Melioidosis and renal failure in a Dutch man after a trip to Gambia.

Melioidosis is due to Burkholderia pseudomallei and is known to be endemic in South-East Asia, while epidemiology of disease in Sub-Saharan Africa is still unclear. Prompt recognition of infection is crucial for adequate antibiotic treatment. Infection can lead to visceral abcesses and awareness of this complication is important for proper management.

Duplex investigations in children: Are clinical signs in children with venous disorders relevant?

OBJECTIVES: Ultra sound colored duplex sonography is the preferred method in diagnosing chronic venous disease. Data in children on incidence, indications, and results are lacking. METHODS: From the total of 9180 duplex investigations performed in our hospital from 2009 to 2012, data on indication and results of the investigation as well as patient characteristics were evaluated retrospectively for the proportion of pediatric patients. RESULTS: Duplex investigations were performed 49 times in 38 children (6-18 years), with an average of 1.3 times (1-6 times) per child. Forty percent showed abnormalities: 17 times deep venous thrombosis was suspected; deep venous thrombosis was objectified in 18%. In the 21 investigations performed for varicosis-related complaints, varicose veins or venous malformations were objectified in 57%. Edema was never a symptom of chronic venous disease. CONCLUSIONS: Duplex investigation is not often performed in children. In children with established deep venous thrombosis, a family history with deep venous thrombosis is common. In general, edema was not seen in children with varicose veins and, therefore, does not seem a reliable clinical sign at young age.

Bloodstream infections in patients with or without cancer in a large community hospital.

PURPOSE: Cancer is associated with an increased risk of acquiring bloodstream infection (BSIs). Most knowledge on pathogens and outcome are derived from specialised cancer centres. We here sought to compare causative micro-organisms in BSIs in patients with or without cancer in a 600-bed teaching community hospital. METHODS: We analysed all positive blood cultures from adult patients between January 2005 and January 2011. RESULTS: A total of 4,918 episodes of BSI occurred in 2,891 patients, of whom 13.4% had a diagnosis of cancer (85.5% with a solid tumour). In both patient groups, Gram-positive isolates were more prevalent (58.7 and 61.4% in patients with and without cancer, respectively) than Gram-negative isolates (31.8 and 32.3%, respectively). Amongst Gram-positive organisms, coagulase-negative staphylococci, Staphylococcus aureus and enterococci were the most frequently isolated in both patient groups; in cancer patients, twice as many BSIs were caused by Enterococcus faecalis and E. faecium. Amongst Gram-negative organisms, Escherichia coli was the most common isolate; in cancer patients, twice as many BSIs were caused by Pseudomonas aeruginosa and Enterobacter cloacae. Yeasts were grown from 3.0% of blood cultures from cancer patients compared to 1.5% of cultures from non-cancer patients. Cancer patients had a 90-day mortality of 35.8% following BSI compared to 23.5% in patients without cancer. CONCLUSION: These data demonstrate distinct BSI pathogens and impaired outcomes in patients with cancer in the setting of a large community teaching hospital.

Low complication rates in the use of port-a-caths in oncology patients.

BACKGROUND: Port-a-caths (PACs) represent an important component of the care of cancer patients, in particular for administration of chemotherapy. We sought to analyse the longevity and complications of PACs in cancer patients in a large community hospital. METHODS: We retrospectively analysed the indications, duration of use, complications and reasons for removal of PACs in cancer patients treated in our centre from January 2005 to December 2010, and compared these with findings in patients who received a PAC in the same period for reasons not related to cancer. RESULTS: During the study period 152 cancer patients received a total of 170 PACs; in the same period, 21 patients received a total of 35 PACs for reasons unrelated to cancer. The total analysis comprised 70,919 days of PAC use. Most cancer patients had a solid tumour (97%). PACs were removed because of a complication in 25 cases in cancer patients (14.7%) vs 15 cases in non-cancer patients (42.9%, p.

The propeller flap concept used in vaginal wall reconstruction.

Most posterior vaginal wall defects are due to abdominoperineal resection for colorectal carcinoma involving the posterior vaginal wall or resection of local malignancies. The rectus abdominis myocutaneous flap, the modified Singapore flap and the gracilis myocutaneous flap remain workhorse solutions for this type of vaginal reconstruction. The introduction of the perforator concept has introduced new therapeutic options using the gluteal donor site region. Recently, perforator-based gluteal flaps have been described as a reliable solution for reconstruction of posterior vaginal wall defects, with low donor site morbidity. Here, we present a new technique to optimise results and minimise morbidity to the patient.

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.

Necrotizing fasciitis: case report and review of literature.

We report a case of necrotizing fasciitis of the lower limb. This medico-surgical emergency is a life-threatening invasive soft-tissue infection which primarily involves the fascia superficialis and rapidly extends along subcutaneous tissue with relative sparing of skin and underlying muscles. Clinical presentation includes fever, signs of systemic toxicity and pain out of proportion to clinical findings. Paucity of cutaneous findings early in the course of the disease makes diagnosis challenging. The confirmation of the diagnosis is often made after surgical debridement. Delay in diagnosis and/or treatment correlates with poor outcome, leading to sepsis and/or multiple organ failure. Radiologic studies including plain radiographs, CT-scan or MRI may help to diagnose necrotizing fasciitis. Prompt surgical debridement, intravenous antibiotics, fluids and electrolytes management and analgesia are mainstays of the therapy. Adjuvant treatments like clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulins are discussed.

