Midterm changes in iliac limb apposition after endovascular aortic aneurysm repair.

BACKGROUND: Literature is scarce on the course of iliac endograft limb apposition after endovascular aortic aneurysm repair (EVAR), which is why this study was conducted. METHODS: A retrospective observational imaging study was performed to measure iliac apposition of endograft limbs on the first post-EVAR computed tomography angiography (CTA) scan and on the latest available follow-up CTA scan. With center lumen line reconstructions and CT-applied dedicated software, the shortest apposition length (SAL) of the endograft limbs was assessed as well as the distance between the end of the fabric and the proximal border of the internal iliac artery or the endograft-internal artery distance (EID). RESULTS: Ninety-two iliac endograft limbs were eligible for measurements, with a median follow-up of 3.3 years. At the first post-EVAR CTA, the mean SAL was 31.9±15.6 mm, and the mean EID was 19.5±11.8. At the last follow-up CTA, there was a significant decrease in apposition of 10.5±14.1 mm (P<0.001) and a significant increase in EID of 5.3±9.5 mm (P<0.001). A type Ib endoleak developed in three patients due to a reduced SAL. The apposition was <10 mm in 24% of limbs at the last follow-up vs. 3% at the first post-EVAR CTA. CONCLUSIONS: This retrospective study documented a significant decrease in post-EVAR iliac apposition over time, partly due to retraction of iliac endograft limbs at mid-term CTA follow-up. Further research is required to identify whether regular determination of iliac apposition may predict and prevent type IB endoleaks.

Endograft apposition and infrarenal neck enlargement after endovascular aortic aneurysm repair.

BACKGROUND: Sufficient apposition and oversizing of the endograft in the aortic neck are both essential for durable endovascular aneurysm repair (EVAR). These measures are however not regularly stated on post-EVAR computed tomography angiography (CTA) scan reports. In this study endograft apposition and neck enlargement (NE) after EVAR with an Endurant II(s) endograft were analyzed and associated with supra- and infrarenal aortic neck morphology. METHODS: In 97 consecutive elective patients, the aortic neck morphology was measured on the pre-EVAR CTA scan on a 3mensio vascular workstation. The distance between the lowest renal artery and the proximal edge of the fabric (shortest fabric distance, SFD), and the shortest length of circumferential apposition between endograft and aortic wall (shortest apposition length, SAL) were determined on the early post-EVAR CTA scan. NE, defined as the aortic diameter change between pre- and post-EVAR CTA scan, was determined at eight levels: +40, +30, +20, +15, +10, 0, -5 and -10 mm relative to the lowest renal artery baseline. The aortic neck diameter and preoperative oversizing were correlated to NE with the Pearson correlation coefficient. The effective post-EVAR endograft oversizing is calculated from the nominal endograft diameter and the post-EVAR neck diameter where the endograft is circumferentially apposed. RESULTS: The median time (interquartile range, IQR) between the EVAR procedure and the pre- and post-EVAR CTA scan was 40 (25, 71) days and 36 (30, 46) days, respectively. The Endurant II(s) endograft was deployed with a median (IQR) SFD of 1.0 (0.0, 3.0) mm. The SAL was <10 mm in 9% of patients and significantly influenced by the pre-EVAR aortic neck length (P=0.001), hostile neck shape (P=0.017), and maximum curvature at the suprarenal aorta (P=0.039). The median (interquartile range) SAL was 21.0 (15.0, 27.0) mm with a median (IQR) pre-EVAR infrarenal neck length of 23.5 (13.0, 34.8) mm. The median (IQR) difference between the SAL and neck length was -5.0 (-12.0, 2.8) mm. Significant (P<0.001) NE of 1.7 (0.9, 2.5) mm was observed 5 mm below the renal artery baseline, which resulted in an effective post-EVAR endograft oversizing <10% in 43% of the patients. No correlation was found between NE and aortic neck diameter or preoperative oversizing. CONCLUSIONS: Circumferential apposition between an endograft and the infrarenal aortic neck, SAL, and NE can be derived from standard postoperative CT scans. These variables provide essential information about the post-procedural endograft and aortic neck morphology regardless of the preoperative measurements. Patients with SAL<10 mm or effective oversizing <10% due to NE may benefit from intensified follow-up, but clinical consequences of SAL and NE should be evaluated in future longitudinal studies with longer term follow-up.

