Early and Long-term Outcome after Open Surgical Suprarenal Aortic Fenestration in Patients with Complicated Acute Type B Aortic Dissection.

OBJECTIVES: The purpose of this retrospective cohort study was to determine the early and long-term mortality and morbidity as well as to reveal risk factors influencing the long-term prognosis in patients with complicated acute type B aortic dissection (CABAD) undergoing open surgical suprarenal aortic fenestration (OSSAF). METHODS: Fifty-two patients with CABAD, defined as (impending) rupture, acute enlargement of the false lumen, malperfusion, and/or unrelenting back pain or uncontrollable hypertension despite maximum medical therapy were treated with by surgical repair between 2002 and 2008. Ten patients with (impending) rupture had aortic graft replacement, while 42 (33 men, mean age 55 ± 11 years) had OSSAF. Follow up visits were scheduled at 1, 3-6 and 12 months after the surgery and annually thereafter. Clinical examination and computed tomography angiography findings were investigated at baseline and at subsequent visits. RESULTS: The indications for OSSAF were acute enlargement of the false lumen in four (10%), malperfusion in 17 (40%) (11 lower extremity [26%], 6 visceral [14%]), and unrelenting back pain or uncontrollable hypertension in 21 cases (50%). The 30 day mortality was 21.4% (2 multiple organ failure, 2 heart failure, 3 pneumonia, 1 intestinal necrosis, 1 major hemorrhage). The mean follow up was 84 ± 40 months. The 5 year survival was 70.6%. Eight patients (19%) died during the follow up period (6 aortic ruptures, 2 myocardial infarctions). None of the patients became paraplegic after the surgery. Further surgery or stenting was indicated in nine cases (21%). CONCLUSIONS: OSSAF has been performed with an acceptable early mortality and low paraplegia rate, but late mortality is frequently related to aortic rupture. Stentgraft coverage of the primary entry tear decreases late aortic related deaths, but suprarenal fenestration remains an option for cases not suitable for endovascular techniques.

Safety, clinical outcome, and fracture rate of femoropopliteal stenting using a 4F compatible delivery system.

OBJECTIVE: To determine the safety, clinical outcome, and fracture rate of femoropopliteal interventions using 4F stents. METHODS: Between January 2010 and December 2011, 112 symptomatic patients were treated by stent implantation. Ten patients were lost to follow up; therefore, 102 patients (62 men; mean age 66.4 ± 10.1 years) were retrospectively analyzed. The indication for femoropopliteal revascularization was severe claudication (Rutherford-Becker score = 3) in 63 (62%) patients and chronic critical limb ischemia (Rutherford-Becker score = 4-6) in 39 (38%). Follow up included palpation of peripheral pulses and measurement of ankle brachial index. In patients with suspected in-stent restenosis duplex ultrasonography was performed. In 2013, patients were asked to return for a fluoroscopic examination of the stents. RESULTS: 114 lesions (Trans-Atlantic InterSociety Consensus-C and D, n = 45) were treated with 119 stents (Astron Pulsar, n = 42; Pulsar-18, n = 77). Lesions were long (≥100 mm) in 49 cases and heavily calcified in 35. Stents were long (≥120 mm) in 46 cases. Ten stents were partially overlapped. The technical and clinical success rates were 100%. Two puncture related complications were noted, neither of which required surgical repair. Eleven patients died (myocardial infarction, n = 4; stroke, n = 2; cancer, n = 5) and nine patients underwent major amputation (above knee, n = 4). The primary patency rate was 83% at 6 months and 80% at 12 months. The primary assisted patency rate was 97% at 6 months and 94% at 12 months. The secondary patency rate was 86% at 6 months and 85% at 12 months. The prevalence of fractures was 26% (type III and IV, 10%) after an average follow up of 25 months. CONCLUSION: Femoropopliteal stenting using a 4F compatible delivery system can be accomplished with a low complication rate, acceptable fracture rate, and with similar 12 month patency and revascularization rates as their 6F counterparts.

