Cost and resource utilization for prevention and treatment of foot lesions in a diabetic foot clinic in Belgium.

This prospective observational study was carried out to assess the annual preventive and curative treatment costs for diabetic foot problems. Measures of resource use over the 1-year study period were taken for 151 patients whose lesions covered the entire Wagner classification. Treatment was provided under the current protocols of a multidisciplinary team. The 1993 market prices for health services were used to convert units of health service utilization to expenditures by the social insurance system and the patients. The severity of the foot problems determined the medical cost. Preventive care (47 cases), represented an average cost per case of US$ 880 (1US$ 1993=BEF 30.65). Curative care (120 cases), including diagnostic tests, wound dressings, antibiotic therapy, revascularization and off loading techniques resulted in a mean cost of US$ 5227 per ulcer. Care for the 16 most severe wounds and amputations involved hospitalization and surgery at a mean cost per ulcer of US$ 31716. The most important cost contributers were hospitalizations (72%), drugs (11%) and diagnostic examinations (4%). Preventive treatment for diabetic foot problems can represent a significant saving for the social insurance system as well as for the patients.

Role of lactosyl glycan sequences in inhibiting enteropathogenic Escherichia coli attachment.

Previously, we found that asialo-lactosamine sequences served as receptors for enteropathogenic Escherichia coli (EPEC) binding to Chinese hamster ovary (CHO) cells. In the present report, we have extended these earlier results by examining the ability of lactosamine- or fucosylated lactosamine-bovine serum albumin (BSA) glycoconjugates to inhibit EPEC, strain E2348/69, binding to HEp-2 cells. We found that, consistent with our previous findings with CHO cells, N-acetyllactosamine-BSA was the most effective inhibitor of EPEC localized adherence to HEp-2 cells, with Lewis X-BSA being the next best inhibitor. Further investigation revealed that coincubating EPEC E2348/69 with these BSA glycoconjugates alone caused a decrease in the expression of the bundle-forming pilus structural subunit (BfpA) and intimin by the bacteria. BfpA and intimin expression were reduced to the greatest extent by N-acetyllactosamine-BSA and Lewis X-BSA, respectively. These results suggest that the glycoconjugate inhibition of EPEC binding to HEp-2 cells might be achieved, wholly or in part, by an active mechanism that is distinct from simple competitive antagonism of receptor-adhesin interactions.

Chronic herniation of the lung in a patient with chronic obstructive pulmonary disease. Case report and review of the literature.

Lung herniation is a rare condition and can be classified by both anatomical site and etiology. A 70-year-old man was referred with dyspnea, productive cough, and right-sided chest pain. Radiological investigation showed healed rib fractures and a lung herniation between ribs 8 and 9. Two years after surgical repair the patient is free of complaints. Treatment can be conservative or surgical, but as experience is limited no long-term results have been reported.

Possible mechanisms of collar-induced intimal thickening.

The positioning of a soft silicone collar around the rabbit carotid artery induces intimal thickening. We investigated to which extent occlusion of the vasa vasorum, damage of the perivascular nerve network, and/or changes in blood flow velocity contribute to intimal thickening. To this end, collars with different bores (diameter of inlet and outlet) were positioned around the carotid artery of male rabbits for 14 days. In another experiment, 75% of the wall of fitting collars was removed (open collar). In the midcollar region, the cross-sectional area of the intima reached a maximum (72 +/- 14 mm2/1000) when the endings of the collar fitted the artery closely. Removal of the side wall of these fitting collars reduced intimal thickening by 90%. Examination of unoperated carotid arteries never showed penetration of the adventitia or the media by vasa vasorum. The perivascular neuronal network in the region surrounded by a closed or an open collar was almost completely lost as compared with the zones outside the collar. Both the closed and open collar slightly bent the artery and increased the peak systolic velocity, measured with pulsed color Doppler after 6 hours, to a similar extent as compared with the proximal zone outside the collar. After 2 weeks, the peak systolic velocity within both the closed and open collar was partly normalized and was statistically not different from the proximal zone outside the collar. In conclusion, the geometry of the collar influenced the extent of intimal thickening, whereby more intimal thickening was obtained with a collar whose endings fit the carotid artery, rather than with a loose collar. Moreover, a closed structure was essential. The results obtained with the open collar exclude occlusion of vasa vasorum, damage of the perivascular neuronal network, kinking of the artery, and changes in blood flow velocity as major factors in the collar-induced intimal thickening. Our findings are consistent with the possibility that intimal thickening is the consequence of the combination of both vascular injury and hindrance of transmural flow by the collar. The obstruction of transmural fluid transport may then lead to retention of toxic metabolites, and/or cytokines within the segment enclosed by the collar.