Arterial thrombotic complications in COVID-19 patients.

The coronavirus disease 2019 (COVID-19), a viral respiratory illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been described to predispose to thrombotic disease in both the venous and arterial circulations. We report four cases of an acute arterial occlusion in COVID-19 patients and literature review on the occurrence of arterial thrombosis in patients with COVID-19. Our findings demonstrate that physicians should be vigilant for signs of thrombotic complications in both hospitalized and new COVID-19 patients.

Outcomes of open repair of postdissection abdominal aortic aneurysms.

BACKGROUND: Evidence to guide management of postdissection abdominal aortic aneurysms (PDAAA) is lacking. This study describes the outcomes of open repair of PDAAA. METHODS: A retrospective cohort study was conducted of all consecutive patients treated with open repair for PDAAA after a Stanford type A or type B thoracic aortic dissection between January 2006 and December 2017 in two vascular referral centers. Preceding type B dissection treatment could include conservative or surgical management. Primary outcomes were 30-day mortality, complication rates, survival, and reintervention-free survival. Survival and reintervention-free survival were analyzed using the Kaplan-Meier method. Reintervention was defined as any endovascular or surgical intervention after the index procedure. RESULTS: Included were 36 patients (27 men [75%]) with a median age of 64 years (range, 35-81 years). The 30-day mortality was 2.7%. The median follow-up was 16 months (range, 0-88 months). The postoperative course was uneventful in 21 patients (58%). The most frequent complications were postoperative bleeding requiring repeat laparotomy (n = 4), pneumonia (n = 3), congestive heart failure (n = 2), new-onset atrial fibrillation (n = 2), mesenteric ischemia requiring left hemicolectomy (n=1), and ischemic cerebrovascular accident (n = 1). Renal failure requiring hemodialysis developed in one patient. The overall survival at 1 year was 88.8%. Reintervention-free survival was 95.5% after 1 year and 88.6% after 2 years. CONCLUSIONS: Open repair of PDAAA can be performed with a low mortality rate and an acceptable complication rate, comparable with elective open repair of abdominal aortic aneurysms without dissection.

Using flexible methods to determine risk factors for ventilator-associated pneumonia in the Netherlands.

Seven hospitals participated in the Dutch national surveillance for ventilator-associated pneumonia (VAP) and its risk factors. We analysed time-independent and time-dependent risk factors for VAP using the standard Cox regression and the flexible Weighted Cumulative Effects method (WCE) that evaluates both current and past exposures. The prospective surveillance of intensive care patients aged ≥16 years and ventilated ≥48 hours resulted in the inclusion of 940 primary ventilation periods, comprising 7872 ventilation days. The average VAP incidence density was 10.3/1000 ventilation days. Independent risk factors were age (16-40 years at increased risk: HR 2.42 95% confidence interval 1.07-5.50), COPD (HR 0.19 [0.04-0.78]), current sedation score (higher scores at increased risk), current selective oropharyngeal decontamination (HR 0.19 [0.04-0.91]), jet nebulizer (WCE, decreased risk), intravenous antibiotics for selective decontamination of the digestive tract (ivSDD, WCE, decreased risk), and intravenous antibiotics not for SDD (WCE, decreased risk). The protective effect of ivSDD was afforded for 24 days with a delay of 3 days. For some time-dependent variables, the WCE model was preferable over standard Cox proportional hazard regression. The WCE method can furthermore increase insight into the active time frame and possible delay herein of a time-dependent risk factor.

Exhaustion of the immune system by Group A Streptococcus necrotizing fasciitis: the occurrence of late secondary infections in a retrospective study.

