Infective endocarditis in patients after percutaneous pulmonary valve implantation with the stent-mounted bovine jugular vein valve: Clinical experience and evaluation of the modified Duke criteria.

AIMS: Percutaneous pulmonary valve implantation (PPVI) has proven good hemodynamic results. As infective endocarditis (IE) remains a potential complication with limited available clinical data, we reviewed our patient records to improve future strategies of IE prevention, diagnosis and treatment. METHODS: Medical records of all patients diagnosed with Melody® valve IE according to the modified Duke criteria were retrospectively analyzed in three Belgian tertiary centers. RESULTS: 23 IE episodes in 22 out of 240 patients were identified (incidence 2.4% / patient year) with a clear male predominance (86%). Median age at IE was 17.9 years (range 8.2-45.9 years) and median time from PPVI to IE was 2.4 years (range 0.7-8 years). Streptococcal species caused 10 infections (43%), followed by Staphylococcus aureus (n = 5, 22%). In 13/23 IE episodes a possible entry-point was identified (57%). IE was classified as definite in 15 (65%) and as possible in 8 (35%) cases due to limitations of imaging. Echocardiography visualized vegetations in only 10 patients. PET-CT showed positive FDG signals in 5/7 patients (71%) and intracardiac echocardiography a vegetation in 1/1 patient (100%). Eleven cases (48%) had a hemodynamically relevant pulmonary stenosis at IE presentation. Nine early and 6 late percutaneous or surgical re-interventions were performed. No IE related deaths occurred. CONCLUSIONS: IE after Melody® valve PPVI is associated with a relevant need of re-interventions. Communication to patients and physicians about risk factors is essential in prevention. The modified Duke criteria underperformed in diagnosing definite IE, but inclusion of new imaging modalities might improve diagnostic performance.

CFD-based process optimization of a dissolved air flotation system for drinking water production.

Dissolved air flotation (DAF) has received more attention recently as a separation technique in both drinking water as well as wastewater treatment. However, the process as well as the preceding flocculation step is complex and not completely understood. Given the multiphase nature of the process, fluid dynamics studies are important to understand and optimize the DAF system in terms of operation and design. The present study is intended towards a comprehensive computational analysis for design optimization of the treatment plant in Kluizen, Belgium. Setting up the modelling framework involving the multiphase flow problem is briefly discussed. 3D numerical simulations on a scaled down model of the DAF design were analysed. The flow features give better confidence, but the flocs escape through the outlet still prevails which is averse to the system performance. In order to improve the performance and ease of maintenance, design modifications have been proposed by using a perforated tube for water extraction and are found to be satisfactory. The discussion is further reinforced through validating the numerical model against the experimental findings for stratified flow conditions.

20 years of arterial switch operation for simple TGA.

BACKGROUND: Arterial switch operation became the golden treatment for simple transposition of the great arteries (sTGA). We describe our experience with the arterial switch operation regarding long-term outcome and the need for re-intervention. Nevertheless, supravalvular pulmonary stenosis (SPS) remains a concern in the long run. We assess the evolution of SPS over time and evaluate the effect of technical modifications on SPS during our experience. METHODS: We performed a retrospective study on 133 patients operated with ASO for TGA between October 1991 and November 2009. Last report method was used. We reviewed our pediatric cardiology and cardiac surgery database to examine the echocardiographic data and electrocardiograms. A mean follow-up of 9.2 years (+/- 5.83 SD) was reached. RESULTS: One (0.8%) patient deceased postoperatively due to cardiogenic shock. The overall actuarial freedom from reoperation (open and percutaneous) was 88.1%, 78.5% and 76.9% at 1, 5 and 10 years. SPS needed to be treated in 17 patients. Valve regurgitation at final investigation was maximal moderate in 5 patients for the aortic valve, 10 for pulmonary valve and 3 in tricuspid valve. CONCLUSIONS: ASO shows excellent long-term results in sTGA with a very low morbidity and mortality and is therefore the procedure of choice. Re-intervention rate is determined by SPS. Since the extensive mobilization of the pulmonary arteries and the creation of a longer neo-pulmonary root, reduction in SPS was seen with no re-interventions in the second half of the group. To obtain a final comparison with the atrial switch operation, a longer Follow-up is necessary.

Boys with a simple delayed puberty reach their target height.

