of the groin including colour-coded assessment of the femoral vessels. Symptomatic cysts usually need removing by an anterior approach. Loose arthroplastic components can be causative and should be replaced.

[Recurrent acute occlusions of the popliteal artery before age 50: popliteal entrapment syndrome?]. / Rezidivierende akute Verschlüsse der Arteria poplitea vor dem 50. Lebensjahr: Popliteales Entrapment-Syndrom?

Compression of the popliteal artery by the medial head of the gastrocnemius muscle is termed "Popliteal Artery Entrapment". The anatomical course of the artery can be normal or abnormal. The entrapment can cause occlusion of the artery or peripheral embolism. This syndrome is an important differential diagnosis in younger patients with recurrent peripheral arterial ischemia. Diagnosis is made by history, clinical findings, arteriography and CT-scan of the knees. All cases of popliteal artery entrapment, whether the artery is occluded or not, should be operated on.

[Mid-term results of our first 53 "in situ" bypasses]. / Mittelfristige Resultate unserer ersten 53 "in situ"-Bypasse.

The "in situ" bypass technique was adopted by our group in 1986. A total of 53 "in situ" bypasses were carried out until June 1989. The worst symptoms were incapacitating claudication, rest pain or ischemic necrosis, each in about one third of the patients. The site of the distal anastomosis was the popliteal artery below the knee in 40 instances, the peroneal artery in 7 and other infrapopliteal vessels in 6. Valve incisions were performed uneventfully with re-usable instruments featuring a sharp-edged blade and an indicator for rotation control of the blade ("Insitutom RG"). Vein branches were located mostly by angiography, but residual arterio-venous fistula remained a vexing problem. In the beginning they were ligated under local anaesthesia. Later on they were dealt with successfully using transluminal embolization. Patients were last examined in July 1990 when the follow-up time ranged from 12 to 51 months. 5 patients had died and 5 were lost to follow-up. Patency rates were evaluated according to the life-table method. They were gratifying for femoro-popliteal bypasses with 87% after one year and 83% after two and three years. Femoro-tibial-peroneal bypasses performed below average, but their number was too small to draw conclusions.

[Acute ischemia of the lower extremity in an adolescent with Crohn disease]. / Akute Ischämie der unteren Extremität bei einem Jugendlichen mit Morbus Crohn.

The authors report a case with a rare form of peripheral ischaemia. A 25-year-old man with Crohn's disease suffers from sudden ischaemia of his right leg. There is no evidence of entrapment of the popliteal artery, of arterial embolism or Buerger's disease. Thrombocytosis in combination with hypercoagulability as described previously in patients with Crohn's disease seems to be the most probable cause. - In this case percutaneous transluminal thrombectomy and thrombolysis were more successful than surgical thrombectomy using balloon catheters.

Spontaneous reversibility of early reobstruction following percutaneous transluminal angioplasty.

Early reocclusion and late restenosis are well-known problems after percutaneous transluminal angioplasty (PTA). We report here on a phenomenon not described so far in two patients with peripheral arterial occlusive disease who had PTA of the common iliac and the superficial femoral artery, respectively. Both had a good hemodynamic and clinical initial result. However, within two days after PTA symptomatic reobstruction occurred documented by noninvasive measurements. Noteworthy, this reobstruction was spontaneously reversible within days. The possible pathomechanism is discussed.

[Endovascular therapy of aneurysms of the abdominal aorta: report of 4,291 patients of the Eurostar Register]. / Endovaskuläre Therapie von Aneurysmen der Bauchaorta: Bericht über 4291 Patienten des Eurostar-Registers.