[Optimal patient position for catheterisation of the subclavian vein: in the Trendelenburg position without a rolled towel between the shoulder blades]. / Optimale positie van de patiënt bij katheterisatie van de V. subclavia: in Trendelenburgligging, zonder rol tussen de schouderbladen.

OBJECTIVE: To determine the optimal patient position for subclavian-vein catheterisation. DESIGN: Descriptive. METHOD: The anteroposterior diameter of the right and left subclavian vein was measured using B-mode ultrasound in 26 healthy volunteers lying in 4 different positions: horizontally with or without a rolled towel between the should blades, or in the Trendelenburg position with or without a rolled towel. RESULTS: The mean diameter of the subclavian vein was 10.7 mm. There was a statistically significant association between the diameter of the vein and the position of the volunteer, the use of the rolled towel, and the side of the body. The least favourable results were obtained on the left side when the patient was lying horizontally with a rolled towel (8.65 mm). The most favourable results were obtained on the right side when the patient was in the Trendelenburg position without a rolled towel (12.05 mm). CONCLUSION: For successful catheterisation of the subclavian vein, the patient should be placed in the Trendelenburg position without a rolled towel between the shoulder blades, and the puncture should be preferably on the right side.

[Horizontal transfer of bacterial genes and its significance for antibiotic resistance and pathogenicity]. / Horizontale overdracht van bacteriële genen en de betekenis voor antibioticaresistentie en pathogeniteit.

* Sexual reproduction does not occur in bacteria. The point of departure in bacterial reproduction is always that one individual divides itself into two identical descendants. * In the bacterial world, however, there is certainly exchange of hereditary characteristics (DNA). This type of exchange is called horizontal gene transfer. * There are 3 basic ways for the exchange of DNA between bacteria: conjugation, transduction and natural transformation. Each of these has its specific impact on the species. * During conjugation, a piece of DNA is copied in one bacterium and transferred to another via a temporary connection, a conjugative pilus. In this way, for example, a particular gene that codes for resistance against antibiotics can be transmitted. * In transduction, the transfer of DNA takes place with the aid of bacteriophages. The gene that codes for the toxin produced by Vibrio cholerae is spread by transduction. * In transformation, DNA that is located outside the cell is fragmented and imported into the cell, after which, via recombination, the DNA replaces a piece of original DNA in the chromosome of the host. Transformation is responsible for, among other things, antigen variation in the pneumococcal capsule. Antigen variation helps the pneumococci to resist the immune response leading to the forming of antibodies and adequate opsonisation.

Remote superficial femoral artery endarterectomy and distal aSpire stenting: results of a multinational study at three-year follow-up.

AIM: The aim of this study was to examine the results of remote superficial femoral artery endarterectomy (RSFAE) in conjunction with distal aSpire stenting in a multinational study. METHODS: RSFAE is a minimally invasive procedure performed through a limited groin incision. A total of 210 patients were included in this study. The indications for the procedure were claudication in 158 (75%) patients and limb salvage in 52 (25%). After RSFAE the outflow tract atheromatous plaque was ''tacked'' with the aSpire stent, which is an expanded polytetrafluoroethylene (ePTFE) covered nitinol stent with high radial strength, yet it is flexible enough to withstand the compressive forces at the knee joint. Prior to stent deployment, if the stent position is not in optimal position, it can be ''wrapped down'', repositioned and re-expanded. Therefore, not only is the plaque end point tacked, but the collaterals are preserved as well. All patients underwent follow-up examination with serial color-flow duplex ultrasound scanning. RESULTS: The mean length of endarterectomized superficial femoral arteries (SFAs) was 28.2+/-6.2 cm (range 15-43 cm). The primary cumulative patency rate by means of life-table analysis was 60.6+/-4.8% (SE) at 33 months, (mean 17.1 months; range 1-33 months). During follow-up percutaneous transluminal balloon and/or stent angioplasty was necessary in 50 patients for a primary assisted patency of 70.2+/-4.8% at 33 months. The locations of the restenosis after RSFAE were evenly distributed along the endarterectomized artery. There were 2 deaths (myocardial infarctions), 12 (5.7%) wound complications (7 hematomas, 5 skin edge sloughs) and the mean hospital length of stay was only 1.3+/-0.5 days. CONCLUSION: RSFAE with distal aSpire stenting is a minimally invasive, safe durable procedure for the treatment of long-segment SFA occlusive disease.

[Necrotizing fasciitis: diagnosis and treatments]. / Fasciites nécrosantes : stratégie diagnostique et thérapeutique.

