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.

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.

The importance of increased awareness for delirium in elderly patients with rib fractures after blunt chest wall trauma: a retrospective cohort study on risk factors and outcomes.

BACKGROUND: Rib fractures are common in ageing people after trauma and delirium is a complication often seen in acutely hospitalized elderly patients. For both conditions, elderly have an increased risk for institutionalization, morbidity, and mortality. This study is the first to investigate risk factors of delirium in elderly patients with rib fractures after trauma. METHODS: A retrospective chart review was performed on patients ≥65 years admitted with rib fractures after blunt chest wall trauma to the Amphia hospital Breda, the Netherlands, between July 2013 and June 2018. Baseline patient, trauma- and treatment-related characteristics were identified. The main objectives were identification of risk factors of delirium and investigation of the effect of delirium on outcomes after rib fractures. Outcomes were additional complications, length of hospital stay, need for institutionalization and mortality within six months. RESULTS: Forty-seven (24.6%) of 191 patients developed a delirium. Independent risk factors for delirium were increased age, physical impairment (lower KATZ-ADL score), nutritional impairment (higher SNAQ score) and the need for a urinary catheter, with odds ratios of 1.07, 0.78, 1.53 and 8.53 respectively. Overall, more complications were observed in patients with delirium. Median ICU and hospital length of stay were 4 and 7 days respectively, of which the latter was significantly longer for delirious patients (p < 0.001). Significantly more patients with delirium were discharged to a nursing home or rehabilitation institution (p < 0.001). The 6-month mortality in delirious patients was nearly twice as high as in non-delirious patients; however, differences did not reach statistical significance. CONCLUSION: Delirium in elderly patients with rib fractures is a serious and common complication, with a longer hospital stay and a higher risk of institutionalization as a consequence. Increased awareness for delirium is imperative, most importantly in older patients, in physically or nutritionally impaired patients and in patients in need of a urinary catheter.

Peri-Operative Nasal Eradication Therapy Prevents Staphylococcus aureus Surgical Site Infections in Aortoiliac Surgery.

BACKGROUND: Surgical site infections (SSIs) cause considerable morbidity and deaths among patients undergoing vascular surgery. Pre-operative screening and subsequent treatment of nasal Staphylococcus aureus carriers with mupirocin and chlorhexidine reduces the risk of SSIs in cardiothoracic and orthopedic surgery. The aim of this study was to investigate the effect of this screen-and-treat strategy on the development of SSI in patients undergoing aortoiliac surgery. METHODS: A prospective study was performed that enrolled an intervention cohort comprising all patients undergoing aortoiliac surgery from February 2013 to December 2016. Before surgery, patients were screened for S. aureus nasal carriage and, if positive, were treated with mupirocin nasal ointment and chlorhexidine body washes. The presence of SSI was recorded on the basis of the criteria of the U.S. Centers for Disease Control and Prevention. A historic control group was used, consisting of aortoiliac surgery patients in 2010 who tested positive for S. aureus but received no treatment. RESULTS: A total of 374 patients in the study cohort were screened of whom 75 (20.1%) tested positive for S. aureus. Of these patients, 68 were given eradication therapy. In the 2010 cohort, 22 patients (15.7%) were positive. The incidence of S. aureus infection was 0 of 75 in the treatment group versus 3 of 22 (13.6%) in the control group (p = 0.021). Both the 30-day mortality rate (1.3% vs. 13.6%; p = 0.035) and the rate of re-interventions (12.0% vs. 31.8%) were significantly lower in the treated group. CONCLUSION: We conclude that S. aureus nasal screening and eradication with mupirocin and chlorhexidine reduces S. aureus SSI and its complications after aortoiliac surgery.

The COSMAM TRIAL a prospective cohort study of quality of life and cosmetic outcome in patients undergoing breast conserving surgery.