BACKGROUND: Necrotizing fasciitis is a potentially lethal condition for which early and adequate treatment with surgical debridement and broad-spectrum intravenous antibiotics are essential for survival. It is hypothesized that Group A Streptococcus (GAS) necrotizing fasciitis causes exhaustion of the immune system, making these patients more susceptible for late secondary infections. METHODS: A retrospective study was conducted of all patients with necrotizing fasciitis between 2002 and 2016. Patients with necrotizing fasciitis based on macroscopic findings, positive Gram staining, culture or fresh frozen section of fascia biopsies were included. Patients with necrotizing fasciitis were divided into two groups based on the presence of GAS. Of both groups, clinical course, outcome and occurrence of late secondary infections were analyzed. For the occurrence of secondary infections, pneumonia was chosen as reference for late secondary infections. RESULTS: Eighty-one patients with necrotizing fasciitis were included of which 38 (47%) had GAS necrotizing fasciitis and 43 (53%) had non-GAS necrotizing fasciitis. Patients with GAS necrotizing fasciitis were younger (50 vs. 61 years, p=0.023) and more often classified as ASA I (45% vs. 14%, p=0.002) compared with patients with non-GAS necrotizing fasciitis. In-hospital mortality rate for necrotizing fasciitis was 32%. Patients with comorbidities were more likely to die of necrotizing fasciitis compared with patients without comorbidities (OR 7.41, 95% CI 1.58 to 34.63). Twelve patients (39%) with GAS necrotizing fasciitis developed pneumonia compared with four patients (13%) with non-GAS necrotizing fasciitis (p=0.017; OR 4.42, 95% CI 1.124 to 15.79). Median time from diagnosis to development of pneumonia in patients with GAS necrotizing fasciitis was 10 days (IQR 9). CONCLUSION: Patients with GAS necrotizing fasciitis have an increased risk to develop late secondary infections during initial treatment for necrotizing fasciitis compared with patients with necrotizing fasciitis without involvement of GAS. This suggests exhaustion of the immune system after severe GAS infection. LEVEL OF EVIDENCE: III.

[An elderly patient with severe peripheral vascular disease]. / Een oudere met ernstig perifeer arterieel vaatlijden.

BACKGROUND: Peripheral arterial disease is a common condition in elderly patients. Cases of severe peripheral vascular disease can be treated with endovascular revascularization or bypass surgery. An amputation may be necessary if revascularization treatments fail. CASE DESCRIPTION: A 94-year-old woman with dementia, living in a nursing home, was referred to the vascular surgery team for a painful ulcer on the left foot. Revascularization fails and due to the infectious status, an above-the-knee amputation seems necessary. Family and physicians, however, opt for a conservative, palliative policy and in the next few weeks the infectious ulcer develops into mummification. The patient nonetheless experiences a good quality of life until she becomes bedridden because of pneumonia. She dies 11 months after she was diagnosed with critical limb ischaemia. CONCLUSION: Adopting a conservative approach in elderly patients with severe peripheral arterial disease and dementia is a worthwhile alternative to amputation, and can achieve a reasonably good quality of life. Diaries maintained by family members can provide insight into the patient's quality of life.

Midterm Single-Center Results of Endovascular Aneurysm Repair With Additional EndoAnchors.

PURPOSE: To review midterm clinical outcomes of EndoAnchor placement during or after endovascular aneurysm repair (EVAR) or chimney EVAR (ch-EVAR). MATERIALS AND METHODS: A retrospective analysis was conducted of 51 consecutive patients [median age 75 years; 38 men] who underwent EVAR/ch-EVAR with EndoAnchor placement between June 2010 and December 2016 to prevent seal failures (31, 61%) or to treat type Ia endoleak and/or migration (20, 39%). Median aortic neck diameter was 27.7 mm and median neck length was 9.0 mm. Thirty-three (65%) had a conical neck; 48 (94%) had at least 1 hostile neck characteristic. Thirty-two (63%) patients had severe comorbidities (ASA score ⩾III). Eight patients had a single ch-EVAR procedure. Baseline patient characteristics, anatomic variables, procedure details, early and late complications, reinterventions, and aneurysm-related and all-cause mortality rates were recorded. Follow-up imaging was performed with computed tomography angiography (CTA) or duplex ultrasonography. RESULTS: Median procedure time was 100 minutes; a median of 6 EndoAnchors were implanted. There were 10 (10%) residual type Ia endoleaks at the end of the procedure; 9 had resolved by the first postoperative CTA. One residual and 2 new type Ia endoleaks were identified at the first postoperative imaging. Median follow-up for the entire cohort was 24.0 months, during which 3 new type Ia endoleaks were identified. Five of the 6 type Ia endoleaks were treated, 1 resolved spontaneously. There was 1 endograft limb occlusion without clinical consequences, 1 chimney graft occlusion without possibilities for a reintervention, 1 rupture after type IV endoleak (a Nellix device was successfully deployed within the main device), and 1 complete graft explantation for infection. There was no new-onset hemodialysis. Kaplan-Meier estimates of freedom from type Ia endoleak, proximal neck-related reinterventions, and aneurysm-related mortality at 2 years were 87.3%, 92.2%, and 94.0%, respectively. CONCLUSION: EndoAnchors are helpful in the endovascular treatment of unfavorable proximal aortic necks, with fair midterm results.