Effect of carbon source on localized adherence of enteropathogenic Escherichia coli.

Enteropathogenic Escherichia coli (EPEC) strains attach to epithelial cells as discrete clusters of bacteria which are localized at a few sites on the cell surface. Previously, it was shown that this localized-adherence (LA) phenotype is induced by specific growth conditions. We found that wild-type EPEC attached to HEp-2 cells in an LA pattern when the bacteria were grown in Dulbecco's modified Eagle medium (DMEM) containing glucose as the carbon source. In contrast, bacteria incubated in DMEM containing galactose did not adhere to epithelial cells. The latter results were similar to those observed when JPN15, an LA-negative strain, was grown under conditions which promoted bacterial binding. The differences in attachment of wild-type EPEC were independent of the stage of log-phase growth of the cultures and of the number of CFU incubated with the HEp-2 monolayers. Expression of the adherence phenotype by organisms grown in glucose was associated with increased expression of intimin and bundle-forming pilin. In contrast, bacteria grown in medium containing galactose expressed these proteins at levels similar to those observed when JPN15 was grown in medium containing glucose.

Surgical treatment of iatrogenic tracheal lacerations.

Traumatic and iatrogenic injuries of the trachea are uncommon. These injuries which are usually managed by surgery are associated with a high morbidity and mortality. In case of suspected lacerations, bronchoscopy remains the diagnostic procedure of choice. We present two unusual iatrogenic tracheal lacerations due to endotracheal stenting and intubation which were managed by primary suture with coverage of the suture line.

Short-term survival after major pulmonary resections for bronchogenic carcinoma.

From January 27, 1992 to December 12, 1994, 100 consecutive patients (86 men and 14 women) with a mean age of 62.5 years underwent lung resection for a non-small cell lung cancer. Squamous cell carcinoma was predominantly found (52%), followed by adenocarcinoma (23%) and large cell carcinoma (18%). Postoperative staging was Stage 0, 1 patient; Stage I, 57; Stage II, 17; Stage IIIa, 20 and Stage IIIb, 5. Thirty-day mortality was 4% (4 patients) with 10.7% for pneumonectomy and 0% for lobectomy or lesser resection. For the whole group 1-, 2- and 3-year survival rates were 83%, 68% and 65% respectively. Survival rates for N0, N1 and N2 after 3 years were 70%, 59% and 54% respectively. In the univariate analysis, a trend to statistical significance was noted between N0 and N1 (p = 0.08). There was no difference in short-term survival between N0 and N2 which represents a highly selected group of patients with N2 disease. In the multivariate analysis the only two independent variables with impact on survival were number of pack-years and diameter of the tumour (p < 0.05). Ninety-two quality of life questionnaires (EORTC QLQ-C30) were sent to home physicians. We collected 31 questionnaires (34%) after 2.5 months. A clear relationship was not seen between complaints of pain or dyspnea and extent of resection or lung function postoperatively. Instead, the global quality of life seemed to be influenced by the extent of resection to the advantage of a lobectomy and disadvantage of a pneumonectomy. Difficulties related to quality of life analysis are discussed and future directions are given.

Oesophagopleural fistula--a rare sequel of pneumonectomy.

Postpneumonectomy oesophagopleural fistula (OPF) is a devastating situation occurring in 0.2-1.0% of the patients undergoing pneumonectomy. Distinction is made between OPF appearing after pneumonectomy for chronic inflammation and suppuration, and OPF after pneumonectomy for lung cancer. Early and late fistulas (the former appearing within three months of the operation) are found in both groups. We report a case of OPF occurring almost five years after pneumonectomy for malignant lymphoma of the lung. Common signs of OPF are postpneumonectomy empyema and presence of previously ingested food particles in the empyema cavity. Treatment is extremely difficult and prolonged, and often not successful. Amelioration of the nutritional status, drainage of the postpneumonectomy space and closure of the fistula by injecting a sclerosing substance should be attempted. If this fails, the fistula should be closed by direct suture reinforced by a muscular or omental flap.

