Prevalence and risk factors for carriage of ESBL-producing Enterobacteriaceae in Amsterdam.

OBJECTIVES: The objectives of this study were to determine the prevalence of carriage of ESBL-producing Enterobacteriaceae (ESBL-E) in a representative sample of the general adult Dutch community, to identify risk factors and to gain understanding of the epidemiology of these resistant strains. METHODS: Adults enrolled in five general practices in Amsterdam were approached by postal mail and asked to fill in a questionnaire and to collect a faecal sample. Samples were analysed for the presence of ESBL-E. ESBL genes were characterized by PCR and sequencing. Strains were typed using MLST and amplified fragment length polymorphism (AFLP) and plasmids were identified by PCR-based replicon typing. Risk factors for carriage were investigated by multivariate analysis. RESULTS: ESBL-E were found in 145/1695 (8.6%) samples; 91% were Escherichia coli. Most ESBL genes were of the CTX-M group (blaCTX-M-1 and blaCTX-M-15). MLST ST131 was predominant and mainly associated with CTX-M-15-producing E. coli. One isolate with reduced susceptibility to ertapenem produced OXA-48. In multivariate analyses, use of antimicrobial agents, use of antacids and travel to Africa, Asia and Northern America were associated with carriage of ESBL-E, in particular strains with blaCTX-M-14/15. CONCLUSIONS: This study showed a high prevalence of ESBL-E carriage in the general Dutch community. Also, outside hospitals, the use of antibiotics was a risk factor; interestingly, use of antacids increased the risk of carriage. A major risk factor in the general population was travel to countries outside Europe, in particular to Asia, Africa and Northern America.

Definitive seton management for transsphincteric fistula-in-ano: harm or charm?

AIM: The treatment of transsphincteric anal fistula requires a balance between eradication of the disease and preservation of faecal control. A cutting seton is an old tool that is now out of vogue for many surgeons. We hypothesized that the concept remains reliable and safe with results that exceed those reported for many of the more recently described methods. METHOD: A retrospective review was conducted of real-time electronic health records (single institution, single surgeon) of patients presenting during the 14 years between 2001 and 2014 with a transsphincteric anal fistula who were treated with a cutting seton. Excluded were patients with Crohn's disease, fistulae related to malignancy or a previous anastomosis and patients whose fistula was treated by another method including a loose draining seton. Data collection included demographics, duration of the disease, duration of the treatment, outcome and continence. RESULTS: In all, 121 patients (80 men) of mean age 40.2 ± 12.2 years (range 18-76) with a mean follow-up of 5.1 ± 3.3 (1-24) months were included in the analysis. The median duration of symptoms was 6 (1-84) months; 36% had failed other fistula surgery, 12% had a complex fistula with more than one track and 35% had some form of comorbidity. The median time to healing was 3 (1-18) months; 7.4% required further surgery, but eventually 98% had complete fistula healing. The incontinence rate decreased postoperatively to 11.6% from 19% before treatment with 17/121 with pre-existing incontinence resolved and 8/107 new cases developing. CONCLUSION: Despite its retrospective non-comparative design, the study has demonstrated that a cutting seton is a safe, well tolerated and highly successful treatment for transsphincteric anal fistula and is followed overall by improved continence. The results compare very favourably with other techniques.

Electronic structure changes across the metamagnetic transition in FeRh via hard X-ray photoemission.

Stoichiometric FeRh undergoes a temperature-induced antiferromagnetic (AFM) to ferromagnetic (FM) transition at ~350 K. In this Letter, changes in the electronic structure accompanying this transition are investigated in epitaxial FeRh thin films via bulk-sensitive valence-band and core-level hard x-ray photoelectron spectroscopy with a photon energy of 5.95 keV. Clear differences between the AFM and FM states are observed across the entire valence-band spectrum and these are well reproduced using density-functional theory. Changes in the 2p core levels of Fe are also observed and interpreted using Anderson impurity model calculations. These results indicate that significant electronic structure changes over the entire valence-band region are involved in this AFM-FM transition.

Efficacy of management algorithm for reducing need for sphincterotomy in chronic anal fissures.

