Feasibility and Reaction Thresholds of Double-Blind, Placebo-Controlled Peanut and Nut Food Challenges Using Gingerbread Matrix.

INTRODUCTION: Double-blind, placebo-controlled food challenges are an important tool in diagnosing food allergies. PRACTALL recommends a dose-escalation schedule of 3-3,000 mg of food protein and a top dose of at least 2,000 mg to avoid false-negative results. This retrospective observational study tests the thresholds and feasibility using a previously published gingerbread matrix. METHODS: Data of food provocations with peanuts and nuts in children from 2015 to 2019 in the Reinier de Graaf Hospital were analyzed. We performed the food challenge following a schedule of 1, 3, 10, 30, 100, 300, 1,000, and 3,000 mg allergen protein. The feasibility of ingestion of the gingerbread matrix was determined by analyzing the amount of consumed gingerbread. RESULTS: 513 food challenges performed in 365 children (median age 6.9 years) were analyzed. Forty percent (204/513) of the food challenges were positive. Fifteen children already reacted at 1 mg protein (7%), 3 with a grade 3 reaction. The median cumulative amount of gingerbread matrix the children could eat on 1 day was 130.3 g. The median cumulative amount of allergen protein eaten was 2,585 mg; only 49% reached the minimum desired cumulative amount of 3,500 mg allergen protein. Despite that, there were no reported reactions at home in the 86% who introduced the allergen after a negative challenge. CONCLUSION: Seven percent of the children react on a starting dose of 1 mg of food protein. Therefore, when using the PRACTALL guidelines, early responders can be expected. Ingestion of a cumulative dose of 3,500 mg to reach a false-negative rate of maximum 5% is not feasible in most children using the gingerbread matrix. However, the cumulative dose may be reduced without increasing false-negative results, making challenges with the gingerbread matrix feasible for all age groups.

Reactions to peanut at first introduction in infancy are associated with age ≥8 months and severity of eczema.

BACKGROUND: Previous studies have shown the efficacy of the early introduction of peanut to prevent peanut allergy. Due to the exclusion of infants with sensitization to peanut, it remains unclear what the optimal timing of introduction is. METHODS: The PeanutNL study was performed in 6 pediatric allergology centers in the Netherlands. Infants referred for the clinical early introduction of peanut to prevent peanut allergy underwent skin prick tests for peanut and an oral peanut challenge at a median age of 6 months. RESULTS: One hundred sixty two of 707 infants (23%) who had never eaten peanut before were sensitized to peanut, of which 80 (49%) had wheals of >4 mm. Sixty seven of 707 infants (9.5%) had a positive oral challenge to peanut at first introduction. Multivariate analysis revealed that age (p < .001) and SCORAD eczema severity scores (p = .001) were significant risk factors. Introduction of peanut at ≥8 months in infants with moderate and severe eczema resulted in an increased risk (odds ratio 5.24 (p = .013) and 3.61 (p = .019), respectively) of having reactions to peanut as compared to introduction before 8 months. A family history of peanut allergy and previous reactions to egg were not identified as independent risk factors. CONCLUSION: These results suggest that peanut should be introduced before the age of 8 months to reduce the risk of reactions at first exposure in infants with moderate and severe eczema. Furthermore, since children with severe eczema have the highest risk of reactions, the clinical introduction of peanut should be considered, at the latest at the age of 7 months.

A mortality prediction model for elderly patients with critical limb ischemia.

OBJECTIVE: To aid physicians in the process of shared decision-making, many predictive models for critical limb ischemia (CLI) have been constructed. However, none of these models is in widespread use. Predicting survival outcomes for a specific individual may be used to guide treatment selection. The aim of this study was to construct a 6-month survival-predicting model representative of elderly patients with CLI undergoing surgical or endovascular treatment. METHODS: An observational cohort study including all patients with CLI aged ≥65 years who underwent surgical or endovascular treatment of CLI between January 2013 and June 2018 was conducted. The model to predict survival at 6 months was based on a multivariable Cox proportional hazards regression model and a penalized likelihood method. The performance of the model was judged by means of the area under the receiver operating characteristic curve. RESULTS: In total, 449 patients were included in the study population. The median age was 76 years (range, 65-97 years), and 52.8% of the population was male. Surgical treatment was performed in 303 patients (67.5%), and 146 underwent endovascular treatment (32.5%). The estimated 30-day survival was 92.7% (standard error [SE], 1.2%); 6-month survival, 80% (SE, 1.9%); and 12-month survival, 71% (SE, 2.1%). Variables with the strongest association with 6-month mortality were age, living in a nursing home, physical impairment, and American Society of Anesthesiologists class. The area under the receiver operating characteristic curve of the 6-month mortality model was 0.81 (95% confidence interval, 0.76-0.85; P < .001). CONCLUSIONS: A prediction model constructed for 6-month mortality of elderly patients undergoing surgical or endovascular treatment of CLI showed that age, living in a nursing home, physical impairment, and American Society of Anesthesiologists class have the highest association with an increase in mortality. These factors may be used to identify patients at risk for mortality in shared decision-making.

