Caregiver strain on informal caregivers when providing care for older patients undergoing major abdominal surgery: a longitudinal prospective cohort study.

BACKGROUND: Health-care systems nowadays rely on complementary patient care by informal caregivers. The need for, and burden on, informal caregivers will likely increase in the upcoming years. This study aimed to examine the burden on caregivers when providing care for elderly patients undergoing major abdominal surgery. METHODS: A single-centre longitudinal cohort study was conducted between November 2015 and June 2018 in the Amphia hospital in Breda, the Netherlands. Patients aged 70+ undergoing elective surgery for colorectal carcinoma (CRC) or an abdominal aortic aneurysm (AAA) were included in this study. Informal caregiver burden was assessed and compared over time using the Caregiver Strain Index (CSI) at the outpatient clinic visit, at discharge, 2 weeks post-discharge and after 6 and 12 months. The effects of patient- and caregiver-related factors on the experienced caregiver strain were examined. RESULTS: CSI scores of 248 caregivers were significantly increased at discharge (3.5 vs 2.6; p < 0.001) and 2 weeks post-discharge (3.3 vs 2.6; p < 0.001). After 12 months, scores dropped below baseline scores (1.8 vs 2.6; p = 0.012). The highest strain was observed 2 weeks post-discharge for AAA patients and at discharge for CRC patients. Older age, physical or cognitive impairment and burden of comorbidity were associated with an increased caregiver strain at baseline. Type of surgery was independently associated with the change in mean CSI scores over time; a bigger change in caregiver burden is observed after open surgery. CONCLUSION: In the early postoperative period, perceived caregiver strain was significantly increased. Psychological support for caregivers may be advisable, with timing of this support depending on diagnosis and patient-related factors. TRIAL REGISTRATION: This manuscript was retrospectively registered on 05-04-2016 in the Netherlands Trial Register (NTR5932). http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5932.

Effect of conservative treatment in aortoiliac occlusive disease.

Objective: To determine the effect of primary conservative treatment without revascularization in patients with proven aortoiliac occlusive disease (AIOD) presenting with intermittent claudication (IC).Background: The initial treatment of IC should focus on supervised exercise therapy (SET) and pharmacotherapy. Nowadays, primary endovascular revascularization (EVR) has become increasingly popular in patients with all types of AIOD. But in daily practice, EVR is often performed without initially extensive exercise.Method: This is a single centre retrospective study from December 2012 to September 2017. Primary outcomes were maximum walking distance (MWD) and patient satisfaction. Secondary outcomes were revascularization rate and mortality.Results: Twenty-four patients were included. Mean age was 64 years (SD: 9). Mean follow-up was 28 months (SD: 17). Nineteen patients (80%) had SET. In 18 (75%) patients, the MWD was improved compared to the initial situation. In five (21%) patients, the MWD stayed the same. The MWD of one (4%) patient decreased. Overall satisfaction rate was 87%. Three patients (13%) were not satisfied with the conservative treatment and eventually got an EVR. There was no disease related death.Conclusions: Conservative treatment, especially with SET, has acceptable subjective symptom outcomes in selected patients with AIOD. It could be a good alternative treatment for certain patients with AIOD and IC.

Risk factors for postoperative delirium after elective major abdominal surgery in elderly patients: A cohort study.

