The benefit of revascularization in nonagenarians with lower limb ischemia is limited by high mortality.

OBJECTIVE/BACKGROUND: Owing to the increased life expectancy of the population the number of very old patients referred to vascular surgical units has increased. Advanced age is a well known risk factor in patients undergoing surgical interventions for lower limb ischemia. However, amputation performed on an elderly person living independently will lead to permanent institutional care. The aim of this study was to evaluate the outcome of patients aged 90 years and older with lower limb ischemia undergoing surgical or endovascular revascularization. METHODS: Two hundred and thirty-three nonagenarians with either chronic critical limb ischemia (CLI) or acute limb ischemia (ALI) who underwent revascularization at the authors' institution between 2002 and 2013 were included in this retrospective study. Risk factors were evaluated and survival, limb salvage, and amputation free survival (AFS) assessed. RESULTS: The median age of the study population was 92 years (range 90-100 years). The majority (81.1%) of the patients were female. One in four (24.5%) patients had diabetes, and the incidence of coronary artery disease was 79.8%. Seventy-three percent of the patients had CLI and 27% of had ALI. Seventy percent of the patients underwent surgical revascularization and 30% were treated endovascularly. The majority (72.5%) of the patients maintained their independent living status; 27.5% ended up in institutional care post-operatively. Similarly, the majority (82.0%) of the patients maintained their walking ability, while 18% were not able to ambulate independently after revascularization. One year survival, limb salvage, and AFS rates were 50.9% versus 48.6% (p = .505), 85.1% versus 87.0% (p = .259), and 45.7% versus 44.4% (p = .309) in the surgical versus endovascular group, respectively. Dementia was an independent risk factor of poor AFS (odds ratio: 1.56; 95% confidence interval: 1.077-2.272; p = .019). CONCLUSION: Good limb salvage can be achieved by both surgical and endovascular revascularization, and independent living can be maintained in the majority of the patients. However, the benefit of revascularization is limited owing to high mortality, especially in patients with dementia.

Treatment of diabetic foot ulcers.

Diabetic foot ulcers are a major health care problem. Complications of foot ulcers are a leading cause of hospitalization and amputation in diabetic patients. Diabetic ulcers result from neuropathy or ischemia. Neuropathy is characterized by loss of protective sensation and biomechanical abnormalities. Lack of protective sensation allows ulceration in areas of high pressure. Autonomic neuropathy causes dryness of the skin by decreased sweating and therefore vulnerability of the skin to break down. Ischemia is caused by peripheral arterial disease, not by microangiopathy. Poor arterial inflow decreases blood supply to ulcer area and is associated with reduced oxygenation, nutrition and ulcer healing. Necrotic tissue is laden with bacteria apt to grow in such an environment, which also impairs general defence mechanisms against infection. Infections often complicate existing ulcers, but are seldom the cause for ulcers. Protective footwear helps to reduce ulceration in diabetic feet at risk. Relieving pressure on the ulcer area is necessary to allow healing. Blood supply needs to be improved by revascularisation whenever compromised. Systemic antibiotics are helpful in treating acute foot infections, but not uninfected ulcers. Osteomyelitis may underlie a diabetic ulcer and is often treated by resection of the infected bone and always by antibiotics, the mode and length of treatment depending on the adequacy of the debridement. The aim of ulcer bed preparation is to convert the molecular and cellular environment of the chronic ulcer to that of an acute healing wound by debridement, irrigating and cleaning. Moist dressings maintain wound environment favorable for healing. All attempts should be done to prevent diabetic foot ulceration and treat existing ulcers by multidisciplinary teams in order to decrease amputations. Indeed, improvement in ulcer healing has been observed with primary healing rates of 65-85% in mixed series. Even when healed, diabetic foot should be regarded as a life-long condition and treated accordingly to prevent recurrence. Long-term efforts have reduced amputation 37-75% in different European countries over 10-15 years.

Comparison between flutter valve drainage bag and underwater seal device for pleural drainage after lung surgery.