Incidence and Risk Factors for Delirium in Elderly Patients with Critical Limb Ischaemia.

OBJECTIVE: Delirium is associated with adverse outcomes, such as increased mortality and prolonged hospital stay. Information on the risk factors for delirium in elderly patients with critical limb ischaemia (CLI) is scarce. The aim of this study was to analyse the incidence of delirium and to identify risk factors for delirium in elderly patients undergoing surgical or endovascular treatment. METHODS: A retrospective cohort study was conducted including patients aged ≥ 65 years undergoing surgical or endovascular treatment for CLI between January 2013 and June 2018. Delirium was scored using the DOSS (Delirium Observation Screening Scale) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. Risk factors for delirium were analysed using logistic regression. The discriminative ability of the model was calculated using the area under the receiver operating characteristics (AUROC) curve. RESULTS: In total, 392 patients were included, of which 70 (17.9%) developed delirium. Factors associated with an increased risk of delirium were: age, odds ratio (OR) 1.05 (95% confidence interval (CI) 1.0-1.1), history of femoral endarterectomy, OR 4.7 (95% CI 1.5-15), physical impairment, OR 2.2 (95% CI 1.1-4.5), history of delirium, OR 2.7 (95% CI 1.4-5.3), general anaesthesia, OR 2.6 (95% CI 1.2-5.7) and pre-operative anaemia, OR 5.9 (95% CI 2.3-15). The AUROC was .82 (95% CI 0.76-0.87, p < .001). Delirium was associated with more respiratory, renal and surgical complications, as well as a prolonged hospital stay and a more frequent discharge to a nursing home. CONCLUSION: Delirium occurs frequently in patients with critical limb ischaemia undergoing any type of invasive treatment. This study identified multiple risk factors for delirium that may be helpful to delineate patients susceptible to its development.

Impact of the COVID-19 Lockdown Strategy on Vascular Surgery Practice: More Major Amputations than Usual.

BACKGROUND: The aim of this study is to investigate the impact of the coronavirus disease 2019 (COVID-19) lockdown period on the number and type of vascular procedures performed in the operating theater. METHODS: A total of 38 patients who underwent 46 vascular procedures during the lockdown period of March 16th until April 30th, 2020, were included. The control groups consisted of 29 patients in 2019 and 54 patients in 2018 who underwent 36 and 66 vascular procedures, respectively, in the same time period. Data were analyzed using SPSS Statistics. RESULTS: Our study shows that the lockdown during the COVID-19 pandemic resulted in a significant increase in the number of major amputations (42% in 2020 vs. 18% and 15% in 2019 and 2020, respectively; P-value 0.019). Furthermore, we observed a statistically significant difference in the degree of tissue loss as categorized by the Rutherford classification (P-value 0.007). During the lockdown period, patients presented with more extensive ischemic damage when than previous years. We observed no difference in vascular surgical care for patients with an aortic aneurysm. CONCLUSIONS: Measurements taken during the lockdown period have a significant effect on non-COVID-19 vascular patient care, which leads to an increased severe morbidity. In the future, policy makers should be aware of the impact of their measurements on vulnerable patient groups such as those with peripheral arterial occlusive disease. For these patients, medical care should be easily accessible and adequate.

Adverse Cardiac Events and Mortality in Patients with Critical Limb Ischemia.