BACKGROUND: Prehabilitation programs have recently been suggested as potentially able to lower the incidence of delirium in elderly patients undergoing major abdominal surgery. For these prehabilitation programs to become successful, it is essential to identify those patients who are most likely to develop a delirium. MATERIAL AND METHODS: A single-centre cohort study was conducted. Inclusion criteria were: age ≥70 years and scheduled for abdominal surgery for colorectal cancer or an abdominal aortic aneurysm between January 2013 and June 2018. Baseline patient, surgical, anaesthesiologic and haematological characteristics were collected. A risk factor analysis was conducted, with postoperative delirium as primary outcome, by performing a multivariable logistic regression analysis. RESULTS: In this study, 627 patients were included, of whom 64 (10%) developed a delirium. Variables that differed significantly between delirious and non-delirious patients were age, burden of comorbidity, renal impairment, hypertension, cognitive impairment, history of delirium, physical and nutritional impairment, open surgery, preoperative anaemia and erythrocyte transfusion. After multivariable logistic regression analysis, risk factors for postoperative delirium after major abdominal surgery were renal impairment (OR 2.2; 95%CI 1.2-4.3), cognitive impairment (OR 4.1; 95%CI 1.8-9.2), an ASA score ≥ 3 (OR 2.0; 95% CI 1.0-3.9), being an active smoker (OR 2.7; 95%CI 1.3-5.8), ICU admission (OR 7.1; 95%CI 3.5-14.3), erythrocyte transfusion (OR 2.4; 95%CI 1.2-4.9) and a diagnosis of colorectal cancer (CRC); (OR 4.0; 95% CI 1.7-9.6). Prehabilitation had a protective effect (OR 0.5; 95% CI 0.3-0.9). CONCLUSION: Postoperative delirium is a frequent complication after major abdominal surgery in the elderly, especially in octogenarians and after open procedures. Renal impairment, cognitive impairment, being an active smoker, ICU admission, erythrocyte transfusion and a diagnosis of CRC are important risk factors for the development of delirium. Prehabilitation lowers the risk of developing a delirium.

Multimodal prehabilitation to reduce the incidence of delirium and other adverse events in elderly patients undergoing elective major abdominal surgery: An uncontrolled before-and-after study.

BACKGROUND: Delirium is a common and serious complication in elderly patients undergoing major abdominal surgery, with significant adverse outcomes. Successful strategies or therapies to reduce the incidence of delirium are scarce. The objective of this study was to assess the role of prehabilitation in reducing the incidence of delirium in elderly patients. METHODS: A single-center uncontrolled before-and-after study was conducted, including patients aged 70 years or older who underwent elective abdominal surgery for colorectal carcinoma or an abdominal aortic aneurysm between January 2013 and October 2015 (control group) and between November 2015 and June 2018 (prehabilitation group). The prehabilitation group received interventions to improve patients' physical health, nutritional status, factors of frailty and preoperative anaemia prior to surgery. The primary outcome was incidence of delirium, diagnosed with the DSM-V criteria or the confusion assessment method. Secondary outcomes were additional complications, length of stay, unplanned ICU admission, length of ICU stay, readmission rate, institutionalization, and in-hospital or 30-day mortality. RESULT: A total of 360 control patients and 267 prehabilitation patients were included in the final analysis. The mean number of prehabilitation days was 39 days. The prehabilitation group had a higher burden of comorbidities and was more physically and visually impaired at baseline. At adjusted logistic regression analysis, delirium incidence was reduced significantly from 11.7 to 8.2% (OR 0.56; 95% CI 0.32-0.98; P = 0.043). No statistically significant effects were seen on secondary outcomes. CONCLUSION: Current prehabilitation program is feasible and safe, and can reduce delirium incidence in elderly patients undergoing elective major abdominal surgery. This program merits further evaluation. TRIAL REGISTRATION: Dutch Trial Registration, NTR5932.

The Role of Delirium and Other Risk Factors on Mortality in Elderly Patients with Critical Limb Ischemia Undergoing Major Lower Limb Amputation.

BACKGROUND: Delirium in patients with critical limb ischemia (CLI) is associated with increased mortality. The main goal of this study was to investigate the association between delirium and mortality in patients undergoing major lower limb amputation for CLI. In addition, other risk factors associated with mortality were analyzed. METHODS: An observational cohort study was conducted including all patients aged ≥70 years with CLI undergoing a major lower limb amputation between January 2014 and July 2017. Delirium was scored using the Delirium Observation Screening Score in combination with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Risk factors for mortality were analyzed by calculating hazard ratios using a Cox proportional hazards model. RESULTS: In total, 95 patients were included; of which, 29 (31%) patients developed a delirium during admission. Delirium was not associated with an increased risk of mortality (hazard ratio [HR] = 0.84; 95 % confidence interval [CI]: 0.51-1.73; P = 0.84). Variables independently associated with an increased risk of mortality were age (HR 1.1; 95% CI 1.0-1.1), cardiac history (HR 3.3; 95% CI 1.8-6.1), current smoking (HR 2.9; 95% CI 1.6-5.5), preoperative anemia (HR 2.8; 95% CI 1.1-7.2), and living in a nursing home (HR 2.2; 95% CI 1.1-4.4). CONCLUSION: Delirium was not associated with an increased mortality risk in elderly patients with CLI undergoing a major lower limb amputation. Factors related to an increased mortality risk were age, cardiac history, current smoking, preoperative anemia, and living in a nursing home.