Bacterial colonization of microbial biofilms in oral squamous cell carcinoma.

OBJECTIVES: The purpose of this prospective clinical study was to identify the bacterial spectra on the surface of oral squamous cell carcinomas (OSCC) in comparison to oral mucosa of patients with a higher risk to emerge an OSCC and a control group to determine their susceptibility to various common antibiotics. MATERIAL AND METHODS: Swabs from 90 patients, 30 patients of each group, were cultured on media for aerobes and anaerobes and tested with agar diffusion and Etest. RESULTS: The predominant pathogens of the normal healthy oral mucosa were aerobes. The ratio between aerobes and anaerobes was 2:1, balanced in risk patients and inverted in the OSCC group. Altogether, 1,006 isolates were cultured. The most frequent strains were 47 viridans streptococci, 30 Staphylococcus species, 14 Enterococcus faecalis, 36 Neisseria species, 14 Escherichia coli, and 23 other aerobes, 66 Peptostreptococcus species, 39 Fusobacterium species, and 34 Prevotella species. The resistance rates in the OSCC group were penicillin 40%, ampicillin 57%, doxycycline 23%, clindamycin 47%, and amoxicillin/clavulanic acid 20%, but up to 100% of pathogens were susceptible to azithromycin, telithromycin, levofloxacin, and moxifloxacin. CONCLUSION: Gram-negative anaerobes play a decisive role in the development of postoperative infections in patients with OSCC. This tumor special type of colonization does not agree with the normal flora of the oral cavity. CLINICAL RELEVANCE: Biofilms on OSCC surfaces provide an important reservoir for anaerobic bacteria. As a consequence, a proposal for an antibiotic prophylactic regime should be given.

Prognostic and therapeutic implications of low aortic valve calcium score in patients with low gradient aortic stenosis.

INTRODUCTION: Low gradient (LG) aortic stenosis (AS) poses a diagnostic challenge. Aortic valve calcium score (AVCS) assessment has emerged as a complementary diagnostic method when echocardiography provides discordant results. However, the diagnostic and prognostic value of AVCS in LGAS has not been thoroughly studied. Our aims were to investigate the prognostic importance of AVCS in LGAS and to assess whether symptomatic patients with LGAS and low AVCS may benefit from aortic valve intervention (AVI). METHODS: 327 symptomatic patients (78.5±7.3 years, 51% women) with severe AS defined by the aortic valve area who underwent computed tomography for transcatheter aortic valve intervention (TAVI) planning were enrolled. AVCS was measured. AVCS<2000 AU in men and<1200 AU in women was considered low AVCS. RESULTS: 243 patients had high gradient (HG) and 84 had LGAS. Low AVCS was present in 25(10%) of the HG and 34(40%) of the LGAS cases. Over a median follow-up period of 4.9 years, 194 deaths occurred. In multivariate analysis, AVCS was a significant independent predictor of all-cause mortality among HGAS (aHR:2.317; CI:1.104-4.861; p= 0.026), but not among LGAS (aHR:0.848; CI:0.434-1.658; p=0.630) patients. After propensity score matching between patients who underwent AVI and those who were medically treated, AVI (94% TAVI) was a significant and independent predictor of survival among LG AS patients with low AVCS even after adjustment for clinical variables (aHR:0.102, CI:0.028-0.369; p<0.001). CONCLUSION: The prevalence of low AVCS is much higher in LGAS than in HGAS. In symptomatic severe LGAS low AVCS did not entail a better prognosis. AVI is equally beneficial in LGAS patients with high or low AVCS, similarly to HGAS.

Early restenosis after eversion carotid endarterectomy versus carotid stenting: a single-centre retrospective study.