Determination of Stent Frame Displacement After Endovascular Aneurysm Sealing.

PURPOSE: To describe and validate a new methodology for visualizing and quantifying 3-dimensional (3D) displacement of the stent frames of the Nellix endosystem after endovascular aneurysm sealing (EVAS). METHODS: The 3D positions of the stent frames were registered to 5 fixed anatomical landmarks on the post-EVAS computed tomography (CT) scans, facilitating comparison of the position and shape of the stent frames between consecutive follow-up scans. Displacement of the proximal and distal ends of the stent frames, the entire stent frame trajectories, as well as changes in distance between the stent frames were determined for 6 patients with >5-mm displacement and 6 patients with <5-mm displacement at 1-year follow-up. The measurements were performed by 2 independent observers; the intraclass correlation coefficient (ICC) was used to determine interobserver variability. RESULTS: Three types of displacement were identified: displacement of the proximal and/or distal end of the stent frames, lateral displacement of one or both stent frames, and stent frame buckling. The ICC ranged from good (0.750) to excellent (0.958). No endoleak or migration was detected in the 12 patients on conventional CT angiography at 1 year. However, of the 6 patients with >5-mm displacement on the 1-year CT as determined by the new methodology, 2 went on to develop a type Ia endoleak in longer follow-up, and displacement progressed to >15 mm for 2 other patients. No endoleak or progressive displacement was appreciated for the patients with <5-mm displacement. CONCLUSION: The sac anchoring principle of the Nellix endosystem may result in several types of displacement that have not been observed during surveillance of regular endovascular aneurysm repairs. The presented methodology allows precise 3D determination of the Nellix endosystems and can detect subtle displacement better than standard CT angiography. Displacement >5 mm on the 1-year CT scans reconstructed with the new methodology may forecast impaired sealing and anchoring of the Nellix endosystem.

Adhering to a national surgical care bundle reduces the risk of surgical site infections.

BACKGROUND: In 2008, a bundle of care to prevent Surgical Site Infections (SSIs) was introduced in the Netherlands. The bundle consisted of four elements: antibiotic prophylaxis according to local guidelines, no hair removal, normothermia and 'hygiene discipline' in the operating room (i.e. number of door movements). Dutch hospitals were advised to implement the bundle and to measure the outcome. This study's goal was to assess how effective the bundle was in reducing SSI risk. METHODS: Hospitals assessed whether their staff complied with each of the bundle elements and voluntary reported compliance data to the national SSI surveillance network (PREZIES). From PREZIES data, we selected data from 2009 to 2014 relating to 13 types of surgical procedures. We excluded surgeries with missing (non)compliance data, and calculated for each remaining surgery with reported (non)compliance data the level of compliance with the bundle (that is, being compliant with 0, 1, 2, 3, or 4 of the elements). Subsequently, we used this level of compliance to assess the effect of bundle compliance on the SSI risk, using multilevel logistic regression techniques. RESULTS: 217 489 surgeries were included, of which 62 486 surgeries (29%) had complete bundle reporting. Within this group, the SSI risk was significantly lower for surgeries with complete bundle compliance compared to surgeries with lower compliance levels. Odds ratios ranged from 0.63 to 0.86 (risk reduction of 14% to 37%), while a 13% risk reduction was demonstrated for each point increase in compliance-level. Sensitivity analysis indicated that due to analysing reported bundles only, we probably underestimated the total effect of implementing the bundle. CONCLUSIONS: This study demonstrated that adhering to a surgical care bundle significantly reduced the risk of SSIs. Reporting of and compliance with the bundle compliance can, however, still be improved. Therefore an even greater effect might be achieved.