Review: Quality of life in lower limb peripheral vascular surgery.

PURPOSE: Vascular intervention studies generally consider patency and limb salvage as primary outcomes. However, quality of life is increasingly considered an important patient-oriented outcome measurement of vascular interventions. Existing literature was analyzed to determine the effect of different treatments on quality of life for patients suffering from either claudication or critical limb ischemia. BASIC METHODS: A review of the literature was undertaken in the Medline library. A search was performed on quality of life in peripheral arterial disease. Results were stratified according to treatment groups. PRINCIPAL FINDINGS: Twenty-one articles described quality of life in approximately 4600 patients suffering from peripheral arterial disease. Invasive treatment generally results in better quality of life scores (at a maximum of 2 years of follow-up), compared with non-invasive treatment. In patients with critical limb ischemia, successful revascularization improves quality of life scores. Only one study reported long-term results. CONCLUSIONS: Increase in quality of life scores can be found for any intervention performed for peripheral arterial disease. However, there is scarce information on long-term quality of life after vascular intervention.

Bilateral emphysematous pyelitis: a rare encounter in urology.

Gas-forming infection of the kidneys can affect either the parenchyma or the collecting system. They are known as emphysematous pyelonephritis (EPN) and emphysematous pyelitis (EP) respectively. Bilateral EPN is a fairly established entity and numerous articles about this condition have been published. However, much less is known about bilateral EP. We report a rare case of bilateral EP and a literature review of this disease. A 66-year-old woman with long-standing bilateral staghorn calculi presented with bilateral EP and severe sepsis. She was treated with antibiotics and bilateral double-J stents to drain the upper urinary tracts. She recovered after 1 month of intensive care and medical therapy. Percutaneous nephrolithotomy (PCNL) had been scheduled to treat her staghorn calculi. A literature search on MEDLINE and Google Scholar with the terms "bilateral emphysematous pyelitis" only found 1 case report in English and another 2 reports in the Korean language that discussed bilateral EP. The collective experience of these few cases, including the present case, suggests that bilateral EP runs a more benign course than bilateral EPN. It should be diagnosed as soon as possible with computed tomography (CT) scans of the renal system. Current evidence shows that can be treated successfully with timely antibiotics. Drainage of the collecting system either percutaneously or with placement of double-J stents might facilitate recovery.

Reinterventions following endovascular abdominal aortic aneurysm repair: the learning curve of time.

AIM: The DREAM and EVAR-1 trial show a higher reintervention rate after endovascular aneurysm repair (EVAR) compared to open repair. Since the initiation of these trials, endovascular-graft design and the experiences with EVAR have evolved substantially. The aim of this study was to compare the need for reinterventions in our recent EVAR procedures with our early procedures. METHODS: A retrospective review of our prospectively maintained database of all patients undergoing an elective EVAR for infrarenal abdominal aortic aneurysm (AAA) was performed. The 68 patients treated between 2000 and 2006 were defined as the "Early EVAR" group; the 41 patients treated between 2006 and 2008 were defined as the "Recent EVAR" group. The median follow-up was 63.3 (range 2-111) and 43.7 (range 1-61) months in the Early and Recent EVAR group respectively. RESULTS: Treatment related mortality occurred in three (4.4%) patients in the Early EVAR group. No treatment related mortality occurred in the Recent EVAR group. In the Early EVAR group 16 reinterventions occurred in 13 patients (19.1%) and in the Recent EVAR group three reinterventions occurred in three patients (7.5%). This difference was statistically significant (P=0.039). CONCLUSION: In our center, continued experiences with EVAR, improvement of graft design and a different management of complications have led to a significant decrease in reinterventions after EVAR. These findings and a review of the literature suggests that current need for reintervention after EVAR is substantially less than reported in the early trials.