BACKGROUND: Lateral internal sphincterotomy is the most effective treatment for chronic anal fissure (CAF), but carries a risk of faecal incontinence. We aimed to analyse efficacy and acceptance of a treatment algorithm in reducing the rate of necessary sphincterotomies. METHOD: Patients with CAF seen from 2001 to 2010 were retrospectively analysed. All patients were offered all steps of the algorithm nitroglycerine (NTG) → Botox (BTX) → surgery, unless symptoms or patient preference demanded a more aggressive treatment. Patients were followed up in clinic, and treatment was advanced if a step either failed or caused intolerable side effects. RESULTS: Two hundred and nine patients were included in the analysis. Mean duration of symptoms was 25.6 months and mean follow up 16 months. One hundred and 41 patients started on NTG, 36 on BTX, and 31 went straight to surgery. One patient opted for no treatment. Symptoms persisted in 58 (41.1%) of 141 NTG patients. Forty-five (31.9% of NTG subset) were advanced to BTX and 13 (9.2% of subset) to surgery. Of the 81 (36 primary + 45 secondary) BTX patients (38.8% of the total), only 11 (13.6% of subset) required surgery. A total of 55 (31 primary + 24 secondary; 26.3%) patients needed surgery: two (3.6%) fissures did not heal, one patient developed an abscess, 14 (25.5%) had prolonged wound healing and two (3.6%) developed a recurrent fissure after the sphincterotomy had healed. CONCLUSION: Our algorithm is effective in CAF and the majority of patients respond to conservative management. Only 26.3% of all patients require surgery, which is effective but also carries some temporary morbidity.

Suppression of near-Fermi level electronic states at the interface in a LaNiO3/SrTiO3 superlattice.

Standing-wave-excited photoemission is used to study a SrTiO3/LaNiO3 superlattice. Rocking curves of core-level and valence band spectra are used to derive layer-resolved spectral functions, revealing a suppression of electronic states near the Fermi level in the multilayer as compared to bulk LaNiO3. Further analysis shows that the suppression of these states is not homogeneously distributed over the LaNiO3 layers but is more pronounced near the interfaces. Possible origins of this effect and its relationship to a previously observed metal-insulator-transition in ultrathin LaNiO3 films are discussed.

Modified Hanley procedure for management of complex horseshoe fistulae.

PURPOSE: Horseshoe fistulae are challenging due to configuration and sphincter involvement. In view of the new treatment options for fistulae (e.g. collagen plug), aim of our study was to review the outcome of patients primarily treated with a traditional approach. METHODS: We retrospectively reviewed patients who presented between 2003 and 2008, with a posterior horseshoe abscess/fistula and were treated with a modified Hanley procedure and seton management. Excluded were Crohn's disease, fistulae from malignancy/surgical complications, and other treatment methods. Data collection included demographics, duration of the disease, and of the treatment, outcome, and incontinence. RESULTS: Twenty-three patients (M/F 20/3) were analyzed. Mean age was 50.3 + or - 10.2 years, median symptom duration 24 months; three patients (19%) had previously received colostomies without resolution. All patients received a posterior midline cutting seton. The average total number of setons was 3 + or - 1.3 (range 2-7), with removal after 1.6 + or - 1.2 months upon resolution of induration and suppuration. The cutting seton was tightened in monthly intervals on average 4.9 + or - 2.2 times. Follow-up was 15.4 + or - 9.7 months: 91.3% patients had complete healing time within 8.1 + or - 4.5 months; 19/23 patients recovered fast, and were able to work no later than 4 weeks postoperatively (2 patients retired, 2 on disability for other reasons). No incontinence was found. CONCLUSIONS: Fecal diversion alone did not resolve horseshoe fistulae. A modified Hanley procedure with drainage of the deep postanal space and cutting and draining setons proved to be safe, successful, and did not result in complaints of fecal incontinence. Completion of the treatment took months, but patients remained functional even with setons in place.

Robotic-assisted laparoscopic repair of rectovesical fistula after Hartmann's reversal procedure.

The case is of a 59-year-old male with history of severe ischemic colitis following emergent intervention for a ruptured infrarenal aortic aneurysm who subsequently underwent left hemicolectomy, partial proctectomy, and Hartmann colostomy. The patient later underwent reversal of the Hartmann colostomy with diverting ileostomy. The surgery was complicated by a right ureteral and posterior bladder injury that resulted in a large rectovesical fistula involving the right hemitrigone and right ureteral orifice. An attempt to repair the rectovesical fistula at an outside facility was unsuccessful. Then, he underwent a robotic-assisted laparoscopic repair of rectovesical fistula, including simple prostatectomy, excision of rectovesical fistulous tract, rectal closure, peritoneal and omental flap interposition, bladder neck reconstruction, vesicourethral anastomosis and right ureteral reimplantation. There were no intraoperative or postoperative complications, and the patient was discharged at postoperative day 4; cystoscopy at 6-week follow-up demonstrated a successful closure of the fistula, at which time the ureteral stents were removed.