BACKGROUND: Cosmetic result in breast cancer surgery is gaining increased interest. Currently, some 30-40% of the patients treated with breast conserving surgery (BCS) are dissatisfied with their final cosmetic result. In order to prevent disturbing breast deformity oncoplastic surgical techniques have been introduced. The extent of different levels of oncoplastic surgery incorporated in breast conserving surgery and its value with regard to cosmetic outcome, patient satisfaction and quality of life remains to be defined. The aim of this prospective cohort study is to investigate quality of life and satisfaction with cosmetic result in patients with breast cancer, undergoing standard lumpectomy versus level I or II oncoplastic breast conserving surgery. METHODS: Female breast cancer patients scheduled for BCS, from 18 years of age, referred to our outpatient clinic from July 2015 are asked to participate in this study. General, oncologic and treatment information will be collected. Patient satisfaction will be scored preceding surgery, and at 1 month and 1 year follow up. Photographs of the breast will be used to score cosmetic result both by the patient, an independent expert panel and BCCT.Core software. Quality of life will be measured by using the BREAST-Q BCT, EORTC-QLQ and EQ-5D-5 L questionnaires. DISCUSSION: The purpose of this prospective study is to determine the clinical value of different levels of oncoplastic techniques in breast conserving surgery, with regard to quality of life and cosmetic result. Analysis will be carried out by objective measurements of the final cosmetic result in comparison with standard breast conserving surgery. The results of this study will be used to development of a clinical decision model to guide the use oncoplastic surgery in future BCS. TRIAL REGISTRATION: Central Commission of Human Research (CCMO), The Netherlands: NL54888.015.15. Medical Ethical Commission (METC), Maxima Medical Centre, Veldhoven, The Netherlands: 15.107. Dutch Trial Register: NTR5665 , retrospectively registered, 02-25-2016.

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.

Radial Head Arthroplasty: A Systematic Review.

BACKGROUND: Despite the expanding body of literature on radial head arthroplasty, the increasing understanding of elbow anatomy, biomechanics, and kinetics, and the evolution of surgical techniques and prosthesis designs, there is currently no evidence to support one type of radial head prosthesis over another. The purposes of the present report were to review the literature and to explore the association between prosthesis design variables and the timing of surgery and the outcome of modern radial head arthroplasty. METHODS: The literature search was limited to studies involving skeletally mature patients. Major databases were searched from January 1940 to May 2015 to identify studies relating to functional and subjective outcomes and radiographic results after radial head arthroplasty. RESULTS: Thirty articles involving 727 patients were included. Seventy percent of the implants were made of cobalt-chromium, 15% were made of pyrocarbon, 9% were made of titanium, and 6% were made of Vitallium. Seventy percent were monopolar, and 30% were bipolar. Twenty-one percent were cemented in place, 32% were press-fit, 32% were intentionally loose-fit, and 15% were fixed with an expandable stem. The weighted average duration of follow-up was 45 months. The rate of revision ranged from 0% to 29% among studies. The incidence of revision was 8% during 2,714 person-years of follow-up across all 727 patients, yielding a crude overall revision rate of 2.06 per 100 person-years of follow-up. The revision rate was not significantly affected by prosthesis polarity, material, or fixation technique, nor was it significantly affected by the delay of treatment. There was also no significant effect of prosthesis polarity, material, or fixation technique on postoperative range of motion. The Mayo Elbow Performance Score was only reported for half of the overall patient population, but, among those patients, the combined rate of excellent and good results was 85%. Seven percent of the overall patient population underwent secondary surgery about the elbow other than revision surgery. Twenty-three percent were reported to have 1 or more complications. CONCLUSIONS: On the basis of our analysis of the peer-reviewed English-language literature on radial head arthroplasty from January 1940 to May 2015, there seems to be no evidence to support one type of radial head prosthesis over another. The only exception is that silicone prostheses have been shown to be biologically and biomechanically insufficient. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cemented bipolar radial head arthroplasty: midterm follow-up results.