Association of common genetic variants with breast cancer risk and clinicopathological characteristics in a Chinese population.

Genome-wide association studies (GWAS) have identified various genetic susceptibility loci for breast cancer based mainly on European-ancestry populations. Differing linkage disequilibrium patterns exist between European and Asian populations, and thus GWAS-identified single nucleotide polymorphisms (SNPs) in one population may not be of significance in another population. In order to explore the role of breast cancer susceptibility variants in a Chinese population of Southern Chinese descent, we analyzed 22 SNPs for 1,191 breast cancer cases and 1,534 female controls. Associations between the SNPs and clinicopathological features were also investigated. In addition, we evaluated the combined effects of associated SNPs by constructing risk models. Eight SNPs were associated with an elevated breast cancer risk. Rs2046210/6q25.1 increased breast cancer risk via an additive model [per-allele odds ratio (OR) = 1.43, 95 % confidence interval (CI) = 1.26-1.62], and was associated with estrogen receptor (ER)-positive (per-allele OR = 1.39, 95 % CI = 1.20-1.61) and ER-negative (per-allele OR = 1.55, 95 % CI = 1.28-1.89) disease. Rs2046210 was also associated with stage 1, stage 2, and stage 3 disease, with per-allele ORs of 1.38 (1.14-1.68), 1.48 (1.25-1.74), and 1.58 (1.28-1.94), respectively. Four SNPs mapped to 10q26.13/FGFR2 were associated with increased breast cancer risk via an additive model with per-allelic risks (95 % CI) of 1.26 (1.12-1.43) at rs1219648, 1.22 (1.07-1.38) at rs2981582, 1.21 (1.07-1.36) at rs2981579, and 1.18 (1.04-1.35) at rs11200014. Variants of rs7696175/TLR1, TLR6, rs13281615/8q24, and rs16886165/MAP3K1 were also associated with increased breast cancer risk, with per-allele ORs (95 % CI) of 1.16 (1.00-1.34), 1.15 (1.02-1.29), and 1.15 (1.01-1.29), respectively. Five SNPs associated with breast cancer risk predominantly among ER-positive tumors (rs2981582/FGFR2, rs4415084/MRPS30, rs1219648/FGFR2, rs2981579/FGFR2, and rs11200014/FGFR2). Among our Chinese population, the risk of developing breast cancer increased by 90 % for those with a combination of 6 or more risk alleles, compared to patients with ≤3 risk alleles.

Pathophysiology and treatment of edema following femoropopliteal bypass surgery.

Substantial lower-limb edema affects the majority of patients who undergo peripheral bypass surgery. Edema has impairing effects on the microvascular and the macrovascular circulation, causes discomfort and might delay the rehabilitation process of the patient. However, the pathophysiology of this edema is not well understood. The Cochrane Library and Medline were used to retrieve literature on edema following peripheral bypass surgery. Factors other than local wound healing alone are suggested in the literature to play a role, given the severity and duration of this edema. Hyperemia, microvascular permeability, reperfusion-associated inflammation and lymphatic disruptions are likely to facilitate the development of edema. Preventive methods could be lymphatic-sparing surgery, intraoperative antioxidative therapy and postoperative elevation. Successful treatment strategies to reduce postoperative edema are based on lymph massage and external compression. In conclusion, the pathophysiology of edema following peripheral surgery is not fully understood, although reperfusion-associated inflammation and lymphatic disruptions are likely to play a crucial role. When future less-invasive techniques prove to be successful, postoperative edema might be minimized. Until then, a careful lymphatic-sparing dissection should be executed when performing a peripheral bypass reconstruction. Postoperatively, the use of compression stockings and leg elevation are currently the golden standards.

Quality of life in perspective to treatment of postoperative edema after peripheral bypass surgery.