BACKGROUND: Both surgical and endovascular treatment in elderly patients with critical limb ischemia are associated with high mortality rates. Patients with critical limb ischemia are at increased risk of adverse cardiovascular events and subsequent cardiovascular death. Little is known about the incidence and consequences of these adverse events. The aim of this study was to investigate the effect of adverse cardiac events on mortality in patients with critical limb ischemia undergoing surgical or endovascular treatment. METHODS: A retrospective cohort study including all patients with critical limb ischemia aged ≥65 undergoing surgical or endovascular treatment for critical limb ischemia between January 2013 and June 2018 was conducted. Data on adverse cardiac events were collected from medical records. The effect of an adverse cardiac event on mortality during 6 months follow-up was analyzed with a multivariable cox proportional hazards model to adjust for confounders. Effects are displayed as hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: A total number of 449 patients were included. Median age was 76 years, 52.8% of patients were male. In total, 51 patients (11%) developed an adverse cardiac event, 31 patients (10%) in the surgical group and 20 patients (14%) in the endovascular group. After adjustment for confounders, adverse cardiac events were associated with an increased risk of mortality (HR 3.5 95% CI 2.1-5.9). CONCLUSIONS: This study showed that adverse cardiac events commonly occur in elderly patients with critical limb ischemia. Adverse cardiac events continue to occur even months after treatment and are associated with an increased mortality risk. These findings justify routine cardiac evaluation in both surgical and endovascular treatment. Additionally, frequent postdischarge cardiac follow-up in the outpatient clinic may be helpful in limiting the occurrence of adverse cardiac events.

Quality of Life and not Health Status Improves After Major Amputation in the Elderly Critical Limb Ischaemia Patient.

OBJECTIVES: A patient-oriented appraisal of treatment has become extremely important, particularly in elderly patients with critical limb ischaemia (CLI). Quality of life (QoL) is an important patient-reported outcome in vascular surgery. Frequently, the physical domain of QoL questionnaires represents an 'objective' evaluation of performing activities, which is expected to be impaired after major limb amputation. However, an objective appraisal of physical function is an assessment of health status (HS) and not of QoL. Little is known about the subjective appraisal of physical health (QoL). The goal of this study was to evaluate, prospectively, QoL in relation to HS in elderly CLI patients undergoing major limb amputation. METHODS: Patients suffering from CLI aged 70 years or older were included in a prospective observational cohort study with a follow-up period of 1 year. Patients were divided according to having had an amputation or not. The World Health Organization Quality Of Life-BREF (WHOQOL-BREF) was used to asses QoL. The 12-Item Short Form Health Survey (SF-12) was used to measure HS. These self-reported questionnaires were completed five times during follow-up. RESULTS: Two-hundred patients were included of whom 46 underwent a major limb amputation within one year. Amputees had a statistically significant improvement of their physical QoL after six months (14.0 vs. 9.0 (95% CI -7.84;-1.45),p = 0.005) and after a one-year follow-up (14.0 vs. 9.0 (95% CI -9.58;-1.46),p = 0.008). They did not however show any statistically significant difference in HS. For non-amputees, both physical QoL and HS improved. An instant statistically significant improvement of the physical QoL appeared 1 week after inclusion (12.0 vs. 10.9 (95% CI -1.57;-0.63),p<0.001). Similarly, statistically significant improvement in the physical HS first occurred at 1 week follow-up (29.0 vs. 28.9 (95% CI -5.78; -2.23),p = 0.003). CONCLUSIONS: There is a clear difference between patients' functioning (HS) and the patients' appraisal of functioning (QoL). In elderly CLI patients, this study clearly suggests a discrepancy between the physical QoL (WHOQOL-BREF) and HS (SF-12) measurements in vascular amputees. This raises the question, which outcome measurement is the most relevant for elderly CLI patients. Individual treatment goals should be kept in mind when assessing the HS or QoL outcome of patients undergoing hospital care. With respect to shared decision making, distinctive and subjective QoL questionnaires, like the WHOQOL-BREF, provide a very important outcome measurement and should be used in future research.

Genome-wide association study and meta-analysis in multiple populations identifies new loci for peanut allergy and establishes C11orf30/EMSY as a genetic risk factor for food allergy.

