Epidemiology and molecular typing of VRE bloodstream isolates in an Irish tertiary care hospital.

OBJECTIVES: Ireland has the highest rate of vancomycin-resistant Enterococcus faecium (VREfm) isolated from blood of nosocomial patients in Europe, which rose from 33% (110/330) in 2007 to 45% (178/392) in 2012. No other European country had a VREfm rate from blood cultures of >25%. Our aim was to elucidate the reasons for this significantly higher rate in Ireland. METHODS: The epidemiology and molecular typing of VRE from bloodstream infections (BSIs) was examined in a tertiary care referral hospital and isolates were compared with those from other tertiary care referral centres in the region. RESULTS: The most common source of VRE BSIs was intra-abdominal sepsis, followed by line-related infection and febrile neutropenia. Most of the isolates were positive for vanA; 52% (43/83) possessed the esp gene and 12% (10/83) possessed the hyl gene. Genotyping by SmaI macrorestriction analysis (PFGE) of isolates revealed clonal relatedness between bloodstream isolates and environmental isolates. VRE BSI isolates from two other tertiary care hospitals in the Dublin region showed relatedness by PFGE analysis. MLST revealed four STs (ST17, ST18, ST78 and ST203), all belonging to the clonal complex of hospital-associated strains. CONCLUSIONS: Irish VRE BSI isolates have virulence factor profiles as previously reported from Europe. Typing analysis shows the spread of individual clones within the hospital and between regional tertiary care hospitals. Apart from transmission of VRE within the hospital and transfer of colonized patients between Irish hospitals, no other explanation for the persistently high VREfm BSI rate in Ireland has been found.

Disorders of the intestinal mesenteric lymphatic system.

Disorders of the intestinal lymphatic transport system are rare and typically associated with protein losing enteropathy (PLE). Hypoproteinemia caused by intestinal lymphangiectasia is often associated with lymphedema of the legs and occasionally with chyluria, chylometrorrhea and chylous ascites. This article examines the varied presentations of lymphangiectasia syndromes including its pathophysiology. Diagnosis is based on signs and symptoms, specific laboratory findings, and confirmed by contrast small bowel series, lymphography and best of all laparoscopy. We describe 12 patients with PLE secondary to primary intestinal lymphangiectasia (1980-1991). Treatment was non-operative (dietary) in 8 patients and surgical in 4 including segmental resections of the jejunum in two, lymphatic-mesenteric venous anastomosis in one, and peritoneal-venous (LeVeen) shunt in one with overall satisfactory results.

Aneurysms of the palmar arch and a proper digital artery: case report and literature review.

The first reported case of multiple aneurysms of both the palmar arch and a proper digital artery is described. A palmar arch aneurysm was excised, and two end-to-end anastomoses were necessary to restore the blood flow. Microsurgical repair was the only possible treatment in this case. The authors believe that the vascular anatomy should always be restored as naturally as possible. No treatment was necessary for the more distal aneurysms.

[Microsurgery and associated therapies for the treatment of lymphedema of the limbs]. / La microchirurgie et les thérapies associées pour le traitement des lymphoedèmes des membres.

Between 1967 and 1986, 170 cases of primary or secondary lymphedema of upper or lower limbs were operated upon using the indirect lymphaticovenous anastomosis technique proposed by Degni. For the lymphedema of upper limbs secondary to axillary lymphadenectomy for breast cancer, satisfactory results were obtained in 40% of cases, the figure rising to 72 and 74% for primary and secondary lymphedema of lower limbs respectively. When surgery is unsuccessful or contraindicated a new therapeutic method is proposed: thermotherapy as developed by Pr. Chang's team in Shanghai based on an ancient traditional Chinese medical method. With the collaboration of a biomedical engineer, a new microwave oven has been constructed and tested for the treatment of lymphedema, and its characteristics are described. Treatment is ambulatory, 45 minutes per day, 5 days per week over 3 weeks. It is very important that patients wear an elastic contention stocking (40 mmHg) between sessions. A total of 55 patients have been treated in this way, most (45) failing to improve after other medical or surgical treatment. All cases treated were of severe lymphedema and subjective and objective (ultrasonography) improvement was noted in 51%, the other 49% obtaining only subjective relief. According to Chinese authors results are maintained after 10 years. Follow up of the present series has been a maximum of one year and longer surveillance is necessary to assess long-term efficacy.