BACKGROUND: To examine the effects of peripheral bypass surgery on patients' quality of life (QoL) as well as to compare two treatment modalities to reduce postoperative edema with regard to patients' QoL. METHODS: This was a randomized controlled trial set in the department of vascular surgery in a nonacademic teaching hospital. Ninety-three patients (mean age, 70 years; 33% Rutherford 5-6), enrolled between August 2006 and September 2009, who underwent peripheral bypass surgery (autologous 57, polytetrafluoroethylene 36). Patients were assigned to intermittent pneumatic compression (n = 46) or to compression stockings (n = 47). The main outcome measure was QoL, measured with the World Health Organization Quality of Life assessment instrument (short form: WHOQOL-BREF). RESULTS: QoL improved on the domain of Physical Health by 7.18 points (P < 0.001 [range, 0-100]) after 2 weeks and by 10.03 points (P < 0.001) after 3 months. Patients who received a polytetrafluoroethylene bypass scored 0.45 points (P = 0.0008 [range, 1-5]) lower at baseline on Global QoL than patients who received an autologous bypass. Type of bypass or edema treatment method did not affect the improvements. Edema did not correlate with QoL. CONCLUSION: Improvement in QoL on the domain Physical Health following femoropopliteal bypass surgery was found as soon as 2 weeks after surgery. Improvement in QoL domains was not influenced by the type of bypass reconstruction. No specific effects of edema on QoL were detected.

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.

Evaluation of A-V impulse technology as a treatment for oedema following polytetrafluoroethylene femoropopliteal surgery in a randomised controlled trial.

OBJECTIVE: To investigate the efficacy of A-V impulse technology (A-V) for oedema prevention and treatment following PTFE femoropopliteal surgery. DESIGN: Prospective randomized clinical trial. MATERIALS: 36 patients undergoing PTFE femoropopliteal bypass reconstructions, either being treated postoperatively with a compression stocking (CS) (Group-1, n = 19) or with A-V (Group-2, n = 17). METHODS: Patients in treatment group-1 used a CS postoperatively during 1 week day and night, patients in group-2 were treated with A-V postoperatively at night during one week. The lower leg circumference was measured preoperatively and at five postoperative time points. RESULTS: Limb circumference has increased postoperatively on day 1 (CS 1.5%/A-V 1.4%), on day 4 (5.7%/6.3%), on day 7 (6.6%/6.1%), on day 14 (7.9%/7.7%) and on day 90 (5.8%/5.2%). Differences between treatment groups were not significant. A re-operation gives a significant 3.9% increase in circumference as compared to a first operation (95% CI: 1.5-6.4%; p = 0.002). CONCLUSION: No significant differences were found in the extent of developed edema between the groups following PTFE femoropopliteal bypass surgery. A redo peripheral bypass operation results in significantly more postoperative oedema than a first-time performed bypass operation.

Surgical removal of an infected aortic endoprosthesis using a wire cutter.

The purpose of this study is to report a new method of removing an infected endoprosthesis from the abdominal aorta using a wire cutter. A 65-year-old man with a ruptured abdominal aortic aneurysm was admitted to our hospital. He was treated with an endovascular abdominal endoprosthesis and discharged one week later. Three months after placement, the patient returned with an infection of the aortic endoprosthesis. The endoprosthesis had been fixed with barbs and hooks above the renal arteries and was surgically explanted by using a wire cutter to cut the hooks. The bare suprarenal stent was left in place. The patient was discharged one month after stent removal, and was treated with oral antibiotics for another ten weeks. At one year follow-up the patient showed no clinical, biochemical, or radiological signs of infection. In conclusion, infected endoprostheses should be surgically removed according to the medical literature. We recognize that removing a Zenith endoprostheses requires a dangerous operation because the hooks of the bare stent are engaged into the supra-renal aorta. This case report documents a new technique to safely remove an infected endoprosthesis with the help of a wire cutter.

Tuberculosis of the chest wall: unusual presentation as a breast lump.

A 33-year-old woman presented with a painless right breast lump of four weeks' duration. There were no symptoms such as fever or night sweats. Mammogram revealed an elliptical lesion in the retromammary region. Ultrasonography showed a hypoechoeic collection deep in the right breast. As the lesion was localised to the chest wall, computed tomography of the thorax was performed. This confirmed a fluid collection in the right anterior chest wall and also bilateral upper lobe consolidations, suggestive of pulmonary tuberculosis with an abscess in the anterior chest wall. Ultrasound-guided core needle biopsy confirmed a Mycobacterium tuberculosis infection. It is unusual for a tuberculous abscess of the chest wall to present as a painless breast lump. We also present a companion case of tuberculous mastitis to illustrate their distinct imaging features.

