Evaluation of Staphylococcus aureus Eradication Therapy in Vascular Surgery.

INTRODUCTION: Surgical site infections (SSI) are a serious complication in vascular surgery which may lead to severe morbidity and mortality. Staphylococcus aureus nasal carriage is associated with increased risk for development of SSIs in central vascular surgery. The risk for SSI can be reduced by perioperative eradication of S. aureus carriage in cardiothoracic and orthopedic surgery. This study analyzes the relation between S. aureus eradication therapy and SSI in a vascular surgery population. METHODS: A prospective cohort study was performed, including all patients undergoing vascular surgery between February 2013 and April 2015. Patients were screened for S. aureus nasal carriage and, when tested positive, were subsequently treated with eradication therapy. The presence of SSI was recorded based on criteria of the CDC. The control group consisted of a cohort of vascular surgery patients in 2010, who were screened, but received no treatment. RESULTS: A total of 444 patients were screened. 104 nasal swabs were positive for S. aureus, these patients were included in the intervention group. 204 patients were screened in the 2010 cohort. 51 tested positive and were included in the control group. The incidence of S. aureus infection was 5 out of 51 (9.8%) in the control group versus 3 out of 104 in the eradication group (2.2%; 95% confidence interval 0.02-1.39; P = 0.13). A subgroup analysis showed that the incidence of S. aureus infection was 3 out of 23 (13.0%) in the control group in central reconstructive surgery versus 0 out of 44 in the intervention group (P = 0.074). The reduction of infection pressure by S. aureus was stronger than the reduction of infection pressure by other pathogens (exact maximum likelihood estimation; OR = 0.0724; 95% CI: 0.001-0.98; p = 0.0475). CONCLUSION: S. aureus eradication therapy reduces the infection pressure of S. aureus, resulting in a reduction of SSIs caused by S. aureus.

Midterm results of autologous saphenous vein and ePTFE pre-cuffed bypass surgery in peripheral arterial occlusive disease.

INTRODUCTION: The graft of choice in lower limb bypass surgery is the autologous saphenous vein (ASV). However, a prosthetic graft is needed in the absence of an ASV. In such situations, we used an expanded polytetrafluoroethylene (ePTFE) pre-cuffed Dynaflo graft as supragenicular bypass or Distaflo graft as infragenicular or femorocrural bypass. In respect to the expanding possibilities of percutaneous transluminal angioplasty (PTA), the indication for bypass surgery moved toward patients with advanced stages of peripheral arterial occlusive disease. For this reason, this study analyzed the current performances of these ePTFE grafts and ASV grafts with special attention to limb salvage. METHODS: In a retrospective study all patients who underwent peripheral bypass surgery between 2004 and 2008 were included. Kaplan-Meier curves were used to express primary patency, secondary patency, and limb salvage rates at 1 and 3 years. Log-rank tests were performed to compare graft types. RESULTS: A total of 272 grafts (ePTFE/ASV: 110/162) were performed in lower limb bypass surgery. The mean follow-up was 20.3 months. The secondary 3-year patency rates were for (n=78) supragenicular grafts (ePTFE/ASV: 45%/94%)*, for (n=124) infragenicular grafts (24%/74%), and 70 for femorocrural grafts (26%/52%). Limb salvage after 3 years was 59% in the ePTFE group versus 78% in the ASV group (P < .05). CONCLUSION: In the current population of vascular patients where no PTA is possible and a peripheral bypass is necessary, the ASV remains the graft of first choice. However, the pre-cuffed ePTFE graft is a good alternative, especially in cases of critical limb ischemia, in respect to an acceptable limb salvage rate.

Effects of psychiatric consultation on medical consumption in medical outpatients with abdominal pain.

