The impact of diabetes on mortality rates after lower extremity amputation.

OBJECTIVE: To assess the impact of diabetes, amputation level, sex and age on mortality rates after lower extremity amputation (LEA) in Belgium, and to assess temporal trends in one-year survival rates from 2009 to 2018. METHODS: Nationwide data on individuals who underwent minor and major LEA from 2009 to 2018 were collected. Kaplan-Meier survival curves were constructed. A Cox regression model with time-varying coefficients was used to estimate the likelihood of mortality after LEA in individuals with or without diabetes. Matched amputation-free individuals with or without diabetes were used for comparison. Time trends were analysed. RESULTS: Amputations 41,304 were performed: 13,247 major and 28,057 minor. Five-year mortality rates in individuals with diabetes were 52% and 69% after minor and major LEA, respectively (individuals without diabetes: 45% and 63%, respectively). In the first six postoperative months, no differences in mortality rates were found between individuals with or without diabetes. Later, hazard ratios (HRs) for mortality in individuals with diabetes (compared with no diabetes) after minor LEA ranged from 1.38 to 1.52, and after major LEA from 1.35 to 1.46 (all p ≤ 0.005). Among individuals without LEA, HRs for mortality in diabetes (versus no diabetes) were systematically higher compared to the HRs for mortality in diabetes (versus no diabetes) after minor and major LEA. One-year survival rates did not change for individuals with diabetes. CONCLUSIONS: In the first six postoperative months, mortality rates after LEA were not different between individuals with or without diabetes; later, diabetes was significantly associated with increased mortality. However, as HRs for mortality were higher in amputation-free individuals, diabetes impacts mortality less in the minor and major amputation groups relative to the comparison group of individuals without LEA.

Cholesterol granuloma mimicking an anterior mediastinal tumor - a case report.

There are many different types of mediastinal masses, which makes it challenging to diagnose them. Furthermore, the clinical presentation can range from asymptomatic to life-threatening. We present the case of a 68-year-old male with an incidental finding of a tumor located in the anterior mediastinum. A computed tomography (CT) of the thorax and an 18-Fluorodeoxyglucose positron emission tomography (PET) suggested a thymoma, which is the most common primary tumor of the anterior mediastinum. The patient was scheduled for a robotic-assisted thoracoscopy (RATS) thymectomy. Both this procedure and the postoperative course were uneventful. The pathology report showed multiple cholesterol granulomas in the mediastinal fat. Furthermore, no malignancy (e.g. a thymoma) could be found. A cholesterol granuloma mimicking an anterior mediastinal tumor is extremely rare.

ABCC8 variants in MODY12: Review of the literature and report of a case with severe complications.

More than 1000 variants of the ATP-binding cassette transporter subfamily C member 8 (ABCC8) gene have been reported in neonatal diabetes mellitus. Up to now only 55 ABCC8 variants were associated with Maturity-Onset Diabetes of the Young 12 (MODY12). We present a c.3544C>T p.(Arg1182Trp) ABCC8 variant in a 35-year-old women who had pronounced microvascular diabetic complications and a charcot arthropathy necessitating a lower limb amputation. The unusual severity of the disease course prompted us to perform a systematic review of all genetic variants in MODY12. The present mutation has mostly been associated with neonatal diabetes and in only three papers reporting a MODY12. The 55 MODY12 variants show a large clinical heterogeneity, even in relatives with the same mutation, ranging from mild impaired glucose tolerance to severe insulin-dependent diabetes mellitus. HbA1c at diagnosis ranged from 5% to 14% and age at diagnosis ranged from 2 to 53 years. However, several case reports lack documentation of diabetic complications. Hence, more detailed reports remain necessary to improve insight in MODY12 pathophysiology and outcome. In this article current data regarding therapeutic management are provided, and key points to consider for the individual patient affected by MODY12 are presented.

Evaluation of Temporal Artery Duplex Ultrasound for Diagnosis of Temporal Arteritis.

BACKGROUND: Temporal arteritis or giant cell arteritis is a form of systemic inflammatory vasculitis closely associated with polymyalgia rheumatica. It may have serious systemic, neurologic, and ophthalmic consequences as it may lead to impaired vision and blindness. Definitive diagnosis is made after histopathologic analysis of a superficial temporal artery (TA) biopsy, which requires a small surgical procedure often under local anesthesia. We investigated whether a noninvasive technique such as duplex ultrasound of the TA could replace histopathological analysis. METHODS: Eighty-one patients referred to our department for TA biopsy were first screened with a duplex ultrasound for a surrounding halo and/or occlusion of the TA. Presence of visual disturbances and unilateral pain (headache and/or tongue/jaw claudication) was noted before TA biopsy. Pathological analysis was considered the gold standard. Correlation between duplex findings, symptoms, and pathology was determined by Spearman's Rho test. The predictive value of a halo and TA occlusion on duplex were determined by ROC curve analysis. RESULTS: A halo or TA occlusion was found in 16.0% and 3.7% of patients, respectively. Unilateral pain was reported in 96% of cases while 82% complained of visual disturbances. Correlation coefficients for halo and occlusion were 0.471 and 0.404, respectively (P < 0.0001), suggesting a moderate correlation between duplex and biopsy. There was no significant correlation between visual impairment or pain and histologic findings. The ROC curve analysis showed a sensitivity of 53.3% and 20.0%, and specificity of 91.9% and 100% for presence of a halo and occlusion of the TA on duplex, respectively. CONCLUSIONS: Arterial duplex is a moderately sensitive but highly specific test for exclusion of temporal arteritis. We observed a moderate correlation between these findings on duplex and histopathological analysis as a gold standard. Arterial duplex may serve as a valuable diagnostic addition to prevent unnecessary surgical procedures and can even substitute biopsy in patients where surgery is not an option.