Cloaca-like deformity with faecal incontinence after severe obstetric injury--technique and functional outcome of ano-vaginal and perineal reconstruction with X-flaps and sphincteroplasty.

OBJECTIVE: Surgical technique and outcomes report. SUMMARY BACKGROUND DATA: Three to eight per cent of vaginal deliveries are complicated by third- or fourth- degree perineal lacerations, resulting in a cloaca-like deformity in up to 0.3%. These three-dimensional defects result in often debilitating incontinence and symptoms similar to a rectovaginal fistula because of the lack of the distal rectovaginal septum. METHOD: Between 2001 and 2006, 12 women (median age 37, range 20-57) with faecal incontinence and a postobstetric-injury-associated cloaca-like deformity underwent an ano-vaginal and perineal reconstruction with X-flaps and sphincteroplasty without primary faecal diversion. RESULTS: The patients presented 13.0 +/- 2.9 years (range 0.5-29 years) after the obstetric injury. The median Cleveland Clinic Florida faecal incontinence score was 16 (range 12-19). In addition, one patient complained of vaginal discharge, another of dyspareunia. All patients had an open rectovaginal communication with a large anterior sphincter defects (mean 160.2 +/- 22.8 degrees, range 113-180). Resting/squeeze pressures were 28.0 +/- 4.4/63.2 +/- 8.1 mmHg, respectively. Pudendal neuropathy was present in five patients. The median length of hospital stay after surgery was 5.3 +/- 0.7 days. Three patients experienced a postoperative rectovaginal fistula, two of which closed spontaneously, whereas the third required faecal diversion and a bulbocavernosus flap. After surgical follow-up of 9.8.3 +/- 2.8 months and long-term follow-up of 38.9.0 +/- 6.9 months, all the patients were satisfied with regards to overall function, continence and cosmetic result. CONCLUSION: Cloaca-like deformity resulting from severe obstetric injury is often not given appropriate attention. Reconstruction of the original anatomy is complex but achieves good results and does not require a prophylactic faecal diversion.

Superconductor to Mott insulator transition in YBa2Cu3O7/LaCaMnO3 heterostructures.

The superconductor-to-insulator transition (SIT) induced by means such as external magnetic fields, disorder or spatial confinement is a vivid illustration of a quantum phase transition dramatically affecting the superconducting order parameter. In pursuit of a new realization of the SIT by interfacial charge transfer, we developed extremely thin superlattices composed of high Tc superconductor YBa2Cu3O7 (YBCO) and colossal magnetoresistance ferromagnet La0.67Ca0.33MnO3 (LCMO). By using linearly polarized resonant X-ray absorption spectroscopy and magnetic circular dichroism, combined with hard X-ray photoelectron spectroscopy, we derived a complete picture of the interfacial carrier doping in cuprate and manganite atomic layers, leading to the transition from superconducting to an unusual Mott insulating state emerging with the increase of LCMO layer thickness. In addition, contrary to the common perception that only transition metal ions may respond to the charge transfer process, we found that charge is also actively compensated by rare-earth and alkaline-earth metal ions of the interface. Such deterministic control of Tc by pure electronic doping without any hindering effects of chemical substitution is another promising route to disentangle the role of disorder on the pseudo-gap and charge density wave phases of underdoped cuprates.

Nosocomial infections in a Dutch neonatal intensive care unit: surveillance study with definitions for infection specifically adapted for neonates.