A randomized controlled clinical trial was conducted in an outpatient clinic of internal medicine to test the hypothesis that a protocol of cooperation and communication between internist and general practitioner, sustained with psychiatric consultation, would reduce medical consumption in a group of medical outpatients with abdominal pain (N = 106). A reduction in medical consumption could not be demonstrated. However, a great variation in protocol adherence was found, partly related to the severity of the psychological problems. There is some evidence that the protocol, if restricted to cases with more severe psychiatric comorbidity, might reduce medical consumption.

Effect of dietary fish oil on renal function and rejection in cyclosporine-treated recipients of renal transplants.

BACKGROUND: Dietary fish oil exerts effects on renal hemodynamics and the immune response that may benefit renal-transplant recipients treated with cyclosporine. To evaluate this possibility, we studied the effect of fish oil on renal function, blood pressure, and the incidence of acute rejection episodes in cyclosporine-treated recipients of renal transplants. METHODS: In a randomized, double-blind trial, 33 recipients of first cadaveric kidney transplants who were treated with cyclosporine and prednisolone ingested 6 g of fish oil daily during the first postoperative year (the fish-oil group), whereas another 33 renal-graft recipients treated with cyclosporine and prednisolone ingested 6 g of coconut oil daily for three months after which time it was stopped (the control group). RESULTS: One year after transplantation, the fish-oil group had higher median values than the controls for glomerular filtration rate (53 vs. 40 ml per minute per 1.73 m2, P = 0.038) and effective renal plasma flow (214 vs. 178 ml per minute per 1.73 m2, P = 0.023) and lower mean arterial pressure (103 vs. 118 mm Hg, P = 0.0011). The cyclosporine doses in the two groups were similar. The cumulative number of rejection episodes was 20 in the controls, as compared with 8 in the fish-oil group (P = 0.029). One-year graft survival also tended to be better in the fish-oil group, (97 vs. 84 percent, P = 0.097). CONCLUSIONS: The daily administration of 6 g of fish oil during the first postoperative year has a beneficial effect on renal hemodynamics and blood pressure in renal-transplant recipients treated with cyclosporine. Although the fish-oil group had significantly fewer rejection episodes than the control group, graft survival at one year was not significantly better in the fish-oil group.

Continuous measurement of blood volume during hemodialysis by an optical method.

A new method is described to noninvasively and continuously measure changes in blood volume (BV) during hemodialysis by means of an optical reflection method with an optical monitor (950 nm) clipped onto the arterial blood line. The amount of reflected light (L) appeared to be linearly proportional to the erythrocyte concentration (r = 0.91). Changes in L correlated well with changes in erythrocyte concentration during hemodialysis (r = 0.94). A study in 10 patients on regular dialysis was done. The BV decrease after 3 hr of treatment was 17.0 +/- 5.2%, and it correlated with the amount of fluid withdrawn by ultrafiltration (mean, 2,519 +/- 589 ml). Five hypotensive episodes were seen that were characterized by a higher rate of BV fall during the preceding 15 min (9.9 +/- 1.9 versus 3.6 +/- 4.3%/hrp; p < 0.05) and by a lower BV value at that moment (78.2 +/- 3.4 versus 84.5 +/- 4.5%; p < 0.025) than in the other five patients at comparable times. It was concluded that this optical method was a means to detect hypovolemia at an early stage and to prevent ultrafiltration induced hypotension.

Diabetic nephropathy in insulin-dependent diabetic patients: renal hemodynamics and derived treatment strategies.

Late complications such as retinopathy and neuropathy contribute substantially to the morbidity of patients with diabetes mellitus but have only moderate effect on their life expectancy. However, once diabetic nephropathy occurs, life expectancy of patients with diabetes mellitus is shortened considerably. This review discusses briefly several possible pathogenetic mechanisms involved in the development of diabetic nephropathy. Changes in renal hemodynamics as the initiating and contributing factor to the development of diabetic nephropathy are discussed in more detail. Finally, the article reviews possible therapeutic measures to prevent the development of diabetic nephropathy, or to slow down its progression.