Laparoscopic hemi-splenectomy.

Laparoscopic splenectomy is now established as a safe and feasible procedure. However, it remains associated with some short- and long-term postoperative complications, especially infectious complications. To our knowledge, this is the first report (with video) focusing on the safety and feasibility of laparoscopic hemi-splenectomy and its surgical outcomes for the treatment of splenic abscesses causing septic emboli. This technique combines the immunological benefits of partial splenectomy and the postoperative benefits of a minimally invasive approach. Further studies are needed to standardize this technique and to assess its immunological and surgical benefits.

Aorto-oesophageal fistula after oesophageal stent placement in a patient with a Roux-en-Y gastric bypass.

A 43-year-old female patient suffered from persistent anastomotic leakage after Roux-en-Y gastric bypass for morbid obesity. Endoscopic stenting of the anastomotic leakage was performed. The patient presented with haematemesis 3 weeks later. An aorto-oesophageal fistula was diagnosed, most likely due to ulceration of the oesophageal stent. The fistula was closed with an endovascular covered aortic stent and a new gastrojejunostomy was created. One year after surgery, the patient is in good condition. Endoscopic stents are increasingly being used to treat anastomotic leakage in bariatric patients. An aorto-oesophageal fistula is a life-threatening complication of stent placement, early clinical recognition is essential. More data are needed on the complications of anastomotic stenting in bariatric patients.

High incidence of intermittent care in HIV-1-infected patients in Curaçao before and after starting cART.

Retention in care is one of the major challenges to scaling up and maximizing the effectiveness of combination antiretroviral therapy (cART). High attrition rates have been reported in the Caribbean region, varying from 6% to 23%. We studied the incidence of and risk factors for intermittent care in a cohort of adult HIV-1-positive patients, who entered into care in Curaçao between January 2005 and July 2009. A total of 214 therapy-naïve HIV-1-infected patients aged 15 years or older, entered HIV care between January 2005 and July 2009. Intermittent care was defined as at least one period of 365 days or longer in which there was no HIV care contact in Curaçao. Cox regression models were used to identify characteristics associated with time to intermittent care. In all, 203 (95%) patients could be classified as having intermittent or continuous care. The incidence of intermittent care before starting cART was 25.4 per 100 person years observation (PYO), whilst it was 6.1 per 100 PYO after starting cART. Being born outside Curaçao was associated with intermittent care before and after starting cART. Time from diagnosis to entry into care was an independent predictor for intermittent care before starting cART. Younger age was independently associated with intermittent care after starting cART. Half of the patients returned to care after intermitting care. Upon returning to care, median CD4 count was 264 cells/mm(3) (IQR, 189-401) for those who intermitted care before starting cART, and 146 cells/mm(3) (IQR, 73-436) in those who intermitted care after starting cART. In conclusion, the incidence of intermitting care is high in Curaçao, especially before starting cART, and intermitting care before starting cART is an independent predictor for starting cART late.

Optimizing chronic HIV care in the Dutch Caribbean: a questionnaire based study on experience and perception of healthcare workers.

OBJECTIVE: Human immunodeficiency virus (HIV) infection has become a chronic disorder for which adaptation of current healthcare practices is needed. In Curaçao, a new organization of chronic HIV care is being set up based on task shifting in which healthcare workers (HCWs) will deliver HIV care more prominently within the primary healthcare system. In preparation for implementation of the proposed task-shifting model, we investigated the perception of HCWs regarding existing HIV care in Curaçao and the need for training in HIV/AIDS among HCWs. SUBJECTS AND METHODS: An in-depth questionnaire based study was used. Nineteen HCWs of seven different cadres were interviewed. The questionnaire constituted four sections: quality of existing HIV care, respondents own knowledge and willingness to be trained, need for training in HIV/AIDS and preferred educational approaches. RESULTS: Quality of existing HIV services in Curaçao is considered acceptable but needs improvement mainly to facilitate integration of chronic HIV care. All respondents indicated that training in HIV/AIDS is needed among HCWs in Curaçao, especially for nurses and general practitioners. All were willing to participate in training with varying amounts of time to be spent. Training should be tailored to the level of expertise of HCWs and to the role a HCW is expected to have in the new healthcare delivery framework. CONCLUSION: There is need for training to ensure the effective integration of chronic HIV care into the existing healthcare delivery system in Curaçao.There is a willingness and need in all cadres for training with e-learning as a preferred educational tool.

Development of quality indicators for the antibiotic treatment of complicated urinary tract infections: a first step to measure and improve care.

BACKGROUND: Appropriateness of antibiotic treatment of urinary tract infection (UTI) is important. The aim of this study was to develop a set of valid, reliable, and applicable indicators to assess the quality of antibiotic use in the treatment of hospitalized patients with complicated UTI. METHODS: A multidisciplinary panel of 13 experts reviewed and prioritized recommendations extracted from a recently developed evidence-based national guideline for the treatment of complicated UTI. The content validity was assessed in 2 consecutive rounds with an in-between discussion meeting. Next, we tested the feasibility, interobserver reliability, opportunity for improvement, and case-mix stability of the potential indicators for a data set of 341 inpatients and outpatients with complicated UTIs who were treated at the urology or internal medicine departments at 4 hospitals. RESULTS: The panel selected and prioritized 13 indicators. Four and 9 indicators were performed satisfactorily in the urology and internal medicine departments, as follows: performance of urine culture, prescription of treatment in accordance with guidelines, tailoring of treatment on the basis of culture results, and a switch to oral treatment when possible in the urology and internal medicine departments; and selective use of fluoroquinolones, administration of treatment for at least 10 days, prescription of treatment for men in accordance with guidelines, replacement of catheters in patients with UTI, and adaptation of the dosage on the basis of renal function in the internal medicine department. CONCLUSION: A systemic evidence- and consensus-based approach was used to develop a set of valid quality indicators. Tests of the applicability of these indicators in practice in different settings is essential before they are used in quality-improvement strategies.