Traumatic type B aortic dissection.

A 37-year-old man was referred with thoracic pain after a deceleration trauma. He also had a cerebral contusion and a wrist fracture. There were no sings of hypovolemic shock. Computerized tomography (CT) of the chest and transoesophageal echocardiography (TEE) demonstrated a type B aortic dissection originating just distal to the left subclavian artery. There was a patent false lumen without rupture or distal ischaemia. Conservative treatment was given. A paralytic ileus developed and abdominal complaints persisted for several months. Angiography showed normal patency of mesenteric vessels. On follow-up, 3 years after the accident a slight aortic dilation was found on CT thorax without development of a post-dissection aneurysm. Blunt thoracic injury to the aorta usually gives rise to aortic rupture in the region of the isthmus, which can be complete or partial. In the latter case a false aneurysm may develop. An intimal tear after blunt trauma leading to type B aortic dissection rarely occurs. General principles regarding treatment of type B dissection also apply to this particular condition.

Role of thoracoscopy (VATS) in pleural and pulmonary pathology.

Although thoracoscopy is not a new procedure, there was a real revival after the introduction of laparoscopy. VATS (video-assisted thoracic surgery) has potential advantages of reduced pain due to smaller incisions and a shorter hospital stay. Main disadvantages are expensive equipment and a probably less adequate operation, especially for therapy of malignant disorders where long-term results are not known. VATS is very useful for investigation of pleural effusion and malignancy. Spontaneous pneumothorax is a very good indication for thoracoscopic treatment, as well as lung biopsy and diagnostic resection of lung metastases. Therapeutic metastasectomy, however, should not be performed by VATS. Regarding bronchogenic carcinoma, VATS is indicated for staging of lung cancer, facilitating sampling of mediastinal and hilar lymph nodes, investigation of pleural effusion, possible pleural dissemination and suspicion of intrapulmonary metastases. Wedge excision of solitary pulmonary nodules by VATS readily reveals the exact diagnosis, but its role in therapy of lung cancer is very limited at the present time.

Pulmonary metastasectomy.

Between 1988 and 1994, 24 patients underwent 32 procedures for pulmonary metastases. Primary tumours were gastrointestinal, malignant melanoma, osteogenic sarcoma, renal cell carcinoma, head and neck cancer and finally testicular carcinoma. Age ranged from 16 to 78 years, with a female/male ratio of 7/17. Pulmonary metastasectomy was performed in 9 cases through median sternotomy, in 21 cases through thoracotomy and in 2 cases by thoracoscopy. In 9 cases repeated resection was necessary. Overall mortality was 0% (95% confidence limits are 0.00 +/- 14.25). Computed tomography of the chest in combination with tumour markers, were most important during follow-up to detect recurrent disease. The overall 5-year actuarial survival and disease-free survival were 0.56 +/- 0.17 and 0.30 +/- 0.14 respectively. With regard to testicular carcinoma 5-year actuarial survival was 100%. Pulmonary metastasectomy is a recommended procedure in the treatment of selected patients with metastatic pulmonary disease. Resections should be as conservative as possible and if necessary, repeated. In our study this procedure proved especially effective in case of testicular carcinoma.

Surgical management of concurrent, coeliac and bilateral iliac artery aneurysms.

A 76-year-old man was admitted with bilateral common iliac artery aneurysms found incidentally on computed tomography. Transfemoral digital subtraction arteriography demonstrated atherosclerotic plaques in the aorta with bilateral common iliac artery aneurysms and a coeliac axis aneurysm. The coeliac artery aneurysm was resected and an aortobifemoral bypass performed with reimplantation of the inferior mesenteric artery into the prosthesis. The patient was well when discharged 2 weeks after operation. The incidence, natural history and management of coeliac axis and iliac artery aneurysms are reviewed.

