Stenting complex aorta aneurysms with the Cardiatis multilayer flow modulator: first impressions.

OBJECTIVES: Our aim was to assess the feasibility and efficacy of the Cardiatis multilayer flow modulator in the treatment of complex aorta aneurysms. METHODS: This is a single-center prospective registry. Six patients (4 males and 2 females; mean age 74 years) with complex aorta aneurysms (unsuitable for endovascular repair with standard, fenestrated, or branched stent grafts) were treated with the Cardiatis multilayer flow modulator. RESULTS: Clinical success was 100%. Median follow-up was 10 months. One patient died the third postoperative day due to aneurysm rupture. Four aneurysms were completely thrombosed between 1 and 6 months after the procedure. The patency of the covered aortic branches was 100%. At 6 months, the sac volume was decreased in two patients, increased in two patients and remains stable in one patient. There were no stent migrations, retractions, thrombosis, fractures, or reinterventions. CONCLUSIONS: The device preserves flow into the covered aortic branches and completed aneurysm thrombosis occurs gradually; however, the stent did not prevent rupture immediately after the implantation. Longer follow-up is mandatory to prove the efficacy of this technology.

Fighting human error : what surgeons can learn from aviators.

BACKGROUND: The rigorous implementation of safety policies have made air travel one of the safest modes of transport. Health institutions and hospital managing bodies increasingly adopt cues from aviation safety protocols and policies in an attempt to reduce medical errors and patient harm. Among hospital staff, surgeons are most likely to be confronted with these aviation-derived safety concepts. METHODS: This article aims to familiarize surgeons with the concepts and methodology of safety policies in modern aviation safety, many of which have been applied in the setting of surgery, or have potential to do so. We review the use of checklists, crew resource management, the sterile cockpit, blame free reporting and human fatigue. We discuss how these concepts can be translated to the operating room and illustrate their relevance through a comparative description of historical air accidents and surgical incidents from our own clinical experience. We also indicate relevant differences and similarities between flight crews and surgical teams and their respective infrastructures, as these may impede or facilitate the adoption of aviation safety policies. Finally, we offer some recommendations to effectively implement aviation safety policies in the operating room.

Skin grafting the contaminated wound bed: reassessing the role of the preoperative swab.

OBJECTIVE: To investigate use of the preoperative wound swab to predict graft failure compared with establishing the indication for skin grafting on clinical grounds alone. METHOD: Patients requiring meshed split-thickness skin grafting were prospectively included; the indication for grafting was established on clinical grounds exclusively. A preoperative swab of the wound bed was taken, but its result was concealed to prevent it influencing clinical decision-making. Negative pressure wound therapy (NPWT) was used for both wound bed preparation and graft fixation.After 2 months, graft area take percentage was measured using digital image processing software and the results validated against the result of the preoperative wound swab. RESULTS: Eighty-seven wounds were included in the study. Mean graft area take percentage was 88%,with five grafts considered complete failures(< 25% take).A posteriori analysis of the wound cultures showed that 53% had been contaminated on grafting, but these did not fare any worse than near-sterile wounds. Qualitative analysis of cultures showed that wounds containing either Pseudomonas aeruginosa or Staphylococcus aureus did have inferior outcome (mean take percentage 78.9% vs 91.3%; p=0.038).Diabetes was also a deteriorating factor (mean take percentage 83.0% vs 90.7%; p=0.004). CONCLUSION: Establishing the indication for skin grafting on clinical grounds exclusively does not yield grossly inferior results. In light of recent advances in skin grafting, including use of NPWT as adjuvant therapy, the requirement for routine preoperative wound swabs may be questioned.

The surgical history of the amputated limb according to the indication for revascularization: diabetic foot, acute ischaemia, aneurysmal disease, chronic arterial occlusive disease.

BACKGROUND: To investigate whether the indication for the first revascularization (diabetic foot, acute ischaemia, aneurysmal disease, chronic occlusive disease) determines the surgical history and survival time in amputated limbs. METHODS: The surgical history of lower extremities amputated between 2002 and 2009 was reviewed for the number of (endo)vascular procedures, minor amputations, wound debridements, complications requiring surgery (acute ischaemia, bleeding, graft infection) and limb survival time (LST). RESULTS: 100 limbs were included in the study. The four groups underwent a similar number of surgical procedures (mean 4.1). Diabetic foot limbs had fewer revascularizations (mean 1.3, p = 0.003) and complications (mean 0.1, p = 0.005), but more minor amputations and wound debridements (mean 1.3, p = 0.002), in a significantly shorter LST (mean 555 days, p = 0.003). Acute ischaemic limbs showed the shortest LST (mean 179 days, p = 0.003) and significantly more complications (mean 0.8, p = 0.005). Limbs initially treated for aneurysmal disease or chronic occlusive disease had the highest number of revascularizations (mean resp. 2.7 and 2.6) and the longest LST (mean resp. 1669 and 1459 days, p = 0.001). Limbs with advanced chronic occlusive disease (rest pain or gangrene) presented with fewer revascularisations (mean resp. 2.5 and 1.8, p = 0.01) and a shorter LST (mean resp. 1284 and 794 days, p = 0.004) compared to claudicants. CONCLUSIONS: Our study suggests that the surgical history and limb survival in amputated limbs is disease and stage specific, and determined by the indication of the first revascularisation.