BACKGROUND: Peanut allergy (PA) is a complex disease with both environmental and genetic risk factors. Previously, PA loci were identified in filaggrin (FLG) and HLA in candidate gene studies, and loci in HLA were identified in a genome-wide association study and meta-analysis. OBJECTIVE: We sought to investigate genetic susceptibility to PA. METHODS: Eight hundred fifty cases and 926 hyper-control subjects and more than 7.8 million genotyped and imputed single nucleotide polymorphisms (SNPs) were analyzed in a genome-wide association study to identify susceptibility variants for PA in the Canadian population. A meta-analysis of 2 phenotypes (PA and food allergy) was conducted by using 7 studies from the Canadian, American (n = 2), Australian, German, and Dutch (n = 2) populations. RESULTS: An SNP near integrin α6 (ITGA6) reached genome-wide significance with PA (P = 1.80 × 10-8), whereas SNPs associated with Src kinase-associated phosphoprotein 1 (SKAP1), matrix metallopeptidase 12 (MMP12)/MMP13, catenin α3 (CTNNA3), rho GTPase-activating protein 24 (ARHGAP24), angiopoietin 4 (ANGPT4), chromosome 11 open reading frame (C11orf30/EMSY), and exocyst complex component 4 (EXOC4) reached a threshold suggestive of association (P ≤ 1.49 × 10-6). In the meta-analysis of PA, loci in or near ITGA6, ANGPT4, MMP12/MMP13, C11orf30, and EXOC4 were significant (P ≤ 1.49 × 10-6). When a phenotype of any food allergy was used for meta-analysis, the C11orf30 locus reached genome-wide significance (P = 7.50 × 10-11), whereas SNPs associated with ITGA6, ANGPT4, MMP12/MMP13, and EXOC4 and additional C11orf30 SNPs were suggestive (P ≤ 1.49 × 10-6). Functional annotation indicated that SKAP1 regulates expression of CBX1, which colocalizes with the EMSY protein coded by C11orf30. CONCLUSION: This study identifies multiple novel loci as risk factors for PA and food allergy and establishes C11orf30 as a risk locus for both PA and food allergy. Multiple genes (C11orf30/EMSY, SKAP1, and CTNNA3) identified by this study are involved in epigenetic regulation of gene expression.

Small percentage of anaphylactic reactions treated with epinephrine during food challenges in Dutch children.

BACKGROUND: Severe allergic reactions, including anaphylaxis, occur during oral food challenges (OFCs) and the first-line treatment of anaphylaxis is epinephrine. OBJECTIVE: To evaluate the percentage of anaphylactic reactions treated with epinephrine during OFCs and to identify associated factors for the administration of epinephrine. METHODS: Children who underwent an OFC with peanut, hazelnut, cow's milk, hen's egg, or cashew nut from 2005 through 2015 in the Netherlands were evaluated. Children with reactions meeting the criteria for anaphylaxis according to the European Academy of Allergy and Clinical Immunology guidelines for food allergy and anaphylaxis were included. Children with an anaphylactic reaction treated with vs without epinephrine were compared. Possible factors associated with the administration of epinephrine, such as age, sex, symptoms consistent with asthma, history of an allergic reaction to the tested allergen, and symptom types during the anaphylactic reaction, were evaluated using logistic regression analysis. RESULTS: Eighty-three children in clinical and research settings (43% boys; median age, 7 years; range, 1-17) who met the criteria for anaphylaxis were included in this study. Thirty-two of 83 children (39%) with anaphylaxis were treated with epinephrine. Respiratory symptoms during the OFC were treated significantly more often with epinephrine than gastrointestinal symptoms (P = .01). CONCLUSION: Only 39% of children with anaphylaxis, according to the guideline criteria, were treated with epinephrine during the OFC and most of these children had respiratory symptoms. There is need for an easy-to-use international guideline for the treatment of allergic symptoms during OFCs.

Life Expectancy and Outcome of Different Treatment Strategies for Critical Limb Ischemia in the Elderly Patients.