Combining the Passeo-18 Lux Drug-Coated Balloon and the Pulsar-18 Bare Metal Stent: 12- and 24-Month Outcomes of the BIOLUX 4EVER Investigator-Initiated Trial.

PURPOSE: To report the outcomes after treating stenotic or occluded femoropopliteal lesions with a drug-coated balloon (DCB) followed by the implantation of a thin-strut self-expanding bare metal stent in the BIOLUX 4EVER trial (ClinicalTrials.gov identifier NCT02211664). MATERIALS AND METHODS: The prospective, multicenter, physician-initiated BIOLUX 4-EVER trial was conducted at 5 centers in Belgium and enrolled 120 patients (mean age 70.9±10.5 years; 79 men) with symptomatic stenotic or occluded de novo femoropopliteal lesions. A fifth of the patients had diabetes mellitus and nearly half had previous peripheral artery interventions. The lesions were a mean 83.3±49.5 mm long with a mean reference vessel diameter of 5.26±0.59 mm. Lesions were treated with a Passeo-18 Lux DCB followed by the implantation of a Pulsar-18 bare metal stent. Follow-up visits were conducted at 1, 6, 12, and 24 months postprocedure; the main outcome was primary patency at 12 months. RESULTS: Technical success was obtained in all patients. Primary patency was observed in 89.9% of patients (95% CI 84.0% to 95.8%) at 12 months and in 83.5% at 24 months (95% CI 89.9% to 97.3%), and freedom from target lesion revascularization was 93.6% (95% CI 89.9% to 97.3%) and 86.1% (95% CI 79.9% to 92.3%), respectively. Ten patients died throughout the course of the trial (90.7% survival at 24 months), all of noncardiovascular causes. The ankle-brachial index improved from 0.68±0.09 at baseline to 0.93±0.11 and 0.93±0.12 at 12- and 24-month follow-up visits (p<0.001). An improvement of at least 1 Rutherford category was observed in 91 of 94 patients (96.8%) at 12 months and 78 of 83 patients (93.4%) at 24 months (p<0.001). CONCLUSION: The combination of a Passeo-18 Lux DCB followed by a Pulsar-18 stent implantation produced safe and effective outcomes in the treatment of femoropopliteal lesions at up to 24 months. Adding paclitaxel to the bare nitinol stent platform by predilating with a Passeo-18 Lux DCB seems to increase efficacy at 1 and 2 years compared with the use of bare metal stents only, which were investigated in the precursor 4-EVER study.

Use of Robotics in Surgical Treatment of Non-small Cell Lung Cancer.

OPINION STATEMENT: Robotic-assisted videothoracoscopic surgery (R-VATS) has become increasingly popular and widely used since its introduction and is nowadays considered a standard treatment approach in many centres for the treatment of non-small cell lung cancer. R-VATS was initially developed to overcome the drawbacks of VATS by offering surgeons more flexibility and three-dimensional optics during thoracoscopic surgery. The effectiveness of R-VATS lobectomy regarding oncological outcomes, morbidity, mortality, and postoperative quality of life (QoL) has been shown in an increasing number of studies. More recently, these results have also been corroborated for sublobar resections, more specifically for segmentectomy. However, no well-powered, multicentre randomized trials have been performed to demonstrate the superiority of R-VATS compared with open surgery or conventional types of VATS (total VATS, uniportal VATS, etc.). The majority of the evidence currently available is based on non-randomized studies, and many studies report conflicting results when comparing R-VATS and conventional VATS. Moreover, there is a lack of data regarding the cost and the cost-efficiency of robotic surgery compared with VATS and open surgery. Current evidence suggests that R-VATS costs are higher than VATS and that a deficit can only be prevented when up to 150-300 thoracic surgery procedures are performed annually. Finally, robotic-assisted laparoscopic surgery showed better ergonomics and reduced musculoskeletal disorders compared with non-robotic laparoscopic surgery.

Myasthenia gravis appearing after thymectomy heralding recurrent thymoma.