The incidence of nosocomial infection in neonatal intensive care units (NICUs) is high compared with other wards. However, no definitions for hospital-acquired infection are available for NICUs. The aim of this study was to measure the incidence of such infections and to identify risk factors in the NICU of the VU University Medical Center, which serves as a level III regional NICU. For this purpose, a prospective surveillance was performed in 1998-2000. We designed definitions by adjusting the current definitions of the Centers for Disease Control and Prevention (CDC) for children <1 year of age. Birth weight was stratified into four categories and other baseline risk factors were dichotomized. Analysis of risk factors was performed by Cox regression with time-dependent variables. The relationship between the Clinical Risk Index for Babies (CRIB) and nosocomial infection was investigated. Furthermore, for a random sample of cases, we determined whether bloodstream infection and pneumonia would also have been identified with the CDC definitions. Seven hundred and forty-two neonates were included in the study. One hundred and ninety-one neonates developed 264 infections. Bloodstream infection (N=138, 14.9/1000 patient-days) and pneumonia (N=69, 7.5/1000 patient-days) were the most common infections. Of bloodstream infections, 59% were caused by coagulase-negative staphylococci; in 21% of neonates, blood cultures remained negative. In 25% of pneumonias, Enterobacteriaceae were the causative micro-organisms; 26% of cultures remained negative. Compared with the Nosocomial Infections Surveillance System (NNIS) of the CDC, our device utilization ratios and device-associated nosocomial infection rates were high. The main risk factors for bloodstream infection were birth weight [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.45-2.17] and parenteral feeding with hospital-pharmacy-produced, all-in-one mixture 'Minimix' (HR 3.69, 95%CI 2.03-6.69); administration of intravenous antibiotics (HR 0.39, 95%CI 0.26-0.56) was a protective risk factor. The main risk factors for pneumonia were low birth weight (HR 1.37, 95%CI 1.01-1.85) and mechanical ventilation (HR 9.69, 95%CI 4.60-20.4); intravenous antibiotics were protective (HR 0.37, 95%CI 0.21-0.64). In a subcohort of 232 very-low-birthweight neonates, the CRIB was not predictive for infection. With the CDC criteria, only 75% (21/28) of bloodstream infections and 87.5% of pneumonias (21/24) would have been identified. In conclusion, our local nosocomial infection rates are high compared with those of NICUs participating in the NNIS. This can be partially explained by: (1) the use of our definitions for nosocomial infection, which are more suitable for this patient category; and (2) the high device utilization ratios.

[Resistant microorganisms in patients transferred from foreign hospitals]. / Resistente micro-organismen bij gerepatrieerde patienten uit buitenlandse ziekenhuizen.

OBJECTIVE: To determine the prevalence of carriers of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and gentamicin-resistant Gram-negative bacilli (GGNB) in patients repatriated from foreign hospitals to The Netherlands. DESIGN: Determination of prevalence. METHOD: In the period May 1998-August 2001, 1167 patients were repatriated. Swab specimens, demographic data and clinical data were obtained during the transfer. RESULTS: The prevalence of carriers of resistant microorganisms was 18.2%. MRSA was carried by 2.7% of the total repatriated group and by 4.7% of patients transferred to a Dutch hospital. Risk factors were antimicrobial treatment (odds ratio (OR): 3.4; 95% CI: 1.2-9.7), length of stay in a foreign hospital > or = 14 days (OR: 5.4; 95% CI: 2.3-12) and artificial ventilation (OR: 8.5; 95% CI: 1.8-41). VRE and GGNB were isolated from 2.7% and 14.1% of patients, respectively. Transfer from Asia or southern, south-eastern and eastern Europe were risk factors for carrying GGNB. CONCLUSION: Carriership of resistant microorganisms was high among repatriated patients. The highest risk of GGNB was more closely associated with the country from which the patient was transferred than the antimicrobial treatment received in the foreign hospital.

Measurement of metabolism in multiple organ failure.

Despite the emphasis on surgical nutrition, clinical research and practice are usually based on gross estimation of caloric requirements and no specific knowledge of caloric balance. One reason for this is the difficulty of measuring O2 and CO2 exchange in critically ill patients. We designed a system for intensive care unit (ICU) bedside measurement of O2 consumption (VO2), CO2 production (VCO2), respiratory quotient (RQ), and indirect calorimetry (E). We measured these variables daily in 57 surgical ICU patients at risk for multiple organ failure. Measured VO2 and E varied widely (+/- 40%) from estimated values. Seventeen patients had a cumulative negative balance of at least 10,000 calories; 13 died. This caloric deficient was reversed by caloric intake in three of these patients; one died. Fifteen patients had positive caloric balance. Only four of these died, but the CO2 load produced by hypercaloric feeding created ventilator weaning problems in some patients. Ventilator weaning was facilitated by decreasing total calories and substituting fat for carbohydrate to reduce the RQ. The incidence of multiple organ failure was higher in patients with large caloric deficits, although cause and effect are not inferred. We conclude that respirometry and indirect calorimetry are helpful for management and essential for nutritional research.

Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain.