Modifications of the vein wall after microsurgical end-to-side artero-venous anastomosis.

The repercussions on the venous wall of the creation of 20 artero-venous anastomoses (AVA) between the femoral artery and vein of the rat have been evaluated. The rats were killed 7, 15, 30, and 90 days after AVA, and AVAs were examined by optical microscopy and by scanning electronic microscopy. Deposits of whitish material that nearly completely occluded the venous lumen were seen, especially in the group studied longer than 90 days. These venous wall lesions, which resemble arteriosclerotic lesions, must be attributed to the new hemodynamic situation created by the AVA. The implications of such findings for the long-term validity of venous graft in vascular microsurgery and the long-term patency of the AVA in hemodialyzed children are discussed.

Multidisciplinary approach to extracorporeal respiratory assist for acute pulmonary failure.

A case of acute post-traumatic pulmonary failure was treated by extracorporeal respiratory assist, after conventional therapy had failed. Veno-venous bypass was established, with low extracorporeal blood flow (1.6-2 l min-1), and high exchange surface area membrane lungs (7 m2), according to the technique of low-frequency positive-pressure ventilation with extracorporeal carbon-dioxide removal. After a first disconnection, the evolution of the lung disease necessitated a second surgical procedure, during which a chest tube perforated the patient's right lower, pulmonary lobe. A two-stage right thoracotomy was performed, with the patient connected to the extracorporeal system, and receiving full heparinization. Massive bleeding and severe hypoxia were encountered, but successfully overcome. The patient is now a long-term survivor.

The microsurgical drainage of the varicocele.

A new technique for surgical treatment of primary and recurrent varicocele is proposed. The technique consists of direct anastomosis of two or three dilated veins of the pampiniform plexus with the great saphenous vein. A connection between a high venous pressure region and a lower pressure region is established. Twenty-five patients were operated on, 7 with recurrent varicocele and 18 with primary varicocele. The immediate and long-term results (6 year follow-up) have always been good.

Experimental lymphatico-venous shunt in the rat: pressure controls and long-term patency.

In a series of rats which underwent end-to-side lymphaticovenous shunts, between precaval lymphatic collector and infrarenal cava vein, pressure values in lymphatic and venous systems and long-term patency of the anastomosis have been evaluated. Lymphatic pressure has always been higher than venous pressure, providing a good physiological basis for the functioning of the shunt. Short-term patency (15 days) was 100% and long-term patency (90 days) 80% in all the controlled animals. The results obtained in this experimental model seem to support the efficacy of this procedure also in its clinical use.

Effect of partial ileal bypass on plasma clearance and binding of lipoproteins to liver membranes in the rabbit.

We studied the effect of partial ileal bypass in the rabbit on the in vivo catabolism of human 125I-labelled low density lipoproteins and on the in vitro binding of human low density lipoproteins and rabbit very low density lipoproteins to hepatic membrane preparations. The in vivo data indicate that partial ileal bypass increases the fractional clearance rate (pools/h) of low density lipoproteins from 0.031 to 0.049 as well as the absolute catabolic rate from 0.495 to 0.605 mg/h. Concomitantly the in vitro binding of both low and very low density lipoproteins to hepatic membranes was increased in membrane preparation from livers of bypassed animals, thus suggesting an increased receptor-mediated uptake of lipoproteins by the liver. This effect may partly explain the hypocholesterolemic activity of partial ileal by-pass.