INTRODUCTION: Thirty to fifty percent of thymoma patients develop myasthenia gravis (MG). In 1.5-28% of cases, MG appears many years after removal of a thymoma. PATIENTS AND METHODS: We present a case report of a 72-year-old female who presented with MG four months after total thymectomy. RESULTS: A 72-year-old female patient presents with MG four months after total thymectomy. Imaging revealed a PET-positive nodule anterior to the superior vena cava. By median sternotomy, the nodule was removed at our hospital. Pathology confirmed a recurrent B2/B3 thymoma with R0 resection. No adjuvant therapy was given. Large population studies show the appearance of new-onset MG associated with recurrent thymoma in 3% of cases. CONCLUSIONS: New-onset MG postthymectomy heralds recurrent disease in 3% of cases. Thorough screening is needed in such patients.

Decreasing rates of major lower-extremity amputation in people with diabetes but not in those without: a nationwide study in Belgium.

AIMS/HYPOTHESIS: The reduction of major lower-extremity amputations (LEAs) is one of the main goals in diabetes care. Our aim was to estimate annual LEA rates in individuals with and without diabetes in Belgium, and corresponding time trends. METHODS: Data for 2009-2013 were provided by the Belgian national health insurance funds, covering more than 99% of the Belgian population (about 11 million people). We estimated the age-sex standardised annual amputation rate (first per year) in the populations with and without diabetes for major and minor LEAs, and the corresponding relative risks. To test for time trends, Poisson regression models were fitted. RESULTS: A total of 5438 individuals (52.1% with diabetes) underwent a major LEA, 2884 people with above- and 3070 with below-the-knee major amputations. A significant decline in the major amputation rate was observed in people with diabetes (2009: 42.3; 2013: 29.9 per 100,000 person-years, 8% annual reduction, p < 0.001), which was particularly evident for major amputations above the knee. The annual major amputation rate remained stable in individuals without diabetes (2009: 6.1 per 100,000 person-years; 2013: 6.0 per 100,000 person-years, p = 0.324) and thus the relative risk reduced from 6.9 to 5.0 (p < 0.001). A significant but weaker decrease was observed for minor amputation in individuals with and without diabetes (5% and 3% annual reduction, respectively, p < 0.001). CONCLUSIONS/INTERPRETATION: In this nationwide study, the risk of undergoing a major LEA in Belgium gradually declined for individuals with diabetes between 2009 and 2013. However, continued efforts should be made to further reduce the number of unnecessary amputations.

Malignant pleural mesothelioma: single-institution experience of 101 patients over a 15-year period.

BACKGROUND: Malignant pleural mesothelioma (MPM) is a rare but aggressive neoplasm that typically originates from the mesothelial surfaces of the pleural cavity. Exposure to asbestos is the principal etiological agent of MPM. The disease is characterized by difficult stage classification and limited consensus on therapeutic approach. We have evaluated the experience with MPM in the Antwerp University Hospital over the past 15 years. METHODS: A database was created with all patients diagnosed with or treated for a MPM between 2001 and 2015. A total of 101 patients were included on which different survival analyses were performed combined with a reproduction of demographic, clinical, histologic and therapeutic data, and these were compared to literature data. RESULTS: Vast majority of our 101 patients were male (80%) with a median age of 66 years at diagnosis with predominantly epitheloid histology (81%). Overall median survival was 18.3 months and overall 1-, 2- and 5-year survival rates were 68%, 37% and 7%, respectively. Kaplan-Meier analysis showed a non-significant difference in survival between the several best (b) TNM-stages (p = .356). A significant difference in survival was observed in patients undergoing surgery versus no surgery (p = .008), between the different histological types (p < .0001) and treatment with chemotherapy alone versus chemotherapy with surgery (p < .0001). Smoking at diagnosis and epitheloid histology have been identified as significant prognostic factors in the multivariate Cox regression model (HR 3.13 and 0.53, respectively). CONCLUSION: Descriptive and survival analysis of our patient database confirmed the limitations of the current staging system and were concordant with literature regarding MPM.

Primary skeletal muscle myoblasts from chronic heart failure patients exhibit loss of anti-inflammatory and proliferative activity.

BACKGROUND: Peripheral skeletal muscle wasting is a common finding with adverse effects in chronic heart failure (HF). Whereas its clinical relevance is beyond doubt, the underlying pathophysiological mechanisms are not yet fully elucidated. We aimed to introduce and characterize the primary culture of skeletal muscle cells from individual HF patients as a supportive model to study this muscle loss. METHODS AND RESULTS: Primary myoblast and myotubes cultures were successfully propagated from the m. vastus lateralis of 6 HF patients with reduced ejection fraction (HFrEF; LVEF <45 %) and 6 age and gender-matched healthy donors. HFrEF cultures were not different from healthy donors in terms of morphology, such as myoblast size, shape and actin microfilament. Differentiation and fusion indexes were identical between groups. Myoblast proliferation in logarithmic growth phase, however, was attenuated in the HFrEF group (p = 0.032). In addition, HFrEF myoblasts are characterized by a reduced TNFR2 expression and IL-6 secretion (p = 0.017 and p = 0.016; respectively). CONCLUSION: Biopsy derived primary skeletal muscle myoblasts of HFrEF patients produce similar morphological and myogenic differentiation responses as myoblasts of healthy donors, though demonstrate loss of anti-inflammatory and proliferative activity.