The surgeon and the law on patient's rights for minors.

The law of August 22nd, 2002 concerning patients' rights (LPR) gave a new dimension to the relationship between the physician and the patient. According to this law, it is up to the physician to judge if a patient is able to exercise his own rights or if the patient needs assistance from a representative. In the particular case of the patient being a minor, this often leads to a difficult situation because of the absence of validated criteria to evaluate the capacity of judgment of a minor patient. The triangular relationship physician-patient-parents might be hampered when the parents are involved in a divorce. In daily practice, there are many questions concerning the physicians' attitude towards the rights of the minor patient, particularly in cases of medical intervention. By means of case histories, we describe several problematic situations: the right of free choice of the physician, the right of the minor to obtain informational privacy, obtaining consent for a medical intervention. In cases where there is a divorce, the situation is even more difficult. Solutions are provided to act as effectively as possible in the minors' interests and to offer support to the physician. Note: According to article 388 of the Belgian Civil Code a minor is a person, either male or female, who has not attained the age of 18 years.

Fatal intracerebral haemorrhage following carotid endarterectomy in a patient with cerebral amyloid angiopathy.

A 68-year-old man underwent carotid endarterectomy for symptomatic carotid artery stenosis. Immediately after surgery the patient suffered dramatic neurological deterioration, due to massive cerebral bleeding. Pathological examination revealed cerebral amyloid angiopathy. This condition is known to predispose to spontaneous, as well as anticoagulation induced, cerebral haemorrhage. Surgical intervention needing anticoagulation in elderly patients at risk for congophilic angiopathy should be performed with extreme caution.

Deontological aspects of medicine, more specifically for the surgeon in a changing social environment.

In this article the authors highlight a few ethical and deontological bottlenecks that currently exist in surgery. In particular, it concerns the poor application of patient's rights legislation so far by surgeons in the field, the need for fixed agreements in hospital departments and in hospitals, and the difficult exercise of handling patient information privacy. Furthermore the reduction in the number of candidate-specialists and subsequent consequences are considered. To guarantee the quality criteria within 'office-based medicine', structural solutions are presented. To conclude, the subject of publicity via internet sites is dealt with.

From retroperitoneoscopic lumbar sympathectomy to total laparoscopic abdominal aorta surgery: how to learn.

The aim of this report is to describe the steps we followed to build up laparoscopic experience progressively towards total laparoscopic aorta surgery. The techniques of retroperitoneoscopic lumbar sympathectomy, hand-assisted laparoscopic aorta surgery and total laparoscopic aorta surgery are discussed and illustrated. Surgical tips and tricks and advice concerning selection of patients and surgical techniques are proposed. The 30-day morbidity and mortality rates of laparoscopic, standard open and endovascular abdominal aorta aneurysm repair were compared.

Men with atherosclerotic stenosis of the carotid artery have lower testosterone levels compared with controls.

AIM: There is evidence to suggest an inverse association between serum levels of testosterone and coronary heart disease. The aim of this study was to compare endogenous sex hormone levels of men with severe internal carotid artery (ICA) atherosclerosis with age-matched controls. METHODS: Metabolic parameters and sex hormones were measured or calculated in 124 male patients undergoing carotid endarterectomy for high grade ICA stenosis and in 124 age-matched male controls. The presence or absence of atherosclerotic stenosis of ICA was determined by high resolution B-mode ultrasound. RESULTS: The cases had statistically significant lower levels of total testosterone (TT) (medians: 3.8 microg/L versus 4.3 microg/L, P=0.005) and sex hormone binding globulin (SHBG) (means: 39.8+/-17.2 versus 54.3+/-34.3 nmol/L, P<0.001) compared to controls. Multivariate linear regression analysis, adjusted for all clinical and physiologic parameters, showed a significant inverse association between ICA stenosis and TT (b=-0.158, P=0.013) and SHBG (beta=-0.259, P<0.001). CONCLUSION: This study provides evidence of a positive association between low serum androgen levels and severe ICA atherosclerosis in men. It suggests that higher, but physiological, levels of androgens could have a protective role in the development of atherosclerosis.