BACKGROUND: The treatment of critical limb ischemia (CLI) in the elderly patients is challenging because of the comorbidity and fragility of these patients. We analyzed survival in relation to different treatment options and estimated life expectancy of our study group by age and gender. METHODS: All patients aged ≥70 years, presenting with chronic CLI, between 2006 and 2013 were included. The treatment was conservative, endovascular, surgical, or by primary major amputation. The interest was in the effect of conservative versus nonconservative treatment on survival. Furthermore, we compared mortality and life expectancy between the study population to the overall Dutch population by age and gender. RESULTS: In total, 686 legs in 651 patients were treated. Initial treatment of patients was conservative (n = 181), endovascular (n = 259), surgical (n = 169), or amputation (n = 42). The overall 1-year mortality was 29%. Patients were stratified by age: 70-79 (n = 350) years and ≥80 (n = 301) years. Higher mortality rate ratios (RR) were found in octogenarians compared with patients aged 70-79 years, in the endovascular (P < 0.001) and surgical (P < 0.001) group. The mortality RRs of conservative relatively to nonconservative treatment was 0.84 (95% confidence interval: 0.65-1.09; P = 0.19), not significantly differing between both age groups (P = 0.74). The mortality RR of 3.72 of our study population to the Dutch general population was high, with an excess mortality of 272%. Life expectancy at the age of 70 years was substantially decreased by 9 and 8 years for, respectively, the male and female population. CONCLUSIONS: Mortality rates in elderly patients with CLI are high, corresponding with a decreased life expectancy, regardless of the type of intervention. Revascularization is associated with high periprocedural mortality, especially in octogenarians. Conservative treatment is noninferior to nonconservative treatment in terms of mortality and should be considered as the treatment in octogenarians with substantial comorbidity.

Reinterventions after Endovascular Revascularization in Elderly Patients with Critical Limb Ischemia: An Observational Study.

BACKGROUND: Endovascular-first strategy for critical limb ischemia is widely accepted, especially in elderly patients, because of the increasing patency rates and minimally invasive character. Nonetheless, the impact of reinterventions because of endovascular treatment failure in this population is not well known. The aim of this study was to evaluate the reintervention rate and outcomes following reinterventions. METHODS: Patients aged >70 years with critical limb ischemia as a result of aortoiliac, femoropopliteal, and/or crural disease, treated by "endovascular-first strategy" between 2006 and 2013, were retrospectively analyzed. Follow-up was until 31 December 2014. Primary end point was freedom from reintervention or major amputation. Secondary outcome measures were limb salvage and mortality after reintervention. Reintervention was defined as endovascular or surgical re-revascularization and categorized into early reintervention (<3 months) and late reintervention (>3 months). RESULTS: In total, 263 patients were treated by endovascular revascularization. The majority (60%) of the treated lesion was located in the femoropopliteal segment. In total, a reintervention was performed in 32%, with 48% performed within 3 months. Freedom from reintervention or major amputation at 1 and 3 years was 0.71 ± 0.03 and 0.61 ± 0.03, respectively. The 1-year Kaplan-Meier estimate amputation-free survival was 0.35 ± 0.06 in the early reintervention group, compared with 0.73 ± 0.06 in the late reintervention group and 0.71 ± 0.04 in the no reintervention group (P < 0.001; log rank). The 1-year mortality in the early reintervention group was 0.35 ± 0.06, compared with 0.14 ± 0.05 in the late reintervention group and 0.29 ± 0.04 in the group who did not require reintervention (P = 0.047; log rank). CONCLUSIONS: Endovascular revascularization first strategy for critical limb ischemia results in high reintervention rates in elderly patients. Failure of the endovascular revascularization requiring early reintervention is associated with lower amputation-free survival.

Infection Risk Following Common Femoral Artery Endarterectomy Versus a Hybrid Procedure.

BACKGROUND: Hybrid revascularization combines open lower extremity surgery and endovascular procedures to simultaneously treat atherosclerotic lesions on multiple levels in patients with peripheral arterial occlusive disease (PAD). Hybrid surgery appears to be a safe strategy for multilevel stenosis revascularization, though the risk of surgical site infection (SSI) has not been clearly investigated. This study evaluates the development of SSI following common femoral artery endarterectomy (CFE) and hybrid revascularization procedures. METHODS: A retrospective study was performed including all patients undergoing CFE, as standalone or as part of a hybrid procedure, due to PAD between January 2013 and December 2016. Preoperative, intraoperative, clinical, and follow-up information was gathered prospectively and reviewed retrospectively. The presence of SSI was recorded based on criteria of the Centre for Disease Control. RESULTS: A total of 229 CFEs were performed. One hundred thirty-two as a standalone procedure, 65 combined with iliofemoral angioplasty, and 32 combined with peripheral angioplasty. Nineteen patients (8.3%) developed an SSI, of which 4 were deep infections. Ten infections (7.6%) occurred in the CFE-only group, 5 (7.7%) in the iliofemoral hybrid group, and 4 (12.5%) in the peripheral hybrid group (P = 0.65). Five patients (2.1%) required surgery to control the infection. The mean duration of stay was 5 days for patients without SSI versus 20 days for patients who developed an SSI (P < 0.0001). CONCLUSIONS: The hybrid procedure combining open femoral endarterectomy with endovascular revascularization is a safe procedure with no significant differences in infection rates between open surgery, central, or peripheral hybrid revascularization.