BACKGROUND: The Eurostar project is a multicentred database of the outcome of endovascular repair of infra-renal aortic aneurysms. From 1996 to March, 2002, 113 European centres of vascular surgery have contributed. The purpose of this article is to review the medium term (up to 7 years) results of endovascular aneurysm repair as reported to Eurostar. PATIENTS AND METHODS: Patients intended for endovascular aneurysm repair were notified to the Eurostar Data Registry Centre before treatment in order to eliminate bias due to selective reporting. The following data was collected on all patients: (1) their demographic details and the anatomical characteristics of their aneurysms, (2) details of the endovascular device used, (3) procedural complications and the immediate outcome, (4) results of contrast enhanced CT imaging at 1, 3, 6, 12, 18 and 24 months after operation and at yearly intervals thereafter, (5) all adverse events. Life table analysis was performed to determine the cumulative rates of: (1) death from all causes, (2) secondary intervention. RESULTS: By March 2002, pre- and postoperative data of 4291 patients had been registered. The median duration of follow-up was 12 mo (range 0-96). Successful deployment was achieved in 97.8% of the patients with a perioperative (30 day) mortality of 2.4%. Early conversion to open repair occurred in 1.3%. Late rupture of the aneurysm occurred in 35 patients. The significant factors were endoleaks, graft migration and kinking. Late conversion to open repair occurred at an annual rate of approximately 2%. Risk factors (indications) for late conversion were endoleaks, graft migration and kinking. CONCLUSIONS: Endovascular repair of infra-renal aortic aneurysms using the first and second-generation devices that predominated in this study is associated with a risk of early or late failure of 3% per year, based upon an analysis of observed primary endpoints of rupture and conversion.

[Indications for, technique and interpretation of arterial Doppler sonography from the vascular surgeon's viewpoint]. / Indikation, Technik und Interpretation der arteriellen Doppler-Sonographie aus gefässchirurgischer Sicht.

Doppler sonography is one of the most important diagnostic tools for angiologists and vascular surgeons and also for general practitioners with an interest in vascular disease. It can be carried out easily and at low cost and, at the same time, provides reproducible, quantitative data on which further diagnostic and therapeutic decisions can be based. First, systolic arterial pressures in the anterior and posterior tibial and in the peroneal arteries are measured, with the Doppler probe placed at ankle level. A cuff is wrapped around the lower leg and inflated until the Doppler signal disappears. The highest value measured in each leg is termed ankle pressure. Division of the latter by systolic brachial pressure results in the so-called ankle-brachial index or "ABI". Ankle pressure and ABI correlate well with clinical findings. In normal individuals it is greater than 1. In claudication it ranges between 0.3 and 0.9, in patients with resting pain between 0.1 and 0.5 and with ischemic tissue loss between 0.0 and 0.2. After angioplastic or surgical revascularization procedures, a fall of the ABI by 0.15 or more is an indication of relevant hemodynamic deterioration and, therefore, calls for further investigation by arteriography or color duplex sonography.

[Functional therapy of Achilles tendon rupture]. / Zur funktionellen Therapie der Achillessehnenruptur.

We are going to present two cases with functional treatment of Achilles tendon ruptures. We define a treatment as functional if the involved limb is either not immobilized at all or whenever the immobilization is incomplete and for a limited time only and when no operation is necessary. The functional treatment is presented as an alternative, and we are going to present the advantage and disadvantage.

[Accidents with bicycles and motorcycles. The injury pattern, costs, and possibilities for prevention]. / Unfälle mit Zweiradfahrzeugen. Verletzungsmuster, Kosten, Möglichkeiten der Prävention.

This review comprises all 641 patients subjected to inpatient treatment in 1976, 1980 and 1984 at the Basel district hospital after accidents involving bicycles or motorcycles. A study of the case histories--supplemented by phone conversations--yielded the following results: Accidents involving bicycles or motor-driven bicycles were seen in all age groups, but motorcycle accidents occurred exclusively among the younger generation. Whereas motorcycle accidents mostly happened during joyrides, accidents with bicycles or mobikes mainly occurred on the way to work. The incidence rate was highest during summertime and in the rush hours at noon or in the evening. Motorcycle accidents resulted in more severe injuries, longer hospitalisation, longer periods of disability and higher costs than bicycle or mobike accidents the latter being mainly characterised by mostly slight head injuries and the former by injuries of the legs and arms.