Spinal cord stimulation. New regulation of national health insurance.

Since January 1, 2008, the Belgian national health insurance (INAMI/RIZIV) edited a new agreement for the prolongation of the pilot-study on spinal cord stimulation for chronic critical unreconstructable lower limb ischemia. After a short introduction and a summary of the results of the initial Belgian pilot study (2000-2005) on spinal cord stimulation, the official new text is now published in both languages.

Aortoesophageal fistula following endovascular exclusion of a thoracic aneurysm.

The aim of this study was to report a case of aortoesophageal fistula following endovascular exclusion of a thoracic aneurysm, treated conservatively with fatal outcome. Endovascular exclusion of a thoracic aneurysm was performed in a 64-year-old female patient. Three months later the diagnosis of an aortoesophageal fistula was made and minimal surgery (cervicotomy and jejunostomy) was performed, combined with antibiotherapy and catheter flushing of the infected excluded aneurysm thrombus. The patient died in septic shock 9 weeks later. As reported, following conventional thoracic aortic aneurysm surgery, endovascular stenting of the thoracic aorta can be complicated by aortoesophageal fistula. Management should be surgical, since the outcome under conservative management seems invariably fatal. However, it looks as if the poor condition of these patients may not permit open surgical treatment.

Gender differences in cardiovascular risk factors in a carotid endarterectomy population.

AIM: Present knowledge about the epidemiology and the distribution of the cardiovascular risk factors of carotid artery atherosclerosis is limited. The aim of the study was to detect possible gender differences in cardiovascular risk factors in carotid endarterectomy patients. METHODS: Between 1998 and 2003 the cardiovascular risk factors of 804 consecutive isolated carotid endarterectomies were prospectively recorded. The data of 567 men and 237 women were compared and subgroup analysis of young and old male and female subjects was performed. RESULTS: The number of cardiovascular risk factors per patient is higher in men, hypertension is more predominant in women, tobacco use is twice as often present in men. The most frequent risk factors are, in men, tobacco use and hypertension, and, in women, hypertension and hyperlipidemia. The most frequent combination in the male group is tobacco/hypertension/hyperlipidemia and in the female group hypertension/hyperlipidemia. The gender differences were more striking in patients younger than 75 years, after this age the number of cardiovascular risk factor per patient declined in both sexes, the number of smokers decreased but remains higher in men, diabetes is more frequent in women and hypertension and hyperlipidemia become the important risk factors in men as well in women. CONCLUSIONS: There are gender differences in the distribution and in the combinations of cardiovascular risk factors in our selected patients. These findings suggest that screening for carotid artery atherosclerosis should particularly be aimed at people with the combinations of risk factors described above.

Clinical spectrum of endobronchial tuberculosis in elderly patients.

We describe 11 elderly patients with bacteriologically proved endobronchial tuberculosis, representing 15% of our 73 geriatric patients with pulmonary tuberculosis in the period 1980 to 1987. In seven (64%) of the 11 patients, an incorrect diagnosis was initially made. Cough, mostly nonproductive, was invariably present, and general symptoms (fever, anorexia, weight loss) predominated over specific pulmonary symptoms. The radiographic features were rather "unusual": in only two (18%) of the 11 cases, apicoposterior consolidations with or without cavitation were found. Fiberoptic bronchoscopy showed a range of endobronchial abnormalities that included ulcerations, mass lesions, and fibrostenoses. Antituberculous treatment generally led to satisfactory results. Still, residual bronchostenosis was observed in four (57%) of seven patients in whom a control bronchoscopy was done. In one of these four patients, a pneumonectomy had to be performed for uncontrollable retro-obstructive infections, and in another, repeated endoscopic dilatations were effective. In elderly patients, endobronchial tuberculosis should be considered in the differential diagnosis, especially in the presence of chronic cough. In these patients, the chest roentgenogram may be clear or suggestive of bronchial carcinoma or pneumonitis.

Four-stage tuberculin testing in elderly subjects induces age-dependent progressive boosting.