Endovascular aneurysm repair with Zenith graft. Complications caused by leg extensions.

AIM: A large amount of Zenith endovascular stent complications is due to problems with the leg extensions. This kind of complication has never been reported in literature. The aim of this study was to monitor the complications of endovascular abdominal aneurysm repair (EVAR) performed with the Zenith endovascular graft occurred in the Amphia Ziekenhuis in Breda to see how many recurrences were due to leg extension. METHODS: The study enrolled all patients (N.=66) treated with the Zenith endograft in the period between October 2000 and September 2006. Mortality, complications and the number of reinterventions were analysed. Average age of the patients was 73.4 years, average follow-up was 24.5 months and average aneurysm size was 61.5 mm. Radiologic follow-up was performed by computed tomography scans and X-rays. RESULTS: Postoperative mortality rate was 0%. The overall mortality rate during follow-up was 3%. Ten patients required a total number of 12 reinterventions (15%). The average time for reintervention was 10 months after the primary operation. Mortality, complication and reintervention rates were comparable with those reported in the literature, but 75% of these reinterventions were related to the leg extensions. CONCLUSION: Authors observed that nine out of 12 complications which required reintervention were due to problems with one of the leg extensions. This is the first study that specifies clearly the percentage of problems with leg extensions in EVAR (75%). When placing a Zenith endovascular graft extra attention should be paid to optimal placement of the leg extensions.

Effects of temperature and pH on adsorption of basic brown 1 by the bacterial biopolymer poly(gamma-glutamic acid).

Poly(gamma-glutamic acid) (gamma-PGA), an extracellular polymeric substance (EPS) synthesized by Bacillus species, was explored to study its interaction with the basic brown 1 dye by conducting a systematic batch adsorption study as affected by two critical parameters, temperature and pH. Adsorption isotherms were closely predicted by Temkin equation among the eight isotherm models tested. The rate of adsorption was very rapid attaining equilibrium within 60 min and the kinetics were well described by both modified second-order and pseudo second-order models. Boyd's ion exchange model, which assumes exchanges of ions to be a chemical phenomenon, also fitted the kinetic data precisely. The adsorption rate increased with increasing solution temperature, however, a reversed trend was observed for the adsorption capacity. Changes in enthalpy, entropy and free energy values revealed dye adsorption by gamma-PGA to be an exothermic and spontaneous process involving no structural modification in gamma-PGA, whereas the activation energy of 37.21 kJ/mol indicated dye adsorption to be reaction-controlled. Following a rise in solution pH, the dye adsorption increased and reached a plateau at pH 5, while the maximum release of dye from spent gamma-PGA occurred at pH 1.5, suggesting a possible ion exchange mechanism. Ion exchange adsorption of basic dyes by gamma-PGA was further proved by the presence of two new IR bands at approximately 1600 and 1405.72 cm(-1), representing asymmetric and symmetric stretching vibration of carboxylate anion, for dye-treated gamma-PGA.

Encapsulation of lycopene extract from tomato pulp waste with gelatin and poly(gamma-glutamic acid) as carrier.

Tomato pulp waste, a byproduct obtained during the processing of tomato juice, has been shown to be a rich source of lycopene. The objectives of this study were to use gelatin and poly(gamma-glutamic acid) (gamma-PGA) as coating materials for the encapsulation of lycopene extract from tomato pulp waste. Initially, lycopene was extracted with supercritical carbon dioxide, followed by microencapsulation using an emulsion system consisting of 4.5% gelatin, 10% gamma-PGA, and 4.8% lycopene extract. Analysis of differential scanning calorimetry revealed that the thermal stability of the coating material could be up to 120 degrees C, with a mean particle size of 38.7 microm based on Coulter counter analysis. The total weight of microencapsulated powder was 617 microg with the yield of lycopene being 76.5%, indicating a 23.5% loss during freeze drying. During storage of microencapsulated powder, the concentrations of cis-, trans-, and total lycopene decreased along with increasing time and temperature. A fast release of lycopene in the powder occurred at pH 5.5 and 7.0, while no lycopene was released at pH 2.0 and 3.5.