AIM OF THE STUDY: The purpose of the present study was to compare the use of a conventional underwater seal device with suction and a flutter valve drainage bag for pleural drainage after lung surgery. PATIENTS AND METHODS: Altogether 59 patients undergoing elective lung surgery except pneumonectomy between February 2001 and April 2002 were prospectively randomized to receive postoperative pleural drainage by 28F chest tube(s) attached to underwater seal device placed on negative pressure of 15 cm of water or flutter valve drainage bag. Following withdrawal of four patients from the study, 55 patients were evaluated (31 patients in the underwater seal device group and 24 patients in the flutter valve drainage bag group). RESULTS: In the conventional underwater seal device group the mean drainage time was 2.6 (SD +/- 2.0) days and in the flutter valve drainage bag group the mean drainage time was 3.3 days (SD +/- 4.0); difference -0.8, 95% confidence interval (CI) -2.4 to 0.9. The mean length of hospitalization in the surgical ward was 3.6 (SD +/- 2.7) and 4.1 (SD +/- 4.4) days respectively (difference -0.5, 95% CI -2.5 to 1.4). CONCLUSIONS: The results of this study suggest that flutter valve drainage system is a safe and feasible alternative in managing postoperative air leaks and haemorrhage after lung surgery other than pneumonectomy if air leaks are not extremely massive.

Flutter valve drainage bag is a useful device for the pleural drainage.

BACKGROUND AND AIMS: The purpose of the present study was to compare the use of the flutter valve pleural drainage bag and the conventional underwater seal system for the pleural drainage in the treatment of pneumothorax and pleural effusion. PATIENTS AND METHODS: Altogether fifty patients who needed the pleural drainage at our hospital between February and October 1999 were randomized to this prospective study either into the flutter valve pleural drainage group or into the conventional underwater seal pleural drainage group, 25 patients in each. RESULTS: In the conventional underwater seal system group, the mean drainage time was 4.1 (SD +/- 4.0) days and in the flutter valve drainage bag group 4.8 (SD +/- 4.9) days (difference -0.7, 95% confidence interval (CI) -3.3 to 1.8). The mean length of hospitalization was 16.3 (SD +/- 20.9) days and 18.7 (SD +/- 27.0) respectively (difference -2.4, 95% CI -16.1 to 11.3). CONCLUSIONS: The results of this study suggest that flutter valve drainage bag is a safe and feasible system in the most cases when pleural drainage is needed in the treatment of pneumothorax and pleural effusion.

Internal Mammary Artery Harvesting and Antibiotic Concentrations in Sternal Bone During Coronary Artery Bypass.

The concentrations of two antibiotics (vancomycin and cefuroxime) in sternal bone during coronary artery bypass surgery were analyzed to examine whether antibiotic penetration is impaired after dissection and harvesting of the left internal mammary artery for grafting. Bone samples (250 mg of cancellous sternal bone from both halves of the dissected manubrium) were obtained at the time of sternal opening and closure. Twenty patients undergoing primary coronary artery bypass grafting with the left internal mammary artery were randomized so that ten received 1.5 g of vancomycin over 180 minutes and ten 3 g of cefuroxime over 30 minutes beginning at the time of induction of anesthesia. Serum samples were collected at the same time as the bone samples and 12 h after the start of the infusions. There was a slight difference in vancomycin concentration between two sternal halves after IMA dissection at the time of sternal closure (median difference, 0.2 µg/g, and 95% confidence interval, -0.55 to 0.1). This difference was not statistically significant at the P = 0.05 level (P = 0.15, Wilcoxon matched-pair test). The cefuroxime concentration of the bone was below the detection limit (7.6 to 9.2 µg/g) in all ten patients at the time of sternal closure. Harvesting the internal mammary artery for coronary artery bypass grafting may influence the concentration of vancomycin in the manubrium of the sternum.

Comparison of vancomycin and cefuroxime for infection prophylaxis in coronary artery bypass surgery.

OBJECTIVE: To investigate clinically significant differences between vancomycin and cefuroxime for perioperative infection prophylaxis in coronary artery bypass surgery. DESIGN: A total of 884 patients were randomized prospectively to receive either cefuroxime (444) or vancomycin (440) and were assessed for infectious complications during hospitalization and 1 month postoperatively. SETTING: A university hospital. RESULTS: The overall immediate surgical-site infection rate was 3.2% in the cefuroxime group and 3.5% in the vancomycin group (difference, -0.3; 95% confidence interval, -2.6-2.1). CONCLUSIONS: The data suggest that vancomycin has no clinically significant advantages over cephalosporin in terms of antimicrobial prophylaxis. We suggest that cefuroxime (or first-generation cephalosporins, which were not studied here) is a good choice for infection prophylaxis in connection with coronary artery bypass surgery in institutions without methicillin-resistant Staphylococcus aureus problems. In addition to the increasing vancomycin-resistant enterococci problem, the easier administration and usually lower price of cefuroxime make it preferable to vancomycin.