Quality of Life and Mortality after Endovascular, Surgical, or Conservative Treatment of Elderly Patients Suffering from Critical Limb Ischemia.

BACKGROUND: Revascularization to relieve ischemic pain and prevent limb loss is the cornerstone of critical limb ischemia (CLI) treatment; however, not all elderly patients are deemed fit for revascularization. Patient-related outcome measurements are important in these patients. Quality of life (QoL) results regarding the effect of endovascular, surgical, and conservative treatment on the QoL in the elderly are scarce in the current literature. The goal of this study was to explore the outcomes of the different treatment modalities in elderly patients suffering from CLI, with a specific focus on QoL. METHODS: A total of 195 CLI patients ≥70 years were prospectively included between January 2012 and February 2016 and divided into 6 groups (endovascular revascularization, surgical revascularization, and conservative treatment). Two age groups (70-79 and >80 years) were analyzed. Follow-up was performed at 5-7 days, 6 weeks, and 6 months. World Health Organization Quality of Life-BREF questionnaire was used to determine QoL. The Vascular-Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity score was noted. QoL was used as the primary end point, with mortality and limb salvage as the secondary end points. RESULTS: Six-month mortality was significantly lower in surgically treated patients aged 70-79 years (4%) as compared with endovascular (24%, P = 0.001) or conservative treatment (25%, P = 0.02). There was no significant difference in 6-month mortality in patients >80 years among endovascularly (38%), surgically (15%), and conservatively treated patients (27%). QoL significantly increased at all follow-up moments in surgically treated patients between 70 and 79 years and at 6 months in endovascularly treated patients. Conservatively treated patients did not improve their QoL in this age group. All patients aged >80 years, including conservatively treated patients, showed significantly improved QoL results at 6 months. CONCLUSIONS: Elderly patients judged fit for surgery may benefit the most from surgical revascularization, reporting low mortality rates, low adverse events and significantly gained QoL in multiple domains. However, all 3 treatment modalities have significantly increased physical health at 6 months. Conservative therapy seems to be an acceptable treatment option in patients unfit for revascularization with gained physical health at 6 months.

Dementia in Patients Suffering from Critical Limb Ischemia.

BACKGROUND: Critical limb ischemia (CLI) is a disease that is most prevalent in the elderly population. This group of patients includes patients suffering from comorbidities such as dementia. Mortality rates of both CLI and dementia are higher when compared with the nonaffected population. These demented vascular patients are often deemed unfit for surgery and at risk of respiratory and cardiovascular adverse events. Unfortunately, current literature is lacking in to determining the optimal treatment for demented patients suffering from CLI. The purpose of this study is to determine the prevalence of dementia in patients suffering from CLI, with special interest in the mortality rates of these patients. METHODS: Between January 2012 and October 2015, all patients aged over 70 and suffering from CLI were retrospectively reviewed in the Amphia Hospital, Breda, The Netherlands. Patients with diagnosed dementia before admission by a geriatrician were included in this study. Baseline characteristics were retrieved from patients' medical charts. Primary end point of this study is mortality and the secondary end points include adverse events, reinterventions, and limb salvage. RESULTS: A total of 369 patients suffering from CLI were diagnosed between January 2012 and October 2015. Thirty-one patients (8%) diagnosed with both dementia and CLI were included in this study with a mean age of 82 years old. Conservative therapy was selected as the therapy of choice in 61% of the patients. There was a mortality rate of 32% after 6 months, increasing to 52% after 1 year and 92% after 2 years. Limb salvage rates after 30 days were 84%, dropping to 77% after 6 months. CONCLUSIONS: Eight percent of CLI patients aged above 70 years old are suffering from dementia. Demented patients suffering from CLI are a frail group of elderly patients with a high mortality rate of 52% after 1-year follow-up. Therapy of choice should probably be selected following mutual agreement between vascular surgeons, individual patients, and their families, taking postoperative quality of life, life expectation, and anatomical arterial lesions into account.

Persistence of treatment with 5-grass pollen tablets in patients with allergic rhinitis: a real-life study.