AIM: The aim of our study was to compare the early restenosis rate between patients undergoing carotid artery stenting (CAS) and carotid endarterectomy (CEA) at a single cardiovascular institution. METHODS: In 2004, 368 carotid endarterectomies were carried out on 347 patients and 144 internal carotid artery stentings were performed on 140 patients. The mean follow-up time was 18.4 months (range 6-38 months). Restenosis rates were calculated with the Kaplan-Meyer method and the two groups were compared by using log-rank test. Perioperative outcome was also evaluated and the groups were compared with chi-square test. RESULTS: Significantly more perioperative complications occurred in the CAS group, mainly transient neurological (7.60% vs 2.20% in the CEA group, P<0.05) and cardiovascular symptoms (4.10% vs 1.10% in the CEA group, P<0.05). Moderate restenosis (50-69%) occurred in 11.41% (42/368) of CEA cases and in 4.86% (7/144) of CAS cases (P<0.05). Severe (70%) restenosis rates were 10.05 % in the CEA group and 3.47% in the CAS group (P<0.05). CONCLUSIONS: Incidence of restenosis after carotid artery stening was less common than after carotid endarterectomy. On the other hand, perioperative complications were recorded more often after CAS than following CEA.

Post-traumatic pseudoaneurysm of the great saphenous vein: a case report.

Venous (pseudo)aneurysms are rare entities. Herewith we report a case of the right lower extremity in a 42-year-old woman in whom a non-pulsatile mass was diagnosed only by physical examination as a hematoma and was treated conservatively. Six months later ultrasound and phlebography identified a pseudoaneurysm of the great saphenous vein. Post-traumatic venous pseudoaneurysm should be considered among the differential diagnostic options of a subcutaneous non-pulsatile mass in patients with a history of physical trauma. Surgery was offered which was rejected by the patient. Further one month follow-up showed no change.

Biofilm formation on intrauterine devices in relation to duration of use.

Intrauterine devices (IUDs) are highly effective, long-term methods of contraception; however, IUD use is limited due to concerns about an increased risk of pelvic inflammatory disease (PID) and subsequent complications. A retrospective review of clinical and microbiological data of 127 participants was carried out over a 3 year period. IUDs were removed and sent for microbiological examination. A 10 year old IUD, removed because of the symptoms of PID, was investigated via both microbial culture and scanning electron microscopy. The primary objective of this study was to examine the bacteria present on removed IUDs after different times in situ by using aerobic and anaerobic culture methods. A close association of the distribution of aerobic and anaerobic bacteria on the IUDs with different times in situ was found.

Impact of reflective mulch on yield of strawberry plants and incidence of damage by tarnished plant bug (Heteroptera: Miridae).

The current study investigated the impact of reflective mulch on yield of strawberry plants and incidence of damage by tarnished plant bugs, Lygus lineolaris (Palisot de Beauvois), for three strawberry cultivars: 'Honeoye', 'Earliglow', and two sibling Dayneutrals ('Tribute' and 'Tristar', herein considered as one cultivar). Of all cultivars tested, Honeoye was the most productive and least susceptible to tarnished plant bug. For Earliglow and Honeoye, reflective mulch enhanced productivity of strawberry plants and suppressed density of nymphs per flower cluster and proportion of damaged fruits, but did not significantly impact numbers of nymphs or damaged fruits per hectare, Results with Dayneutrals were not consistently significant. Both in the presence or absence of reflective mulch, proportion of damaged fruits increased with increasing density of nymphs per flower cluster and with decreasing number of fruits harvested per row section, suggesting that planting productive strawberry cultivars or maintaining cultural practices that promote high yield may provide an effective line of defense against tarnished plant bug. These results also suggest that reflective mulch may suppress incidence of damage by tarnished plant bug both directly, by reducing number of nymphs per flower cluster, and indirectly, by enhancing productivity of strawberry plants. Economic analyses evaluating costs and benefits of using reflective mulch, as well as studies investigating mechanisms that underlie the impact of reflective mulch on yield and incidence of damage by tarnished plant bug, are still needed before reflective mulch can be implemented as a management strategy in commercial strawberry fields.