Appropriate antibiotic use reduces length of hospital stay.

Objectives: To define appropriate antibiotic use in hospitalized adults treated for a bacterial infection, we previously developed and validated a set of six generic quality indicators (QIs) covering all steps in the process of antibiotic use. We assessed the association between appropriate antibiotic use, defined by these QIs, and length of hospital stay (LOS). Methods: An observational multicentre study in 22 hospitals in the Netherlands included 1890 adult, non-ICU patients using antibiotics for a suspected bacterial infection. Performance scores were calculated for all QIs separately (appropriate or not), and a sum score described performance on the total set of QIs. We divided the sum scores into two groups: low (0%-49%) versus high (50%-100%). Multilevel analyses, correcting for confounders, were used to correlate QI performance (single and combined) with (log-transformed) LOS and in-hospital mortality. Results: The only single QI associated with shorter LOS was appropriate intravenous-oral switch (geometric means 6.5 versus 11.2 days; P < 0.001). A high sum score was associated with a shorter LOS in the total group (10.1 versus 11.2 days; P = 0.002) and in the subgroup of community-acquired infections (9.7 versus 10.9 days; P = 0.007), but not in the subgroup of hospital-acquired infections. We found no association between performance on QIs and in-hospital mortality or readmission rate. Conclusions: Appropriate antibiotic use, defined by validated process QIs, in hospitalized adult patients with a suspected bacterial infection appears to be associated with a shorter LOS and therefore positively contributes to patient outcome and healthcare costs.

Results of open pararenal abdominal aortic aneurysm repair: single centre series and pooled analysis of literature.

Objectives Endovascular treatment of pararenal abdominal aortic aneurysm has gained terrain over the past decade, despite the substantial need for reinterventions during follow-up. However, open repair is still a well-established treatment option. With the current study we report the results of a consecutive series of elective primary open pararenal abdominal aortic aneurysm repair in a tertiary vascular referral centre, combined with an overview of current literature and pooled data analysis of perioperative mortality of open and endovascular pararenal abdominal aortic aneurysm repair. Methods A retrospective analysis of a prospective database of all elective open pararenal abdominal aortic aneurysm repairs in the St. Antonius Hospital between 2005 and 2014 was performed. Primary endpoint was 30-day mortality. Secondary endpoints were 30-day morbidity, new onset dialysis, reintervention free survival, and overall survival during follow-up. Results Between 2005 and 2014, 214 consecutive patients underwent elective open pararenal abdominal aortic aneurysm repair. Mean age was 69.8 (±7.1) years, 82.7% (177/214) were men, and mean abdominal aortic aneurysm diameter was 62 (±11) mm. Thirty-day mortality was 3.4%. Thirty-day morbidity was 27.1%, which predominantly consisted of pneumonia (18.7% (40/214)), cardiac events (3.3% (7/214)), and new onset dialysis (2.8% (6/214)). Estimated five-year overall survival rate was 74.2%. 0.9% (2/214) of patients required abdominal aortic aneurysm-related reintervention, and an additional 2.3% (5/214) required surgical repair of an incisional hernia. Pooled analysis of literature revealed a 30-day mortality of 3.0% for open pararenal repair and 1.9% for fenestrated endovascular repair. Conclusion Open pararenal abdominal aortic aneurysm repair in the era of increasing endovascular options results in acceptable perioperative morbidity and mortality rates. Mid-term reintervention rate is low compared to fenestrated endovascular aneurysm repair. Expertise with open repair still remains essential for treatment of pararenal abdominal aortic aneurysms in the near future, especially for those patients that are declined for endovascular treatment.

Internal and External Validation of a Computer-Assisted Surveillance System for Hospital-Acquired Infections in a 754-Bed General Hospital in the Netherlands.