BACKGROUND: Thoracic epidural analgesia is considered the method of choice for postthoracotomy analgesia, but it is not suitable for every patient and is associated with some risks and side effects. We therefore evaluated the effects of an extrapleural intercostal analgesia as an alternative to thoracic epidural analgesia. METHODS: In a prospective, randomized study, pain control, recovery of ventilatory function, and pulmonary complications were analyzed in patients undergoing elective lobectomy or bilobectomy. Two groups of 15 patients each were compared: one received a continuous extrapleural intercostal nerve blockade (T3 through T6) with bupivacaine through an indwelling catheter, the other was administered a combination of local anesthetics (bupivacaine) and opioid analgesics (fentanyl) through a thoracic epidural catheter. RESULTS: Both techniques were safe and highly effective in terms of pain relief and recovery of postoperative pulmonary function. However, minor differences were observed that, together with practical benefits, would favor extrapleural intercostal analgesia. CONCLUSIONS: These results led us to suggest that extrapleural intercostal analgesia might be a valuable alternative to thoracic epidural analgesia for pain control after thoracotomy and should particularly be considered in patients who do not qualify for thoracic epidural analgesia.

Carriage of resistant microorganisms in repatriates from foreign hospitals to The Netherlands.

In a prospective survey conducted between May 1998 and September 2001, the prevalence of carriage of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and gentamicin-resistant Gram-negative bacilli (GGNB) was determined in 1167 patients repatriated from foreign hospitals to The Netherlands. Swab specimens, demographic data and clinical data were obtained during transfer of the patients from the foreign hospitals. The total prevalence of carriage of resistant microorganisms was 18.2%. MRSA was carried by 2.7% of all patients, and by 4.7% of the patients repatriated to a Dutch hospital. Antimicrobial treatment (adjusted odds ratio (OR) 3.4; 95% confidence interval (CI) 1.2-9.7), length of stay in a foreign hospital of > 14 days (adjusted OR 5.4; 95% CI 2.3-12) and artificial ventilation (adjusted OR 8.5; 95% CI 1.8-41) were risk factors for carriage of MRSA. VRE and GGNB were isolated from 2.7% and 14.1% of the patients, respectively. Transfer from Asia, and southern, southeastern and eastern Europe, were risk factors for carriage of GGNB. These carriage rates were high compared to those found in patients in Dutch hospitals, where the rates are < 1% for MRSA, 2% for VRE, and 4.5% for GGNB. The highest risk of acquisition of GGNB was associated with the country from where the patient was repatriated, rather than with the antimicrobial treatment received by the individual patient in the foreign hospital.

Evaluation of necrotizing pancreatitis in the opossum by dynamic contrast-enhanced computed tomography: correlation between radiographic and morphologic changes.

BACKGROUND: The ability to quantitate the extent of acinar cell necrosis with contrast-enhanced computed tomography (CT) during acute pancreatitis is uncertain. STUDY DESIGN: Acute hemorrhagic necrotizing pancreatitis was induced in opossums by obstructing their biliopancreatic duct for up to seven days or by retrograde injection of a bile-trypsin taurocholate mixture into the opossum pancreatic duct. At selected times, groups of three animals each were examined by dynamic contrast-enhanced CT, and the abnormalities on the images were quantitated. Immediately following CT, the animals were sacrificed and the extent of necrosis was quantitated by morphometric analysis of tissue samples at the light microscope level. RESULTS: The CT severity score as well as the degree of nonenhancement on dynamic contrast-enhanced CT were both closely correlated with the extent of acinar cell necrosis (r = 0.91 and r = 0.97, respectively). CONCLUSIONS: The degree of pancreatic nonenhancement on dynamic contrast-enhanced CT can be used to quantitate the extent of pancreatic necrosis during acute necrotizing pancreatitis.

Nosocomial outbreak of gentamicin-resistant Klebsiella pneumoniae in a neonatal intensive care unit controlled by a change in antibiotic policy.

Between August and November 1997, a nosocomial outbreak caused by gentamicin-resistant Klebsiella pneumoniae occurred in the Neonatal Intensive Care Unit (NICU) of our hospital. Thirteen neonates became colonized and three of them became infected. Comparison of the isolates by amplified fragment length polymorphism (AFLP) revealed clonal similarity for isolates of eight neonates (homology > 90%). Cultures from environmental specimens were negative for gentamicin-resistant K. pneumoniae. A case-control study was conducted to identify risk factors associated with acquisition of gentamicin-resistant K. pneumoniae. Risk factors were low gestational age and birth weight. These neonates need more care and handling and may therefore, be more at risk of colonization. Length of stay on the NICU was significantly longer for cases, but mean time until colonization (6.3 days) was shorter than the total stay for controls (9.5 days). No single member of the medical or nursing staff was significantly more involved with cases than with controls. The outbreak was stopped by replacing gentamicin by amikacin as the antibiotic of first choice whenever the use of an aminoglycoside antibiotic was indicated.