Changes in the plasma concentration of soluble thrombomodulin in patients with severe carotid artery stenosis after eversion endarterectomy.

OBJECTIVE AND DESIGN: The purpose of the study was to investigate the putative role of soluble thrombomodulin (sTM) in severe carotid artery stenosis. MATERIALS AND METHODS: We prospectively studied 64 patients who were undergoing carotid endarterectomy (2001-2003). Plasma sTM concentration was determined in each patient before surgery and at 14 months postsurgery. -308 TNF-alpha promoter polymorphism was also determined. RESULTS: Strong negative correlation was found between the preoperative duplex scan values and the plasma sTM concentrations (R = -0.418, p = 0.0006). Patients with 308 A TNF-alpha genotype had significantly lower (p = 0.0415) preoperative sTM values than their counterparts with no such polymorphism. Soluble TM concentrations measured in plasma samples taken at the end of the postsurgical follow-up period of 14 months duration were significantly higher compared to the preoperative values (p < 0.0001). CONCLUSIONS: Our present findings indicate that sTM may be adsorbed to the atherosclerotic plaques or inflamed endothelium in carotid arteries. The pathological significance of this adsorption remains to be determined.

Enterotoxigenic Bacteroides fragilis in Hungary.

Bacteroides fragilis, which constitutes about 1% of the colonic microflora in humans, is the most frequent anaerobic species involved in abscesses, soft-tissue infections and bacteraemias. Additionally, enterotoxigenic strains of B. fragilis have been demonstrated to be associated with diarrhoea in domestic animals and humans. Enterotoxigenic strains of B. fragilis derived from stool specimens and from infectious processes produce a toxin which induces a cytotoxic response in HT-29 colon carcinoma cells. These findings prompted us to investigate the prevalence of enterotoxigenic strains of B. fragilis isolated from various clinical specimens in Hungary. A total of 134 strains were collected from different clinical settings: 74 from infectious processes, 20 from stools of healthy subjects and 40 from the faeces of patients with diarrhoea where no other enteric pathogen could be isolated. Cell culture assays with HT-29 cells were performed on the filtered culture supernatants of the isolated strains. Of the 134 strains, 34 (25.3%) proved toxin-positive. The presence of free toxin was also observed in 20 of 50 (40%) of the faeces of adults with diarrhoea.

Karyotyping of Candida albicans and Candida glabrata isolates from recurrent vaginal infections by pulsed-field gel electrophoresis.

In the present study, 16 women with recurrent vulvovaginal candidiasis (RVVC) due to Candida albicans and Candida (Torulopsis) glabrata were followed for a period of 4 to 12 months, and 36 vaginal isolates were evaluated by pulsed-field gel electrophoresis (PFGE). Eleven women were infected by C. albicans and 5 by C. glabrata. Three electrophoretic karyotypes of C. albicans and 3 of C. glabrata were identified throughout the follow-up. All patients but one was infected with the same karyotype of C. albicans or C. glabrata during the follow-up period. Two different karyotypes of C. glabrata were identified in one patient in the course of 12 months. The results confirmed the diversity of the karyotypes of C. albicans and C. glabrata causing vulvovaginitis, and demonstrated the persistence of colonization with the same strain over different periods of time despite therapy (15/16 women).

The possible role of anaerobic bacteria in chronic prostatitis.