BACKGROUND: In patients with allergic rhinitis, treatment adherence to allergen immunotherapy varies greatly in randomized and real-life studies. OBJECTIVE: To evaluate the use of a 5-grass pollen tablet as sublingual immunotherapy, its treatment persistence, and the reasons for discontinuation in a real-life clinical setting. METHODS: This multicenter, prospective, open-label, noncontrolled observational study evaluated the use of sublingual immunotherapy with a 5-grass pollen tablet in a cross-sectional population of patients (≥5 years old) with grass pollen-induced allergic rhinitis with or without asthma. The primary objective was to determine the percentage of patients persisting with treatment across 1 season in a pre-co-seasonal scheme. Secondary objectives included evaluation of reasons for treatment discontinuation, safety and adverse events; effectiveness (based on physician and patient assessments), and treatment compliance. RESULTS: The study included 196 patients (49.2% male, mean age 27.5 years, range 5.3-65.7 years), with treatment provided by 47 participating physicians. Sixty-seven percent of patients had polysensitivity and 32% had coexistent asthma. On average, patients were treated for 7 months with the 5-grass pollen tablet. After 1 month, 85% of all patients persisted with treatment, and 70% persisted after 7 months. Treatment discontinuation was due chiefly to known side effects (mild to moderate local allergic reactions). Most patients reported symptom improvement; 80% of all patients intended to continue treatment next season. CONCLUSION: Most patients with allergic rhinitis treated pre-co-seasonally with a 5-grass pollen tablet persisted with treatment after the first pollen season. Patients were willing to continue their treatment in the following season owing to improvement of symptoms.

Quality Assessment of Video Mediastinoscopy Performed for Staging in Non-Small Cell Lung Cancer.

Background Mediastinoscopy is considered to be the gold standard for mediastinal staging for patients with non-small cell lung cancer (NSCLC). The diagnostic value depends on how this procedure is performed, which has resulted in drafting a guideline by the European Society of Thoracic Surgery (ESTS). Biopsy of at least stations 4R, 4L, 7, and if present stations 2R and 2L, is recommended. The objective of this study is to assess the quality of the mediastinoscopies performed in our hospital for NSCLC. Methods Medical records of 102 consecutive patients with suspected or proven NSCLC and a performed cervical mediastinoscopy between January 2009 and November 2014 were analyzed in a retrospective cohort study. The number of biopsied stations and complications has been prospectively documented, together with their clinical data. Results Cervical mediastinoscopy was performed in 102 patients and in 51 (50%) patients biopsy was taken of stations 4R, 4L, and 7. N2/N3 disease emerged more significantly (p < 0.05) if biopsies were taken of at least the paratracheal stations 4R/4L and the subcarinal region. The incidence of major complications was 3.9%. Conclusion In our clinic, 50% of the mediastinoscopies performed are executed following the ESTS guidelines. Our results subscribe the need to biopsy at least the paratracheal stations 4L/4R and the subcarinal region to obtain a reliable assessment of the mediastinum.

The diagnostic value of component-resolved diagnostics in peanut allergy in children attending a Regional Paediatric Allergology Clinic.

BACKGROUND: To date, diagnosing food allergies in children still presents a diagnostic dilemma, leading to uncertainty concerning the definite diagnosis of peanut allergy, as well as to the need for strict diets and the potential need for adrenalin auto-injectors. This uncertainty in particular is thought to contribute to a lower quality of life. In the diagnostic process double-blind food challenges are considered the gold standard, but they are time-consuming as well as potentially hazardous. Other diagnostic tests have been extensively studied and among these component-resolved diagnostics appeared to present a promising alternative: Ara h2, a peanut storage protein in previous studies showed to have a significant predictive value. METHODS: Sixty-two out of 72 children, with suspected peanut allergy were analyzed using serum specific IgE and/or skin prick tests and specific IgE to several components of peanut (Ara h 1, 2, 3, 6, 8, 9). Subsequently, double-blind food challenges were performed. The correlation between the various diagnostic tests and the overall outcome of the double-blind food challenges were studied, in particular the severity of the reaction and the eliciting dose. RESULTS: The double-blind provocation with peanut was positive in 33 children (53 %). There was no relationship between the eliciting dose and the severity of the reaction. A statistically significant relationship was found between the skin prick test, specific IgE directed to peanut, Ara h 1, Ara h 2 or Ara h 6, and the outcome of the food challenge test, in terms of positive or negative (P < .001). However, we did not find any relationship between sensitisation to peanut extract or the different allergen components and the severity of the reaction or the eliciting dose. There was no correlation between IgE directed to Ara h 3, Ara h 8, Ara h 9 and the clinical outcome of the food challenge. CONCLUSIONS: This study shows that component-resolved diagnostics is not superior to specific IgE to peanut extract or to skin prick testing. At present, it cannot replace double-blind placebo-controlled food challenges for determination of the eliciting dose or the severity of the peanut allergy in our patient group.