OBJECTIVE To evaluate a computer-assisted point-prevalence survey (CAPPS) for hospital-acquired infections (HAIs). DESIGN Validation cohort. SETTING A 754-bed teaching hospital in the Netherlands. METHODS For the internal validation of a CAPPS for HAIs, 2,526 patients were included. All patient records were retrospectively reviewed in depth by 2 infection control practitioners (ICPs) to determine which patients had suffered an HAI. Preventie van Ziekenhuisinfecties door Surveillance (PREZIES) criteria were used. Following this internal validation, 13 consecutive CAPPS were performed in a prospective study from January to March 2013 to determine weekly, monthly, and quarterly HAI point prevalence. Finally, a CAPPS was externally validated by PREZIES (Rijksinstituut voor Volksgezondheid en Milieu [RIVM], Bilthoven, Netherlands). In all evaluations, discrepancies were resolved by consensus. RESULTS In our series of CAPPS, 83% of the patients were automatically excluded from detailed review by the ICP. The sensitivity of the method was 91%. The time spent per hospital-wide CAPPS was ~3 hours. External validation showed a negative predictive value of 99.1% for CAPPS. CONCLUSIONS CAPPS proved to be a sensitive, accurate, and efficient method to determine serial weekly point-prevalence HAI rates in our hospital. Infect Control Hosp Epidemiol 2016;1-6.

Endovascular treatment of complex abdominal aortic aneurysms by combining different types of endoprostheses.

PURPOSE: To describe an off-the-shelf method for the treatment of abdominal aortic aneurysms with hostile (large, >30 mm) neck and/or small (<20 mm) aortic bifurcation. CASE REPORT: We describe five patients with large aortic necks and/or small aortic bifurcations, which were treated by combining an AFX endoprosthesis with a Valiant Captiva endograft, and additional proximal endoanchors when deemed necessary. Initial technical success was 100%. Follow-up ranged from 228 to 875 days. One patient suffered a type 1A and 1B endoleak at 446 days follow-up, which were successfully treated by endovascular means. CONCLUSION: Combining the AFX and Valiant Captiva endografts is an off-the-shelf solution for treatment of large diameter aortic necks and small aortic bifurcations in patients deemed unfit for open repair or declined for fenestrated endografts. Longer follow-up is required to assess the long-term safety with special focus on aortic neck dilation.

The significance of regional hemoglobin oxygen saturation values and limb-to-arm ratios of near-infrared spectroscopy to detect critical limb ischemia.

This study examines the application of near-infrared spectroscopy to noninvasively detect critical limb ischemia using regional hemoglobin oxygen saturation in percentage values and regional hemoglobin oxygen saturation limb-to-arm ratios. The regional hemoglobin oxygen saturation values and regional hemoglobin oxygen saturation limb-to-arm ratios were calculated in 61 patients with critical limb ischemia (group A). Measurements were performed in rest at four fixed spots at the most affected lower limb and at a reference spot at both upper arms. Similar measurements were performed in the left lower limb of 30 age-matched control patients without peripheral arterial disease (group B). The regional hemoglobin oxygen saturation values and regional hemoglobin oxygen saturation limb-to-arm ratios were significantly different at all measured spots between the groups (all p < 0.001), except for the regional hemoglobin oxygen saturation limb-to-arm ratios of the distal vastus lateralis (p = 0.056). However, a broad overlap of individual regional hemoglobin oxygen saturation values and regional hemoglobin oxygen saturation limb-to-arm ratios was found in both groups, which resulted in poor discriminative predictive value of single measurements. Single measurements of regional hemoglobin oxygen saturation values and regional hemoglobin oxygen saturation limb-to-arm ratios at all measured spots have poor discriminative predictive value in detection of critical limb ischemia. Measurement of regional hemoglobin oxygen saturation values and regional hemoglobin oxygen saturation limb-to-arm ratios at any of the measurement spots has no added value in detecting lower limb ischemia in individuals compared with current diagnostic modalities.

[Healthcare-associated infections on readmission: 1 in 3 is linked to previous hospital admission]. / Zorggerelateerde infecties bij heropname: 1 op de 3 ziekenhuisinfecties is gerelateerd aan eerdere opname.