BACKGROUND: Theoretical advantages of bipolar over monopolar radial head arthroplasty include better accommodation of radiocapitellar malalignment, reduction of capitellar abrasion, and reduction of stress at the bone-to-cement and cement-to-implant interfaces. Our purpose was to report the midterm results of cemented bipolar radial head arthroplasty. METHODS: Twenty-five patients were treated by cemented bipolar radial head arthroplasty for acute fracture of the radial head, earlier treatment that had failed, or posttraumatic sequelae. One patient refused follow-up after surgery. Results are presented for the remaining 24 patients. RESULTS: At a mean follow-up of 50 months (range, 24-72 months), 1 prosthesis (4%) had been removed 2 years after implantation for dissociation of the prosthesis due to failure of the snap-on mechanism. There were 2 (8%) additional radiologic failures in the subluxated position: 1 prosthesis due to malalignment of the radius onto the capitellum and another due to ulnohumeral erosion. The average flexion-extension arc was 129° (range, 80°-140°), and the average pronation-supination arc was 131° (range, 40°-180°). According to the Mayo Elbow Performance Score, the combined excellent and good results accounted for 83%. In 8 patients, the bipolar design compensated for radiocapitellar malalignment. CONCLUSIONS: The overall midterm outcome of this series of 25 cemented bipolar radial head arthroplasties can be considered favorable. There was 1 (4%) revision and 2 (8%) additional radiologic failures. The bipolar design was able to compensate for radiocapitellar malalignment. We suggest considering a cemented bipolar radial head prosthesis in case of concerns about radiocapitellar alignment.

Life Expectancy in Nonagenarians Suffering from Critical Limb Ischemia.

BACKGROUND: Peripheral arterial disease has become an increasing problem in the aging population of the western world with a prevalence of 10-14%. This will result in a growing group of nonagenarians being referred to vascular surgeons, with an estimated growth of 2.5 times the number of nonagenarians between 2015 and 2040. Outcome results of nonagenarians suffering from critical limb ischemia (CLI) are scarce, which can cause difficulties in choosing superior therapy options. We propose that the life expectancy of nonagenarians suffering CLI compared to the overall population of nonagenarians is valuable information required in clinical decision-making. METHODS: Between January 2012 and October 2015, all patients suffering from CLI were retrospectively reviewed in the Amphia Hospital, Breda, The Netherlands. Patients aged ≥90 years at admission were exclusively included. The main outcome result of this study is the life expectancy of nonagenarians suffering from CLI. Closely related to life expectancy is the primary end point of mortality. Secondary end points were adverse events, reoperations, and limb salvage. RESULTS: A total of 36 patients were included in this study of which 27 were women. The median age was 92 years. Conservative therapy was performed in 61% of the patients. Based on 24 deaths (of which 19 were women), the mortality rate ratio of the study group relative to the Dutch population was 3.13 (95% confidence interval [CI], 2.00-4.66; P < 0.000001), adjusted for age and gender. Life expectancy in years of the total Dutch population at age 90 years in 2013 was 3.83 for men and 4.54 for women in contrast to, respectively, 1.23 (95% CI, 0.50-5.69) and 2.70 (95% CI, 1.76-3.74) years in our patient group. CONCLUSIONS: CLI is a severe disease in nonagenarians with a dreadful life expectancy of 1.23 and 2.7 years for men and women, respectively, corresponding with an age- and gender-adjusted mortality rate ratio of 3.13 relative to the Dutch population. Individual factors such as preoperative status, arterial occlusive lesion, and especially predicted postoperative quality of life are important parameters in clinical decision-making. Results of conservative therapy might be acceptable in selected patients, but more focus on quality of life is needed to be conclusive.

Press-fit bipolar radial head arthroplasty, midterm results.