Clinical outcome after re-occlusion of initially successful remote endarterectomy of the superficial femoral artery.

AIM: The clinical consequences of re-occlusion after initially successful arterial revascularization procedures might be as important as patency when it comes to procedure selection. This study evaluates the clinical consequences of re-occlusion after initially successful remote superficial femoral artery endarterectomy (RSFAE), in particular the recurrence and severity of symptoms and the need for re-intervention or amputation. METHODS: A total of 239 successful RSFAEs were performed with a mean endarterectomized segment of 30 cm (10 to 45 cm) between March 1994 and December 2003 in 214 patients (144 males, 163 procedures) with a median age of 63 years (39 to 89 years). Indications for operation were Rutherford category 3 in 174 procedures (73%), Rutherford category 4 in 27 procedures (11%), and Rutherford category 5 in 38 procedures (16%). The incidence and time interval of re-occlusion with the presenting symptoms were recorded as well as the therapeutic consequences. RESULTS: A total of 79 (33%) re-occlusions occurred (40 males, 41 procedures; 34 females, 38 procedures). Eighty percent of patients still had improved or unchanged symptoms following re-occlusion compared to the initial indication for operation, 18% had become worse and 2% were unknown. The mean time between RSFAE and re-occlusion was 17 months (1 day to 88 months). A total of 36 re-interventions were performed: 7 percutaneous recanalisations (one followed by thrombolysis), 5 percutaneous thrombolyses, 1 thrombectomy, 21 venous and 2 prosthetic femoropopliteal bypasses. A further three venous bypasses were planned. Five (14%) of these re-interventions were acute with an overall median time interval between re-occlusion and re-intervention of 41 days (0 to 68 months). Two below-knee amputations were performed: one the same day of re-occlusion, 44 months after RSFAE and one 11 days after re-occlusion, 30 days after RSFAE. CONCLUSION: The clinical consequences of re-occlusion after remote endarterectomy for long occlusive disease of the superfricial femoral artery, from a mixed patient population with 27% ischemic rest pain and gangrene, were mild with 31 elective and only five acute re-interventions and two below-knee amputations.

Effect of pH on binding of mutagenic heterocyclic amines by the natural biopolymer poly(gamma-glutamic acid).

Poly(gamma-glutamic acid) (gamma-PGA), a nontoxic and biodegradable macropolymer, was evaluated for its efficiency in binding three mutagenic heterocyclic amines (HAs), 2-amino-3,4-dimethylimidazo[4,5-f]quinoline (MeIQ), 2-amino-3,4,8-trimethylimidazo[4,5-f]quinoxaline (4,8-DiMeIQx), and 3-amino-1-methyl-5H-pyrido[4,3-b]indole (Trp-p-2), as affected by pH in a batch mode. The maximum HA sorption was attained for pH 3-7 and decreased sharply for pH less than 3. Binding isotherms obtained at pH 2.5 and 5.5 showed different isotherm shapes that belong to S and L types, respectively. The isotherm data at pH 2.5 were well described by a linear form of the Langmuir equation, while at pH 5.5 it showed two distinct curves, which were precisely fitted as multiple Langmuir curves. The deviation of linearity in Scatchard plot proved the multisite HA sorption. The Brunauer-Emmett-Teller equation also fitted better to isotherm data at pH 5.5, suggesting a multisite sorption caused by multimolecular HA layers on gamma-PGA. High HA sorption levels of 1250, 667, and 1429 mg/g at pH 2.5 and 1429, 909, and 1667 mg/g at pH 5.5 were observed for MeIQ, 4,8-DiMeIQx, and Trp-p-2, respectively. Among the HAs studied, the sorption capacity correlated directly with hydrophobicity of HAs and inversely with the number of methyl groups in HA molecules. The plausible binding mechanism of HAs on gamma-PGA may include a combination of hydrophobic, hydrogen-bonding, ionic, and dipole-dipole interactions.