Prostatis, the most common urological disease in men, afflicts between 25 and 50% of all adult men. Four clinical categories are recognized: acute and chronic bacterial prostatitis, non-bacterial prostatitis and prostatodynia. The role of Gram-positive aerobic bacteria and the different anaerobes in chronic bacterial prostatitis is still a matter of debate. During this study, the urethral discharge and the prostatic fluid obtained after prostatic massage of 50 patients with chronic prostatitis, confirmed by clinical examination and resistant to empirical quinolone therapy, were cultured under aerobic and anaerobic conditions. The parallel specimens from 24 patients exhibited high colony counts of Gram-positive and Gram-negative anaerobic bacteria, either alone (18 cases) or in combination with aerobic bacteria (6 cases). The specimens obtained after prostatic massage of the remaining 26 patients were completely negative for both aerobic and anaerobic bacteria. No Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum or Trichomonas vaginalis were isolated from these patients. Patients with chronic prostatitis who gave positive culture results for anaerobes were treated with amoxicillin/clavulanic acid or clindamycin for 3-6 weeks. After treatment, samples were again taken and cultured for all pathogens known to cause prostatitis. These post-therapeutic samples revealed a decrease or total elimination of the symptoms, and no anaerobic bacteria could be detected.

Long-term restenosis rate of eversion endarterectomy on the internal carotid artery.

OBJECTIVES: The eversion endarterectomy of the internal carotid artery was introduced in Hungary in 1991. The aim of this study was to define the long-term restenosis rate of this procedure. PATIENTS AND METHODS: Between 1991 and 1993, 171 operations, on 151 patients, were performed by single surgeon: with long-term follow up of 109 patients, which included annual physical and ultrasound examinations. Restenosis rate and plaque morphology were defined. Survival and patency rate were analysed by life-tables. RESULTS: The combined perioperative stroke morbidity and mortality rate was 0.8%. The 5-year patient survival rate was 85%, the recurrent stenosis free rate was 88% at 5 years. Only 9% of the patients had carotid restenosis of more than 70% during this period. Ultrasound plaque morphology showed calcification in one case. Two patients had re-operations, with plaque histology showed myointimal hyperplasia in each case. CONCLUSIONS: Our results for restenosis are compare favourably with the 2-34% restenosis rate reported in the literature. Ultrasound and histological findings suggest that atherosclerosis does not play a significant role in the development of restenosis after the eversion carotid endarterectomy.

Evaluation of the Etest for susceptibility testing of Mycoplasma hominis and Ureaplasma urealyticum.

The Etest was used for antibiotic susceptibility testing of Mycoplasma hominis and Ureaplasma urealyticum isolates and the results were compared with those obtained with the broth microdilution method. For 50 clinical isolates of M. hominis the MICs of doxycycline, ofloxacin and ciprofloxacin agreed within +/- one dilution and +/- two dilutions in 82-98% and 98-100% of cases, respectively. The MICs of erythromycin, azithromycin, doxycycline, ofloxacin and ciprofloxacin were evaluated for 50 clinical isolates of U. urealyticum. The corresponding levels of agreement were 70-98% and 94-100%, respectively. Reference isolates M. hominis PG-21 and U. urealyticum T-960 were also used. The Etest seems to be an alternative method for determination of MICs of antibiotics with M. hominis and U. urealyticum.

Marked decrease in the levels of two inflammatory markers, hs-C-reactive protein and fibrinogen in patients with severe carotid atherosclerosis after eversion carotid endarterectomy.

OBJECTIVE AND DESIGN: To study changes in the levels of two acute phase proteins, plasma fibrinogen and serum C-reactive protein (hs-CRP) in patients with severe carotid stenosis after eversion endarterectomy. MATERIAL AND SUBJECTS: A total of 117 consecutive patients who underwent eversion endarterectomy were included in the study. Blood samples for acute phase protein measurement were taken before operation as well as 5.7 weeks and 13.8 months (median) post-surgery. Plasma fibrinogen and serum hs-CRP concentrations were promptly determined. RESULTS: During the follow-up period sharp, highly significant (p < 0.0001) drop occurred in the serum concentrations of both acute phase proteins. The drop in the hs-CRP levels during the follow up period was mainly due to decrease in patients with highest baseline CRP levels. CONCLUSIONS: Our present findings indicate that removal of atherosclerotic plaques from the carotid arteries markedly decreases the production of two acute phase proteins due to the decrease of the inflammatory burden or the removal of the advanced plaques able to produce these proteins.