We administered four sequential tuberculin skin tests (5 TU, PPD) with intervals of one week to 223 subjects older than 65 years of age to evaluate whether elderly subjects demonstrated progressive boosting. Indurations of at least 10 mm with increases of at least 6 mm (over the previous test) were considered significant reactions, and these were found in 29 percent of the subjects after test 1, in 43 percent after test 2, in 53 percent after test 3, and in 57 percent after test 4 (p less than 0.05), ie, only about 50 percent of all the positives were detected after the first test. The percentage of positive reactors was inversely related to age (p less than 0.001), yet this age-dependent difference decreased with increasing number of tests. For the 65- to 74-year-old age group, 44 percent reacted positively after the first test and after three tests almost a plateau of 65 to 70 percent positive reactors was reached, suggesting that a minority only of about 30 to 35 percent of these geriatric patients might have outlived their bacilli or were never infected. For the 75- to 84-year-old age group, 24 percent reacted after the first test and 55 percent reacted after the fourth one. For the older than 85-year-old age group, 19 percent positive reactors were found after the first test and 46 percent were found after the fourth test, without clear-cut leveling off toward a plateau value, suggesting that additional tests would induce further boosting. Mean diameters of positive reactions were 15 to 24 mm, and were mostly at least 12 mm larger than in the previous tests. These data support the hypothesis that the negative tuberculin reaction, which is often found in elderly subjects, is mainly due to the failing immune response to tuberculin antigen that can be restored progressively by repeated administrations. These findings, furthermore, emphasize that especially in elderly, care should be taken not to interpret a boosting reaction as a conversion and especially that neither a two-step testing as recommended by the ATS and CDC (Am Rev Respir Dis 1990; 142:723-35) nor even a four-step testing may suffice to detect all positives in this type of population.

Sequential therapy with cefuroxime followed by cefuroxime axetil in community-acquired pneumonia.

STUDY OBJECTIVES: To compare the efficacy of two sequential therapy regimens of IV cefuroxime followed by oral cefuroxime axetil for the treatment of community-acquired pneumonia (CAP). DESIGN: Prospective, multicenter, randomized, open-label, parallel-group study. SETTING: Sixty-six centers in 11 countries (Belgium, Canada, Czech Republic, Germany, Hungary, Ireland, Israel, Poland, Portugal, South Africa, and the United Kingdom). PATIENTS: Six hundred thirty-six adults with CAP requiring hospitalization and initial IV antibiotic treatment. INTERVENTIONS: Cefuroxime, 1.5 g IV tid or bid for 48 to 72 h followed by oral cefuroxime axetil, 500 mg bid for 7 days. MEASUREMENTS AND RESULTS: For clinically evaluable patients, the clinical response rates were equivalent for cefuroxime tid and bid groups posttreatment (cure/improvement, 79% and 84%, respectively) and at follow-up (maintained cure, 87% and 82%, respectively). All signs and symptoms of pneumonia showed improvement at the time of switch from IV to oral therapy. A total of 111 pathogens were isolated, the most common being Streptococcus pneumoniae (23%), Haemophilus influenzae (18%), and Enterobacteriaceae (15%). Bacteriologic clearance was obtained posttreatment in 47 of 49 and 36 of 42 of bacteriologically evaluable patients in the cefuroxime tid and bid groups, respectively. Both regimens were well tolerated with a low incidence of drug-related adverse events, the most common being GI. CONCLUSIONS: Twice daily IV cefuroxime followed by oral cefuroxime axetil is a simple and effective sequential therapy regimen for the treatment of CAP. It offers potential cost savings and can replace the current tid regimen in this indication.

Sequential treatment with vindesine-ifosfamide-platinum (VIP) chemotherapy followed by platinum sensitized radiotherapy in stage IIIB non-small cell lung cancer: a phase II trial.

PURPOSE: Daily administration of cisplatin concomitant with radiotherapy improved the overall survival in inoperable non-small cell lung cancer (NSCLC) in one EORTC study. In this study, we prospectively investigated the efficacy and toxicity of a sequential treatment with three cycles of vindesine-ifosfamide-platinum (VIP) induction chemotherapy, followed by daily cisplatin-sensitized radiotherapy. METHODS: Between June 1993 and June 1995, 23 previously untreated patients with stage IIIB NSCLC with World Health Organization performance status 0 or 1 were included. Chemotherapy consisted of platinum 30 mg/m2 and ifosfamide 1200 mg/m2 i.v. on days 1, 2 and 3, and vindesine 3 mg/m2 i.v. on days 1 and 8, every 4 weeks. After three cycles and at least stable disease, radiotherapy was started (30 Gy in 10 fractions, followed by a boost of 22 Gy in 10 fractions). Each fraction was preceded by Platinum 6 mg/m2 i.v. RESULTS: Nineteen patients completed the sequential therapy. One patient died from neutropenic sepsis during the first cycle of chemotherapy, and three patients had progressive disease after chemotherapy. The overall response rate after sequential therapy was 47% (95% confidence interval 24-80), median survival was 10.6 months, 1- and 2-year survival rates were 47 and 16%, respectively. Major toxicity consisted of neurotoxicity grade III-IV in 18% and of leukopenia grade III-IV in 22% of the patients. Acute radiation pneumonitis grade III occurred in 11% of the patients. CONCLUSION: Three-drug VIP induction chemotherapy followed by cisplatin-sensitized radiotherapy is feasible, with acceptable, albeit substantial, toxicity. In spite of the theoretically promising sequence of therapies, survival results remain disappointingly low.