BACKGROUND: Theoretical advantages of bipolar compared with monopolar radial head arthroplasty include better accommodation of radiocapitellar malalignment, reduction of capitellar abrasion, and reduction of stress at the bone-implant interfaces. Our purpose was to report the midterm results of press-fit bipolar radial head arthroplasty. METHODS: Thirty patients were treated by press-fit bipolar radial head arthroplasty for acute fracture of the radial head, failed earlier treatment, or post-traumatic sequelae. Three patients were lost to follow-up. Results are presented for the remaining 27 patients. RESULTS: At mean follow-up of 48 months (range, 28-73), there had been 3 (11%) revisions. Two involved conversion to prosthetic radiocapitellar hemiarthroplasty for symptomatic capitellar abrasion; a third involved exchange of the articular component (ie, head) for instability. In all, the stems appeared well fixed. A prosthesis in a subluxed position accounted for the 1 (4%) additional radiologic failure. The average flexion-extension arc was 136° (range, 120°-145°), and the average pronation-supination arc was 138° (range, 70°-180°). According to the Mayo Elbow Performance Score, the combined excellent and good results accounted for 70%. CONCLUSIONS: The overall midterm outcome of this series of 30 press-fit bipolar radial head arthroplasties can be considered favorable. Although the revision rate was 11%, the stems were well fixed in all. There was 1 (4%) additional radiologic failure. We suggest considering a press-fit bipolar radial head prosthesis for acute comminuted radial head fractures with limited bone loss of the proximal radius.

Pilot Study of the Pharmacokinetics of Cefotaxime in Critically Ill Patients with Acute Kidney Injury Treated with Continuous Renal Replacement Therapy.

The objective of this study was to describe the pharmacokinetics of cefotaxime (CTX) in critically ill patients with acute kidney injury (AKI) when treated with continuous renal replacement therapy (CRRT) in the intensive care unit (ICU). This single-center prospective observational pilot study was performed among ICU-patients with AKI receiving ≥48 h concomitant CRRT and CTX. CTX was administered intravenously 1,000 mg (bolus) every 6 h for 4 days. CRRT was performed as continuous venovenous hemofiltration (CVVH). Plasma concentrations of CTX and its active metabolite desacetylcefotaxime (DAC) were measured during CVVH treatment. CTX plasma levels and patient data were used to construct concentration-time curves. By using this data, the duration of plasma levels above 4 mg/liter (four times the MIC) was calculated and analyzed. Twenty-seven patients were included. The median CTX peak level was 55 mg/liter (range, 19 to 98 mg/liter), the median CTX trough level was 12 mg/liter (range, 0.8 to 37 mg/liter), and the median DAC plasma level was 15 mg/liter (range, 1.5 to 48 mg/liter). Five patients (19%) had CTX plasma levels below 4 mg/liter at certain time points during treatment. In at least 83% of the time any patient was treated with CTX, the CTX plasma level stayed above 4 mg/liter. A dosing regimen of 1,000 mg of CTX given four times daily is likely to achieve adequate plasma levels in patients with AKI treated with CVVH. Dose reduction might be a risk for suboptimal treatment.

The Size of the Radial Tuberosity is Not Related to the Occurrence of Distal Biceps Tendon Ruptures: A Case-Control Study.

INTRODUCTION: Hypertrophic changes at the radial tuberosity have traditionally been related to distal biceps tendon degeneration and rupture. From supination to pronation of the forearm, the space available for the distal biceps tendon between de lateral ulna and radial bicipital tuberosity (RBT) decreases by almost 50%. A hypertrophic change at the radial tuberosity further reduces this space with impingement of the distal biceps tendon as a result. The purpose of this study was to evaluate whether the size of the RBT plays a role in the pathophysiology of distal biceps tendon ruptures. MATERIALS AND METHODS: Twenty-two consecutive patients with a surgically proven distal biceps tendon rupture were matched to controls, in a 1:1 ratio. The size of the RBT was expressed as a ratio of the maximum diameter of the radius at the RBT to the diameter of the diaphysis just distal to the RBT (RD ratio), measured on standard radiographs of the elbow. The RD ratio of patients and matched controls were compared. RESULTS: The mean RD ratio in control group was 1.25 and not significantly different from the mean 1.30 in the group of patients with a distal biceps tendon rupture. Each 0.1 point increase in RD ratio results in an estimated 60% increase of the rupture odds, which was not significant either. CONCLUSION: Based on the RD ratio on conventional radiographs of the elbow, there was no significant difference in RBT size between patients with a distal biceps tendon rupture and matched controls without biceps tendon pathology.