INTRODUCTION: Final height in boys with delayed puberty is thought to be below target height. This conclusion, however, is based on studies that included patients with genetic short stature. We therefore studied final height in a group of 33 untreated boys with delayed puberty with a target height >-1.5 SDS. METHODS: Standing height, sitting height, weight and arm span width were measured in each patient. Final height was predicted by the method of Greulich and Pyle using the tables of Bailey and Pinneau for retarded boys at their bone age (PAH1) and the tables of Bailey and Pinneau for average boys plus six months (PAH2). RESULTS: Mean final height (175.8 +/- 6.5 cm) was appropriate for the mean target height (174.7 +/- 4.5 cm). The prediction method of Bailey and Pinneau overestimated the final height by 1.4 cm and the modified prediction method slightly underestimated the final height (-0.15 cm). CONCLUSION: Boys with untreated delayed puberty reach a final height appropriate for their target height. Final height was best predicted by the method of Bailey and Pinneau using the tables for average boys at their bone age plus six months.

Hyperthyroidism as a cause of persistent vomiting.

A 32-year-old woman presented with persistent vomiting, epigastric pain and weight loss. A sinus tachycardia was the clue to the diagnosis of hyperthyroidism due to Graves' disease. On treatment with propylthiouracil and a beta-blocking agent, her symptoms resolved within one day, even though her free thyroxine level was still high. Hyperthyroidism is an uncommon, but previously reported cause of persistent vomiting.

[The treatment of gallstone disease in the elderly]. / De behandeling van galsteenlijden bij ouderen.

Gallstone diseases (asymptomatic, symptomatic and complicated) are frequently seen in the elderly; the prevalence increases proportionally with age. At higher ages (> 60 years) the presentation of symptomatic or complicated gallstone disease is frequently atypical. Complicated gallstone disease (especially cholecystitis and cholangitis) in the elderly is associated with high morbidity and mortality rates. The introduction of laparoscopic cholecystectomy has decreased the morbidity and mortality rates of symptomatic and complicated gallstone disease in the elderly; for elective procedures in particular, the risks hardly differ from those for younger patients. Percutaneous cholecystostomy is an effective and safe alternative for (laparoscopic) cholecystectomy in high-risk patients with an acute cholecystitis. Endoscopic retrograde cholangiopancreaticography (ERCP) with sphincterotomy is also the treatment of choice for common bile duct stones in the elderly. After removal of common bile duct stones (whether or not accompanied by cholangitis or pancreatitis) a laparoscopic cholecystectomy should be performed, unless contraindications are present.

[Diagnostic image (51). Right-sided endocarditis in a heroin addict ]. / Diagnose in beeld (51). Rechtszijdige endocarditis bij een heroïneverslaafde.

A 23-year-old heroin addict was admitted with coughing, haemoptoe and fever. Right-sided endocarditis was diagnosed.

[Diagnosis and treatment of hypertension prior to and following introduction of a protocol]. / Diagnostiek en behandeling van hypertensie voor en na invoering van een protocol.

OBJECTIVE: To determine the compliance with and the outcome of a practice guideline introduced for the management of hypertension. DESIGN: Retrospective medical record survey. SETTING: The outpatient clinic of general internal medicine of the Academic Medical Hospital Nijmegen, the Netherlands. METHOD: Daily practice in a period before (1988) and one after (1993) implementation of the guideline were compared. By means of an inventory form we evaluated the compliance with the guideline, the decrease in blood pressure after 1 year's follow-up and the number and dosages of the prescribed drugs. Total costs were approximated from the number of visits and the number of laboratory and imaging evaluations. RESULTS: Compliance with the guideline in 1993 was 72% (24) compared with 65% (27) in 1988. This improvement was predominantly achieved by the junior residents. In 1993 in 15 patients (19%) blood pressure was measured without medication having been stopped. The guideline regarding the frequency of blood pressure measurement was observed in 7 patients (9%). The decrease in systolic and diastolic blood pressure was larger in 1993 than in 1988 (p < 0.05). This result was achieved by a larger number of blood pressure lowering drugs (1.40 (1.06) in 1993 vs. 1.17 (0.98) in 1988): the mean dose of the prescribed drugs was lower. The number of visits rose by 10% to 7.8 (3.7) and the number of diagnostic laboratory procedures by 25% to 956.