OBJECTIVE: To gain insight into the prevalence of healthcare-associated (HAI) infections in hospital patients in the Netherlands, and their link with previous hospital admission. DESIGN: Cross-sectional study. METHOD: This prevalence study was carried out in 36 hospitals at 42 locations in the Netherlands in March 2014. All inpatients at the time of the study were evaluated for the presence of an HAI, according to the standard protocol and in accordance with internationally determined definitions. It was subsequently determined whether the HAI had been acquired during the current admission or was linked to a previous recent admission. Readmission had to have taken place within a predetermined time period. RESULTS: A total of 9,420 patients were evaluated for the presence of an HAI; 470 (5.0%) HAI were reported, of which almost 36% was linked to a previous admission. Two-thirds of the HAI were post-operative surgical-site infections. Almost 88% of the patients with HAI were treated with antibiotics, versus 32% of the patients without HAI. CONCLUSION: Registration of HAI on admission to hospital provides insight into the frequency of HAI that become apparent after discharge. There is no insight into the treatment frequency of HAI by general practitioners. An inventory of the treatment frequency of HAI in primary care is advised, to evaluate infection-prevention policy in hospitals and to optimise primary care.

Trapped cerebral thrombectomy device: A case report of a rare complication.

Intravenous thrombolysis with recombinant tissue plasminogen activator is currently the standard therapy for acute ischaemic stroke when started within 4.5 h of symptom onset. Systemic thrombolytic therapy can, however, lead to potentially lethal bleeding complications and is contra-indicated in several circumstances. Intra-arterial thrombolysis and/or intra-arterial thrombectomy can overcome these drawbacks and even increase the rate of recanalization. While intravenous thrombolysis is a relatively non-complex treatment, intra-arterial therapy in acute ischaemic stroke patients requires a dedicated intervention team which has to be available at all times. In this case report, we describe the multidisciplinary approach of a rare complication of a trapped mechanical thrombectomy device.

Appropriate use of indwelling urethra catheters in hospitalized patients: results of a multicentre prevalence study.

BACKGROUND: Although indwelling urethra catheterization is a medical intervention with well-defined risks, studies show that approximately 14-38% of the indwelling urethra catheters (IUCs) are placed without a specific medical indication. In this paper we describe the prevalence of IUCs, including their inappropriate use in the Netherlands. We also determine factors associated with inappropriate use of IUCs in hospitalized patients. METHODS: In 28 Dutch hospitals, prevalence surveys were performed biannually in 2009 and 2010 within the PREZIES-network. All patients admitted to a participating hospital and who had an IUC in place at the day of the survey were included. Pre-determined criteria were used to categorize the indication for catheterization as appropriate or inappropriate. RESULTS: A total of 14,252 patients was included and 3020 (21.2%) of them had an IUC (range hospitals 13.4-27.3). Initial catheter placement was inappropriate in 5.2% of patients and 7.5% patients had an inappropriate indication at the day of the survey. In multivariate analyses inappropriate catheter use at the time of placement was associated with female sex, older age, admission on a non-intensive care ward, and not having had surgery. Inappropriate catheter use at the time of survey showed comparable associated factors. CONCLUSIONS: Although lower than in many other countries, inappropriate use of IUC is present in Dutch hospitals. To reduce the inappropriate use of IUCs, recommended components of care (bundle for UTI), including daily revision and registration of the indication for catheterization, should be introduced for all patients with an IUC. Additionally, an education and awareness campaign about appropriate indications for IUC should be available.

[Comprehensive quality indicators for measuring hospital antibiotic use]. / Generieke kwaliteitsindicatoren voor antibioticagebruik in het ziekenhuis.

As in other countries, the growing resistance to antimicrobial drugs is also taking place in the Netherlands; the primary cause being the total consumption of antibiotics. Given the steady decline in the discovery of new antimicrobials, better use of agents currently available is warranted. Guidelines describing appropriate antimicrobial therapy play an important role; however, such guidelines are not optimally used in daily practice. Quality indicators can be used to assess the quality of antibiotic treatment and evaluate the impact of interventions aimed at improving care. Quality indicators used for evaluating treatment of infections of the respiratory and urinary tracts are developed previously. A comprehensive set of indicators that could be used to assess the quality of hospital antibiotic use for all bacterial infections has not yet been developed. A new project has recently been started in the Netherlands called 'The development of Reliable generic quality Indicators for the optimalisation of ANTibiotic use in the hospital' (RIANT study) for developing such a set of comprehensive indicators.