Conservative Treatment in Selected Patients with Severe Critical Limb Ischemia.

OBJECTIVE: To assess the outcome of conservative treatment of severe critical limb ischemia (CLI) classified as Rutherford 5/6. BACKGROUND: The preferred therapy for CLI is either endovascular revascularization or bypass surgery. With a growing aged population with more serious comorbidities, these therapies are not always a viable option. Primary amputation leads to decreased mobility and a reduced quality of life. There is a lack of literature regarding the outcome of conservative therapy. METHODS: Hospital charts were reviewed of all patients who were diagnosed with Rutherford classification 5-6 and received conservative treatment and lacked interventional options. Outcome measures were mortality, complete wound closure, and limb salvage rate. RESULTS: 38 patients were included with a median age of 80 years (range 57-97). The amputation rate during follow-up was 16%. In 58% of patients, complete wound closure was achieved. All-cause mortality was 58% with a 2-year survivability rate of 55%. CONCLUSIONS: Conservative management in our selected patients with CLI results in a moderate rate of wound closure and acceptable amputation rates albeit with a high mortality rate. For patients not eligible for endovascular revascularization or bypass surgery, conservative treatment could be a viable option besides primary limb amputation.

Adverse events after treatment of patients with acute limb ischemia.

BACKGROUND: To assess the outcome and the occurrence and consequences of adverse events (AEs) after treatment of acute limb ischemia (ALI). METHODS: Retrospective analysis on intra-arterial thrombolysis (group I) and thromboembolectomy (group II). Outcome measures were primary patency and limb salvage rates. AEs and consequences were registered during admission and 30 days after discharge. RESULTS: A total of 238 procedures were included (group I, 173 vs. group II, 65). The primary patency (P = 0.144) and limb salvage rates (P = 0.166) were not significantly different between both groups. A total of 195 AEs were registered. Most AEs were procedure related and resulted in surgical reintervention (77% vs. 76%). Some AEs resulted in irreversible physical damage (15% vs. 25%) and death (6% vs. 12%). CONCLUSIONS: Both, intra-arterial thrombolysis and thromboembolectomies are adequate therapies; however, they result in a wide variety of AEs resulting in serious morbidity and even death.

The current position of precuffed expanded polytetrafluoroethylene bypass grafts in peripheral vascular surgery.

OBJECTIVE: Long-term results of precuffed expanded polytetrafluoroethylene (ePTFE) grafts used for peripheral bypass surgery are lacking. The aim of this study was to obtain the long-term outcomes of precuffed ePTFE grafts compared with autologous saphenous vein (ASV) grafts used in patients with peripheral arterial disease (PAD). METHODS: A single-institution retrospective study of precuffed ePTFE and ASV graft performances in patients with PAD was undertaken between January 2004 and December 2012. Five-year primary patency, secondary patency, and limb salvage rates were determined by Kaplan-Meier analyses. RESULTS: A total of 467 bypass grafts were included in this study (169 precuffed ePTFE grafts and 298 ASV grafts). Secondary patency rates of ePTFE vs ASV at 1 and 5 years, respectively, were as follows: for 134 supragenicular femoropopliteal bypasses, 60% and 27% vs 89% and 85% (P < .05); for 190 infragenicular femoropopliteal bypasses, 40% and 25% vs 86% and 79% (P < .05); and for 84 femorocrural bypasses, 30% and 14% vs 50% and 50% (P < .05). Five-year limb salvage rates of ePTFE vs ASV for supragenicular femoropopliteal bypasses were 82% vs 94% (P = .16); for infragenicular femoropopliteal bypasses, 41% vs 92% (P < .05); and for femorocrural bypasses, 43% vs 64% (P = .06). CONCLUSIONS: ASV bypasses are still the first-choice conduit in peripheral bypass surgery performed in patients with PAD. Precuffed ePTFE bypasses are acceptable alternatives in the absence of adequate autologous vein.