Risk features for surgical-site infections in coronary artery bypass surgery.

OBJECTIVE: To identify preoperative and perioperative features that may lead to a risk of surgical-site infection (SSI) after coronary artery bypass surgery. DESIGN: 884 patients who underwent coronary artery bypass grafting in 1992 and 1993 were studied. The associations between 23 preoperative and perioperative features and the presence of SSI at the donor site or in the chest area were evaluated by univariate analysis followed by multivariate logistic regression analysis. SETTING: A university hospital. RESULTS: 172 patients (19.5%) either had an SSI recorded before discharge or had received antibiotics prescribed for a suspected SSI during the 1-month surveillance period after discharge. Multivariate logistic regression analysis showed an extreme body mass index (BMI; P=.015), female gender (P=.023), and chronic obstructive pulmonary disease (COPD; P=.030) to be independent risk features for SSI. The donor site was infected in 136 patients (15.4%), an event for which female gender (P=.003) was the only independent risk feature. Forty-seven patients (5.3%) had an SSI of the chest area, with diabetes (P=.003) and extreme BMI (P=.010) as independent risk features. CONCLUSION: Extreme BMI, female gender, and COPD are highly significant independent predictors of the development of SSI. Female gender is a risk feature specifically for SSI at the donor site, whereas diabetes and extreme BMI predict it in the chest area.

Is single-dose antibiotic prophylaxis sufficient for coronary artery bypass surgery? An analysis of peri- and postoperative serum cefuroxime and vancomycin levels.

Preliminary findings have suggested that a single intravenous dose of antibiotic is effective for infection prophylaxis in cardiac surgery. However there are still insufficient data on this proposed regimen. We measured serum cefuroxime and vancomycin levels after three different dosage regimens, in patients undergoing coronary artery bypass grafting (CABG). Sixty patients were randomized into three cefuroxime and three vancomycin groups with 10 patients in each: a group given a one-day course, or an additional dose during cardiopulmonary bypass or a single dose. Serum levels of the antibiotics were measured at various times throughout the operative procedure and until 48 h after the start of prophylaxis. Each of the six dosage regimens maintained serum levels adequate for infection prophylaxis throughout the operative procedure. Serum levels remained above 2 mg/L for more than 8 h postoperatively, even in the single-dose cefuroxime group and above 4 mg/L for more than 24 h with all the vancomycin dosage regimens. Thus a single dose of cefuroxime (3 g or 1.5 g) or vancomycin (1.5 g) seems to achieve and maintain serum levels sufficient for infection prophylaxis several hours after CABG procedures.

A normal rabbit serum containing Golgi-specific autoantibodies identifies a novel 74-kDa trans-Golgi resident protein.

A normal rabbit serum has been identified which contains Golgi-specific autoantibodies. In indirect immunofluorescence experiments the serum was found to stain the juxtanuclear Golgi complex in a variety of cell lines, including human skin fibroblasts, rat osteoblasts, rat myoblasts (L6), baby hamster kidney epithelial cells, and human embryonic kidney cells (293). Thus, the antigen(s) recognized by this serum seems to be well conserved and universally expressed in various mammalian cell types. Immunoelectron microscopy revealed that the epitope resides in the luminal side of the Golgi membranes, and that the antigen is concentrated in the trans-face of the Golgi stacks. In agreement with these results, brefeldin A treatment did not release the antigen from the membranes, but caused its redistribution partly into the endoplasmic reticulum but also into the juxtanuclear area, similarly as with other proteins known to be present in the trans-Golgi cisternae or trans-Golgi network. Our immunoprecipitation studies in human skin fibroblasts demonstrated that the serum recognizes specifically only a single protein with a molecular size of 74 kDa. This protein also cosedimented with a known trans-Golgi-specific marker protein, galactosyltransferase, after fractionation of subcellular organelles by Nycodenz gradient centrifugation. The widespread and polarized expression of this 74-kDa trans-Golgi resident protein suggests that it is required for the late Golgi functions in different mammalian cell types.