Refixation techniques and approaches for distal biceps tendon ruptures: a systematic review of clinical studies.

BACKGROUND: Surgical fixation is the preferred method of treatment for the ruptured distal biceps tendon in active patients. To date, no fixation technique has been proven superior in a clinical setting. The purpose of the study was to systematically review the available literature on approach and fixation methods for distal biceps tendon repair in a clinical setting and to determine the optimal fixation methods of the distal biceps tendon on the radial tuberosity. Our hypothesis was that the outcomes would not be significantly different among the various fixation techniques and approaches. METHODS: A systematic review of the available literature on anatomic reconstruction methods for distal biceps tendon ruptures was performed. The outcome measures evaluated were postoperative range of motion, elbow flexion and supination strength, and complication rates and types. RESULTS: Forty articles were included, representing 1074 patients divided into 4 fixation groups: suture anchors, bone tunnels, interference screws, and cortical buttons. There was no significant difference in range of motion and strength between the different approaches and fixation techniques. Complications were significantly less common after the double-incision approach with bone tunnel fixation (P < .0005). CONCLUSIONS: There were significantly fewer complications after the double-incision approach with bone tunnel fixation. The double-incision approach had significantly fewer complications than the single-incision anterior approach, and the bone tunnel fixation had significantly fewer complications than the other 3 fixation techniques. However, as the double-incision approach was used with bone tunnel fixation in 84% of cases, there was a strong interrelationship between these variables.

The effect of trauma and patient related factors on radial head fractures and associated injuries in 440 patients.

BACKGROUND: Radial head fractures are commonly interpreted as isolated injuries, and it is assumed that the energy transferred during trauma has its influence on the risk on associated ipsilateral upper limb injuries. However, relationships between Mason classification, mechanism of injury, and associated injuries have been reported only once before in a relatively small population. The purpose of this study was to define whether trauma mechanism and patient related factors are of influence on the type of radial head fracture and associated injuries to the ipsilateral upper limb in 440 patients. METHODS: The radiographs and medical records of 440 patients that presented with a fracture of the radial head were retrospectively analyzed. The medical records of all patients were searched for (1) the trauma mechanism and (2) associated injuries of the ipsilateral upper limb. The mechanism of injury was classified as being low-energy trauma (LET) or high-energy trauma (HET). RESULTS: Associated injuries to the ipsilateral upper limb were present in 46 patients (11%). The mean age of patients with associated injuries (52 years) was significantly higher compared to patients without associated injuries (47 years) (P = 0.038), and female patients with a radial head fracture were older than males. Injury patterns were classified as LET in 266 patients (60%) and as HET in 174 patients. HETs were significantly more common in young men. Associated injuries were not significantly different distributed between HET versus LET (P = 0.82). CONCLUSIONS: Injuries concomitant to radial head fractures were present in 11% of patients and the risk for these associated injuries increases with age. Trauma mechanism did not have a significant influence on the risk of associated injuries. Complex elbow trauma in patients with a radial head fracture seems therefore to be suspected based on patient characteristics, rather than mechanism of injury.

Reliability of the Inverse Water Volumetry Method to Measure the Volume of the Upper Limb.

BACKGROUND: Lymphedema of the upper extremity is a common side effect of lymph node dissection or irradiation of the axilla. Several techniques are being applied in order to examine the presence and severity of lymphedema. Measurement of circumference of the upper extremity is most frequently performed. An alternative is the water-displacement method. The aim of this study was to determine the reliability and the reproducibility of the "Inverse Water Volumetry apparatus" (IWV-apparatus) for the measurement of arm volumes. PATIENTS AND METHODS: The IWV-apparatus is based on the water-displacement method. Measurements were performed by three breast cancer nurse practitioners on ten healthy volunteers in three weekly sessions. RESULTS: The intra-class correlation coefficient, defined as the ratio of the subject component to the total variance, equaled 0.99. The reliability index is calculated as 0.14 kg. This indicates that only changes in a patient's arm volume measurement of more than 0.14 kg would represent a true change in arm volume, which is about 6% of the mean arm volume of 2.3 kg. CONCLUSION: The IWV-apparatus proved to be a reliable and reproducible method to measure arm volume.

