Real-world characteristics and outcomes of patients with intermediate high risk acute pulmonary embolism.

BACKGROUND: Exact benefits of currently recommended close monitoring in intermediate high risk acute pulmonary embolism (PE) patients are unknown. METHODS: This prospective observational cohort study determined clinical characteristics, and disease course of intermediate high risk acute PE patients in an academic hospital setting . Frequency of hemodynamic deterioration, use of rescue reperfusion therapy and PE related mortality, were outcomes of interest. RESULTS: Of 98 intermediate high risk PE patients included for analysis, 81 patients (83%) were closely monitored. Two deteriorated hemodynamically and were treated with rescue reperfusion therapy. One patient survived after this. CONCLUSIONS: In these 98 intermediate high risk PE patients, hemodynamic deterioration occurred in three patients and rescue reperfusion therapy of two closely monitored patients led to survival of one. Underlining the need for better recognition of patients benefitting from and research in the optimal way of close monitoring.

First case of severe pneumonic tularemia in an immunocompetent patient in the Netherlands.

Tularemia is a zoonosis caused by different subspecies of the Gram-negative bacterium Francisella tularensis. We report the first case in the Netherlands of pneumonic tularemia caused by the F. tularensis subspecies holarctica after probable occupational inhalation of contaminated aerosols. Notification of cases of tularemia has been mandatory by law in the Netherlands since 1 November 2016.

Improving early diagnosis of pulmonary infections in patients with febrile neutropenia using low-dose chest computed tomography.

We performed a prospective study in patients with chemotherapy induced febrile neutropenia to investigate the diagnostic value of low-dose computed tomography compared to standard chest radiography. The aim was to compare both modalities for detection of pulmonary infections and to explore performance of low-dose computed tomography for early detection of invasive fungal disease. The low-dose computed tomography remained blinded during the study. A consensus diagnosis of the fever episode made by an expert panel was used as reference standard. We included 67 consecutive patients on the first day of febrile neutropenia. According to the consensus diagnosis 11 patients (16.4%) had pulmonary infections. Sensitivity, specificity, positive predictive value and negative predictive value were 36%, 93%, 50% and 88% for radiography, and 73%, 91%, 62% and 94% for low-dose computed tomography, respectively. An uncorrected McNemar showed no statistical difference (p = 0.197). Mean radiation dose for low-dose computed tomography was 0.24 mSv. Four out of 5 included patients diagnosed with invasive fungal disease had radiographic abnormalities suspect for invasive fungal disease on the low-dose computed tomography scan made on day 1 of fever, compared to none of the chest radiographs. We conclude that chest radiography has little value in the initial assessment of febrile neutropenia on day 1 for detection of pulmonary abnormalities. Low-dose computed tomography improves detection of pulmonary infiltrates and seems capable of detecting invasive fungal disease at a very early stage with a low radiation dose.

Stem cell therapy in PAD.

Critical limb ischemia (CLI) continues to form a substantial burden on Western health care. Despite recent advances in surgical and radiological vascular techniques, a large number of patients is not eligible for these revascularisation procedures and faces amputation as their ultimate treatment option. Growth factor therapy and stem cell therapy - both therapies focussing on augmenting postnatal neovascularisation - have raised much interest in the past decade. Based on initial pre-clinical and clinical results, both therapies appear to be promising strategies to augment neovascularisation and to reduce symptoms and possibly prevent amputation in CLI patients. However, the underlying mechanisms of postnatal neovascularisation are still incompletely understood. Both fundamental research as well as large randomised trials are needed for further optimisation of these treatment options, and will hopefully lead to needed advances in the treatment of no-option CLI patients in the near future.

[Lower leg amputation due to critical limb ischaemia: morbidity, mortality and rehabilitation potential]. / Onderbeenamputatie wegens kritieke ischemie: morbiditeit, sterfte en mogelijkheden tot revalidatie.