Intrapulmonary lymph nodes in the differential diagnosis of solitary pulmonary nodules: case report and review of the literature.

A 49-year-old man was admitted for further investigation of a coin lesion with a diameter of 1 cm. He was a heavy smoker with no professional exposure. Since the percutaneous needle biopsy did not yield a definitive diagnosis, a thoracoscopy was performed. The solitary pulmonary nodule was found to be an intrapulmonary lymph node with anthracosilicotic pigment and a thoracoscopic wedge resection was performed. A review of the case reports in the period 1961-1993 shows that intrapulmonary lymph nodes could be more frequent than originally thought. All patients were smokers but professional exposure was not a constant finding. The differential diagnosis and management of the indeterminate solitary pulmonary nodule are discussed.

Colour duplex scanning versus angiography: a retrospective assessment of carotid stenosis.

A retrospective study was performed to investigate the reliability of colour duplex scanning as a screening method in detecting carotid artery disease. The results of this technique and digital subtraction arteriography of 100 carotid bifurcations in 50 patients undergoing carotid endarterectomy were compared. In accordance with suggested standard reports dealing with cerebrovascular disease, the diameter reduction was classified in one of five categories: < 20%, 20-59%, 60-79%, 80-99% and total occlusion. In 78% the gradings determined using digital subtraction arteriography and duplex scanning correlated perfectly, and in 99% of the studied bifurcations the difference was not more than one grade. The sensitivity and specificity of colour duplex scanning in detecting a stenosis with a diameter reduction of more than 60% was 98% and 87.7%, respectively. The best non-invasive method to identify carotid bifurcation disease is duplex scanning. Although the role of duplex scanning as an alternative to angiography is currently evolving, the authors still advocate carotid angiography when surgery is considered.

Effect of enteropathogenic Escherichia coli on adherent properties of Chinese hamster ovary cells.

Enteropathogenic Escherichia coli (EPEC) O111:H2, O119:H6, or O142:H6 caused rapid detachment of Chinese hamster ovary (CHO) cell monolayers within 2 to 4 h of cocultivation. CHO cell detachment was not promoted by nonenteropathogenic E. coli (O125:H4, O126:H27, O157:H7, and O26:H11) and could not be attributed to EPEC production of enterohemolysin or Shiga-like toxins. In contrast, EPEC strains did not promote rapid detachment of Lec1, Lec2, or Lec8 CHO cell monolayers. These CHO cell Lec mutants all express abbreviated glycan sequences on membrane glycoproteins and glycolipids. Although EPEC strains failed to alter the adherent properties of Lec2 cells lacking only terminal sialic acid groups, EPEC adherence to the Lec2 mutant was indistinguishable from that observed with wild-type CHO cells. There was also no significant difference in EPEC-induced actin accumulation or invasion of Lec2 cells. In contrast, EPEC localized adherence to Lec1 and Lec8 mutants, lacking sialyllactosamine (Lec1) or sialic acid and galactose (Lec8) sequences, was reduced by 84 and 93%, respectively. Our results suggest that lactosamine sequences [beta Gal(1-4 or 1-3)beta GlcNAc] not containing sialic acid are sufficient for EPEC adherence, actin accumulation, and invasion of CHO cells. Sialic acid groups, however, may be necessary for EPEC-mediated CHO cell detachment.

Is recurrence of varicose veins after surgery unavoidable?

Recurrence of varicose veins is a common problem. Four main reasons for recurrence are discussed: insufficient understanding of venous anatomy and haemodynamics, inadequate preoperative assessment, incorrect or insufficient surgery and development of new locations of superficial-to-deep insufficiency. Better insight in the variable anatomy of the venous system and better training of junior surgeons in this matter may improve the results of venous operations. Accurate preoperative assessment using (colour) duplex sonography should permit the surgeon to give the patient a differentiated, individualized treatment. Careful dissection of the saphenofemoral junction combined with additional stripping of the long saphenous trunk to just below the knee appears to be the best way to prevent recurrence from the long saphenous vein in the thigh. Concerning the short saphenous vein preoperative location of the exact level of the saphenopopliteal junction is of major importance in the prevention of recurrence. In this way, all diagnostic and surgical efforts should aim to minimize recurrence to about only 5% of patients.