Defining indications for selective chest radiography in the first 24 hours after cardiac surgery.

OBJECTIVE: In the intensive-care unit (ICU), chest radiographs (CXRs) are frequently obtained routinely for postoperative cardiac surgery patients, despite the fact that the efficacy of routine CXRs is known to be low. We investigated the efficacy and safety of CXRs performed after cardiac surgery for specified indications only. METHODS: In this observational cohort study, we prospectively included all patients who underwent conventional major cardiac surgery by median sternotomy in the year 2012. On-demand CXRs could be obtained during the first postoperative period for specified indications only. A routine control CXR was performed on the morning of the first postoperative day for all patients who had not undergone a CXR before that time. The diagnostic and therapeutic efficacy values were calculated for all CXRs. Differences were tested using Fisher's exact test or χ(2) analysis. RESULTS: A total of 1102 consecutive cardiac surgery patients were included in this study. The diagnostic efficacy of CXRs for major abnormalities was higher for the postoperative on-demand CXRs (n = 301; 27%) than for the routine CXRs taken the morning after surgery (n = 801; 73%) (6.6% vs 2.7%, P = .004). The therapeutic efficacy was higher for the on-demand CXRs, whereas the need for intervention after the next-morning, routine CXRs was limited to 5 patients (4.0% vs 0.6%, P < .001). None of these patients experienced a major adverse event. CONCLUSIONS: Defining clear indications for selective CXRs after cardiac surgery is effective and seems to be safe. This approach may significantly reduce the total number of CXRs performed, and will increase their efficacy.

Current factors of fragility and delirium in vascular surgery.

BACKGROUND: Vascular surgery patients are frequently deemed to be in a frail clinical condition and at risk for delirium. Therefore, we evaluated the incidence and independent perioperative risk factors for delirium. In addition, we describe factors on frailty in the various vascular disease groups in current practice. METHODS: This observational longitudinal study included 206 selected patients who were referred to a vascular surgery ward of a large-sized teaching hospital (Amphia Hospital, Breda, The Netherlands) for critical limb ischemia (n = 80), diabetic foot ulcers (n = 27), abdominal aortic aneurysm (AAA) (n = 62), and carotid surgery (n = 37) between April 2013 and December 2013. Data on factors that characterize frailty were collected. Delirium was scored using the Delirium Observation Screening Scale. Multivariable logistic regression analysis was performed to find independent risk factors for delirium. RESULTS: Delirium was present in 24% of the critical limb ischemia patients, in 19% of the patients with a diabetic foot ulcer, in 7% of the patients with an AAA, and in 8% of the patients undergoing carotid surgery (P > 0.05). Of the patients with critical limb ischemia and a delirium, 53% were octogenarians. Multivariable stepwise logistic regression analysis revealed that history of delirium and nurse help at patient's home were independently associated with delirium. Patients with critical limb ischemia scored worse on factors related to frailty compared with the other disease groups in our current clinical practice on vascular surgery. CONCLUSIONS: Delirium is a frequent complication in vascular surgery clinical practice, especially in the elderly. Nurse visits at patients' homes and the Amphia Risk Score for delirium were independent risk factors for delirium in our study population. In this study, we identified patients with critical limb ischemia as the most frail and vulnerable.

A statistical model to predict the reduction of lichenification in atopic dermatitis.