Pulmonary tuberculosis in the adult in a low prevalence area: is the radiological presentation changing?

SETTING: Pulmonary division of a university hospital in Belgium, an area with a relatively low tuberculosis incidence (14.9 per 100 000 population in 1993). OBJECTIVE: To evaluate whether 'unusual' radiographic presentations of pulmonary tuberculosis (PTB) have increased in recent years, especially in elderly and non-indigenous patients. DESIGN: Retrospective study of chest X-rays of 219 patients aged over 18 years with bacteriologically proven PTB in the period 1981-1990, including 92 elderly (> or =65 years) and 17 non-indigenous patients. 'Unusual' presentations consisted of solitary pleural effusion, isolated hilar or mediastinal lymphadenopathies, normal chest X-ray, lower lung field TB, nodular lesions, diffuse infiltrations and atelectasis. RESULTS: There was an increase in 'unusual' presentations, from 24% in 1981-1985 to 35% in 1986-1990, yet this was not statistically significant (P = 0.08). This increase tended to be more pronounced in the elderly age group, i.e., from 24% to 42% compared to 23% to 31% in the younger age group. The proportion of elderly patients in the group with 'unusual' findings was 44% in 1981-1985 and 48% in 1986-1990. In the non-indigenous group, the percentage of 'unusual' findings did not change between the two periods (40% versus 41%). The proportion of non-indigenous patients in the group with 'unusual' findings increased from 7% in 1981-1985 to 13% in 1986-1990; however, this difference was not significant. CONCLUSIONS: In an area with low TB incidence, adult PTB still presents with the classical pattern of reactivation disease. Although not statistically significant, there is a trend towards a relative increase in the frequency of unusual presentations in recent years, which is most pronounced in the elderly and in non-indigenous adults.

Endobronchial tuberculosis mimicking lung cancer in elderly patients.

We report four elderly patients with cough who were referred with the presumptive diagnosis of bronchial carcinoma based on chest X-ray and the macroscopic view on fibreoptic bronchoscopy, but whose final diagnosis was endobronchial tuberculosis. Chest X-ray showed atypical pulmonary infiltrates in three patients, but was normal in one. Bronchoscopic examination revealed ulcerative and/or stenotic lesions. Endobronchial tuberculosis should be considered in differential diagnosis, especially in the elderly.

Impact of age and radiographic presentation on the presumptive diagnosis of pulmonary tuberculosis.

We compared delay in presumptive diagnosing pulmonary tuberculosis (PTB) in elderly and younger patents, yield of diagnosis and whether the yield is influenced by the radiographic presentation, even when PTB was suspected. Time from first complaints to first consideration of PTB was determined as suspicion interval (SI) and from first consideration to diagnosis as recognition interval (RI). Presumptive diagnosis was defined as positive staining for acid-fast bacilli or presence of granulomatous lesions in pulmonary specimens. Inthe elderly and in the younger patients, the mean SI was 111.1 and 878 days respectively (P = NS), and the mean RI was 5.9 and 8.3 days, respectively (P = NS). The mean RI was longer in uncharacteristic than in characteristic radiographic findings in both elderly (8.2 and 4.6 days; P = 0.007) and younger patients (10.6 and 3.9 days; P=0.0001). A diagnosis was obtained in 89/113 elderly (79%) and in 109/138 younger (79%) patients (P=NS) and also in 59/80 (73%) patients with uncharacteristic findings and in 139/170 (82%) patients with characteristic findings (P = NS). In the latter, sputum contributed for 66% ofdiagnosis, whereas it was only 31% in patients with uncharacteristic findings (P < 0.005). In elderly patients with uncharacteristic radiographic findings, diagnosis was obtained from sputum in 41% and from other specimens in 35% (P = NS); in the younger group diagnosis was obtained from sputum in 23% and from other specimens in 48% (P < 0.05). In conclusion, there was no difference in SI and RI in elderly patients in comparison with younger patients. Uncharacteristic radiographic findings increased RI in both age groups. Age or radiographic presentation did not influence diagnosing PTB. In patients with characteristic radiographic findings, diagnosis was especially made from examination of sputum, whereas in those with uncharacteristic findings, diagnosis was more often obtained from the complementary investigation of other specimens.