A simultaneous outbreak on a neonatal unit of two strains of multiply antibiotic resistant Klebsiella pneumoniae controllable only by ward closure.

Two aminoglycoside-resistant strains of Klebsiella pneumoniae caused an outbreak on the neonatal unit at St Thomas' Hospital. One, which affected 18 patients, was capsular type K18 and resistant to newer cephalosporins by the production of the extended-spectrum beta-lactamase SHV-2; the other, which colonized four patients, was capsular non-typeable and did not produce extended-spectrum beta-lactamase. Both strains were probably brought into the unit by carrier patients; the probable carrier of the non-typeable strain was transferred from another hospital but was negative on a single admission screen; the probable carrier of the K18 strain was not screened on admission because he had been born at St Thomas', but his mother had been transferred from another hospital. Despite intensive efforts to control the outbreak by standard methods of hand washing, screening, patient isolation and environmental cleaning, a total of 22 neonates on the unit eventually became colonized or infected. One of three patients with bacteraemia died. A small proportion of samples of expressed breast milk, electronic thermometers and oxygen saturation probes were contaminated by the K18 strain and may have contributed to some of the cross-infection, but this did not explain the extent of the outbreak. The outbreak was controlled only by opening a temporary ward for colonized neonates and another for newly born babies, which allowed the closure and cleaning of the main neonatal unit. Multiply antibiotic resistant klebsiellas may be highly epidemic and cause serious, difficult-to-control outbreaks on neonatal units. All patients, regardless of their admission history, should be screened on admission for carriage of multiply resistant enterobacteria by a sensitive method, and units should have plans for temporary ward closure should outbreaks occur.

Ultra-sonic nebulizers as a potential source of methicillin-resistant Staphylococcus aureus causing an outbreak in a university tertiary care hospital.

An outbreak of methicillin-resistant Staphylococcus aureus (MRSA) occurred on a head and neck surgical (HNS) ward of a university hospital in Amsterdam. The outbreak lasted from May 2000 until November 2000, and MRSA spread to two intensive care units. Amplified fragment length polymorphism analysis indicated that a single clone was responsible for the outbreak. Phage-typing indicated that this clone was of a type that was uncommon in The Netherlands. Strict isolation of patients, according to the Dutch national guidelines, was instituted. During the outbreak, surveillance culture specimens, from patients, healthcare workers, and the environment, were obtained at regular intervals. MRSA was found in the dust filters of nebulizers through which air from the room was filtered and subsequently humidified. These nebulizers were used to humidify tracheostomies. The dust filters were not maintained according to the guidelines. Restricted use and cleaning and disinfection of all ultra-sonic nebulizers led to termination of the outbreak. The outbreak illustrates that to terminate transmission of outbreak strains of MRSA, meticulous measures are necessary, which not only include strict isolation precautions, but also decontamination of the environment. In addition, it demonstrates the necessity of adhering to cleaning and disinfection guidelines for all medical and nursing equipment used in the hospital.

History of laparoscopy.

The history of laparoscopic surgery demonstrates how a close interaction between technology and medical-surgical innovators permitted its ultimate development. Similar revolutions have occurred in information and communication technology and in molecular biology. Within less than 2 decades, surgical management has moved from a disease-oriented approach to one that is more patient-oriented. While the past decade was characterized by the issue of what could be accomplished laparoscopically, the future will focus on the question of which operations should really be performed by this approach.

Spontaneous abrupt changes in the distribution of ventilation: a cause for apparent mismatching on ventilation/perfusion scintigraphy.

A defect seen in the perfusion scan in a region of lung that is normally ventilated is usually interpreted as indicating pulmonary vascular disease. Since the distribution of 99Tcm macro-aggregated albumin (MAA) represents the distribution of perfusion (Q) only at the time of MAA injection, the assumption is required that the distribution of ventilation (V) remains unchanged between MAA injection and the commencement of imaging. We report the V/Q scintigraphic findings in six patients (including four children), in whom this assumption could not be sustained. Thus ventilation imaged with 81Krm was seen to change during image acquisition in lobes that showed perfusion abnormalities. In some, but not all, views the appearances were typical for pulmonary vascular disease, which might easily have been misdiagnosed if the changes in the distribution of ventilation had not announced themselves by occurring during image acquisition. A ventilation image obtained immediately before injection of 99Tcm-MAA may be useful.