Acute symptoms of atopic dermatitis (AD), such as erythema, oedema/papulations and excoriations, respond quickly to topical corticosteroid treatment. Conversely, lichenification is regarded as a troublesome non-acute symptom of chronic AD which can take months of treatment before any improvement is seen. However, very little data actually support this opinion. Here, we analyse lichenification scores in 3 multicentre, short-term studies of nearly similar design. Two of these studies were active comparator dosage trials administered with either fluticasone propionate cream or ointment once or twice daily, the third study was a placebo control. In each of these 4-weeks studies lichenification was measured weekly. For the evaluation of the lichenification score over time a random-coefficients regression model was used. In all active treatments lichenification significantly improved (p < 0.005) within one week. Improvement continued afterwards, with > 80% of patients scoring no, very mild or mild lichenification after 4 weeks. We developed a model in which the lichenification score drops off linearly with the square root of time. The resulting convexly shaped downward time trend of lichenification was significant during all treatments and was significantly stronger during active treatment than with placebo. Fluticasone propionate can improve moderate to severe lichenification in a relative short period of time.

The value of routine chest radiographs after minimally invasive cardiac surgery: an observational cohort study.

BACKGROUND: Chest radiographs (CXRs) are obtained frequently in postoperative cardiac surgery patients. The diagnostic and therapeutic efficacy of routine CXRs is known to be low and the discussion regarding the safety of abandoning these CXRs after cardiac surgery is still ongoing. We investigated the value of routine CXRs directly after minimally invasive cardiac surgery. METHODS: We prospectively included all patients who underwent minimally invasive cardiac surgery by port access, ministernotomy or bilateral video-assisted thoracoscopy (VATS) in the year 2012. A direct postoperative CXR was performed on all patients at ICU arrival. All CXR findings were noted, including whether they led to an intervention or not. The results were compared to the postoperative CXR results in patients who underwent conventional cardiac surgery by full median sternotomy over the same period. MAIN RESULTS: A total of 249 consecutive patients were included. Most of these patients underwent valve surgery, rhythm surgery or a combination of both. The diagnostic efficacy for minor findings was highest in the port access and bilateral VATS groups (56% and 63% versus 28% and 45%) (p < 0.005). The diagnostic efficacy for major findings was also higher in these groups (8.9% and 11% versus 4.3% and 3.8%) (p = 0.010). The need for an intervention was most common after minimally invasive surgery by port access, although this difference was not statistically significant (p = 0.056). CONCLUSIONS: The diagnostic efficacy of routine CXRs performed after minimally invasive cardiac surgery by port access or bilateral VATS is higher than the efficacy of CXRs performed after conventional cardiac surgery. A routine CXR after these procedures should still be considered.

Surgical site infection after multiple groin incisions in peripheral vascular surgery.

BACKGROUND: Patients with peripheral arterial disease (PAD) are at risk for revision surgery in the groin and therefore at potential risk for surgical site infections (SSIs). In an observational study, a cohort of patients with peripheral arterial disease was followed to examine the effect of different incision intervals on SSI-free survival. METHODS: Patients, needing peripheral vascular surgery because of PAD, were retrieved from a prospectively collected database on SSIs after vascular surgery between March 2009 and January 2012, the group consisting of 720 patients. Of these, 255 patients were selected (age 71.9±10.4 y). Cox proportional hazards models were used for event-history analyses. The effect of incision interval was estimated with adjustment for a number of potential confounders. Effects were quantified by means of hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS: No significant effect on the incision interval on SSI-free survival was observed. After separating incisional SSIs into superficial- and deep-seated, a significant linear trend effect of the groin incision interval on deep-incisional SSI development was observed: the shorter the interval, the higher the event rate (HR 1.5 per category, 95% CI 1.1-2.1, p=0.22). Besides the incision interval, the Rutherford classification was a significant risk factor for SSI development (HR 3.0; 95% CI 2.1-4.2; p<0.0005). CONCLUSION: Revision surgery in the groin puts patients at risk for deep-incisional SSI. No effect on superficial incisional SSI development was observed. Besides the incision interval, the Rutherford classification was a significant risk factor for both superficial- and deep-incisional SSI. Quality improvement and better risk stratification schemes are suggested.