A total of 3 patients, a female aged 66 years, a male aged 67 years and a female aged 82 years, presented with rest pain or gangrene of their lower extremities as a result of critical limb ischemia (CLI). Radiographic studies showed non-reconstructable arterial obstructive disease in the 66-year-old female patient, who underwent an uncomplicated primary amputation and subsequent rehabilitation. Bypass surgery was initially performed in the male patient. However, failed reconstruction and progression of ischaemia necessitated transfemoral amputations to be performed, which was followed by impaired rehabilitation. In the 82-year-old female patient gangrene was the indication for primary amputation. She died due to progressive sepsis following surgery. In about 40% of patients with CLI, major lower extremity amputation is the ultimate solution. The morbidity, mortality and rehabilitation potential in CLI and the factors that influence these outcomes are discussed. The most clinically relevant determinants of morbidity, mortality and rehabilitation following major lower extremity amputation are comorbidity, age, preoperative mobility and amputation level.

Oxygen-limited nitrogen removal in a lab-scale rotating biological contactor treating an ammonium-rich wastewater.

A lab-scale Rotating Biological Contactor (RBC) was operated with the purpose of oxygen-limited (autotrophic) nitrification-denitrification of an ammonium-rich synthetic wastewater without Chemical Oxygen Demand (COD). Based on the field observations that RBCs receiving anaerobic effluents come to anoxic ammonium removal, the RBC was inoculated with methanogenic sludge. Some 100 days after the addition of the anaerobic sludge to the reactor as a possible means of a rapid initiation of the nitrogen (N) removal process, a maximum ammonium removal of 1,550 mg N m(-2) d(-1) was achieved. Batch tests with 15N labeled ammonium and nitrite indicated that a large part of that N was removed via oxygen-limited oxidation of ammonium with nitrite as the electron acceptor. The other part was removed via conventional denitrification, presumably with COD released from lysis of cells. Species identification of the most abundant microorganisms revealed that Nitrosomonas spp. were the dominant ammonium-oxidizers in the sludge. Thus far, the molecular characterization of the sludge could not show the presence of Planctomycetes among the most dominant species. Overall this experiment confirms the property of the RBC system to remove ammonium to nitrogen gas without the use of heterotrophic carbon source.

Oxygen-limited autotrophic nitrification/denitrification by ammonia oxidisers enables upward motion towards more favourable conditions.

The hypothesis is formulated that in case of oxygen limitation in the sediment, nitrifiers switch from nitrification to oxygen-limited autotrophic nitrification-denitrification (OLAND) in order to survive and maintain activity. During OLAND, ammonium is oxidised using nitrite as e-acceptor to form dinitrogen gas. As an additional advantage they benefit from the gaseous N(2) formed as a means of transport. In this way, the nitrifiers can move out of the sediment and rise through the water column towards more favourable conditions. At the surface, the bacteria could take up oxygen, and recommence nitrification. In order to test this hypothesis, nitrifying sediment with an overlaying water column was simulated in lab-scale columns. Nitrogen transformations and material transport through the water column were followed after addition of different forms of nitrogen under oxygen-limited conditions. (15)N-labelling experiments showed a large contribution of OLAND to the observed nitrogen deficits. Nitrifier enumerations, fluorescent in situ hybridisation and 16S rRNA gene analysis revealed increased populations of ammonia oxidising nitrifiers in the upper water layers. The results presented support the proposed hypothesis of transport using OLAND. Nitrifying activity in the sediment immediately recovered almost completely from prolonged oxygen-limited incubation when oxygen concentrations were increased.

Oxygen-limited nitrification and denitrification in a lab-scale rotating biological contactor.

Rotating Biological Contactors (RBC) treating highly nitrogenous wastewaters are known to give rise to nitrogen losses, generally assumed to be due to concomitant nitrification and denitrification. In this study, a lab-scale nitrifying RBC reactor was shown to bring about losses of nitrogen of the order of 10 to 20% at ammonium loading rates of up to 2129 mg N m(-2) d(-1), when no extra carbon source was added. These higher removal values could be due to Oxygen-Limited Autotrophic Nitrification and Denitrification (OLAND), because the reactor was operated at oxygen limitation. When methanol was added as a soluble organic carbon source to further diminish oxygen transfer into the deeper parts of the biofilm, the RBC achieved 84% nitrogen removal (loading rate 2300 mg N m(-2) d(-1)) at a COD/N ratio of 3.1. The latter also suggests that the process was occurring parallel to conventional denitrification.