The necrotizing fasciitis is a medico-surgical emergency, characterized by the rapid speard of the infection in the subcutaneous tissue, involving fascia superficialis. Peaucity of cutaneous findings early in the course of the disease makes diagnosis a challenge for physician. Pain out of proportion to clinical findings, fever and signs of systemic toxicity are the keys in identification of necrotizing fasciitis. Delayed diagnosis lead to sepsis syndrom and/or multiple organ failure and correlate with poor oucome. Radiolographs, CT-scan or MRI are main radiologic studies, but such procedures should never delay surgical intervention. Intravenous antibiotics, fluid and electrolyte management and analgesia are needed in addition to radical debridment. Clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulins are discussed treatments. Only prompt recognition and immediat care warrant a lower mortality and morbidity for this life-threatening infection.

[How I treat...fibroproliferative scars]. / Comment je traite...les cicatrices fibroprolifératives.

Following a skin injury like burn, surgery or a trauma, fibroproliferatives scars are responsible of cosmetic, psychologic and symptomatic disorders. Keloids are benign and occur secondary to an imbalance between the synthesis of extracellular matrix and its degradation. There is a lot of therapeutic modalities available. Despite this, recurrence and sometimes increasing lesions are the major complications. Surgery with adjuvant therapy like steroids injections, radiotherapy, silicone materials seems today the best therapeutic choice. A best physiopatholgy's comprehension is at the base of new treatments, but their efficacity still need to be demonstrate in larger studies.

[Relapse of testicular mixed germ cell tumor 15 years after initial treatment]. / Le cas clinique du mois. Récidive d'une tumeur testiculaire mixte 15 ans après le traitement initial.

We report the case of a patient with a symptomatic retroperitoneal tumor. The patient had undergone, 15 years earlier, an orchiectomy and three cycles of chemotherapy for a testicular mixed germ cell tumor. Histology after radical surgical excision revealed a metastasis of mature teratoma. The 183 month interval between initial treatment and relapse is one of the longest ever reported.

Outcome after occlusion of infrainguinal bypasses in the Dutch BOA Study: comparison of amputation rate in venous and prosthetic grafts.

OBJECTIVE: To compare the consequences of occlusion of infrainguinal venous and prosthetic grafts. METHODS: In total, 2690 patients were included in the Dutch BOA study, a multicenter randomised trial that compared the effectiveness of oral anticoagulants with aspirin in the prevention of infrainguinal bypass graft occlusion. Two thousand four hundred and four patients received a femoropopliteal or femorodistal bypass with a venous (64%) or prosthetic (36%) graft. The incidence of occlusion and amputation was calculated according to graft material and the incidence of amputation after occlusion was compared with Cox regression to adjust for differences in prognostic factors. RESULTS: The indication for operation was claudication in 51%, rest pain in 20% and tissue loss in 28% of patients. The mean follow up was 21 months. After venous bypass grafting 171 (15%) femoropopliteal and 96 (24%) femorodistal grafts occluded. After prosthetic bypass grafting 234 (30%) femoropopliteal and 25 (38%) femorodistal grafts occluded. Patients with occlusions in the venous group had more severe ischemia, less runoff vessels and were older than the patients with prosthetic grafts. In the venous occlusion group 54 (20%) amputations were performed compared to 42 (16%) in the prosthetic occlusion group; crude hazard ratio 1.17 (95% CI 0.78-1.75). After adjustment for above mentioned differences in patient characteristics the hazard ratio was 0.86 (95% CI 0.56-1.32). CONCLUSION: The need for amputation after occlusion is not influenced by graft material in infrainguinal bypass surgery.

[Hoarseness in a recent visitor to the tropics through infection of the larynx by Histoplasma capsulatum]. / Heesheid bij een tropenganger door infectie van de larynx met Histoplasma capsulatum.

A 58-year-old man presented with hoarseness and a sore throat for the previous 3 months, which were caused by a laryngeal infection with the fungus Histoplasma capsulatum. He had been infected during a stay in Indonesia. Both his hoarseness as well as the Histoplasma antigen titres in serum responded to therapy with itraconazol. H. capsulatum is found in tropical and subtropical areas worldwide, but infections are most commonly reported from the south of the United States of America. If not asymptomatic, the disease most often presents with pulmonary symptoms. A histoplasmosis presenting as a laryngeal infection is relatively uncommon and can be mistaken for papillomatosis or carcinoma. The diagnosis can be made by microscopy and culture of the fungus; an antigen test is available in the United States.

Multi centre study to assess the feasibility of a new covered stent and delivery system in combination with remote superficial femoral artery endarterectomy (RSFAE).

OBJECTIVES: To evaluate the feasibility and efficacy of an innovative new covered stent and adjustable deployment system (aSpire Covered Stent, Vascular Architects Inc., San Jose, CA, USA) in combination with remote superficial femoral artery endarterectomy (RSFAE) for the treatment of long segment femoropopliteal occlusive disease. DESIGN: Prospective multi-centre trial. MATERIALS AND METHODS: Sixty-two limbs in 61 patients (41 men; median age 69 years, range 40-88) with severe disabling claudication (n=56) or critical limb ischaemia (n=6) were treated in five European centres with aSpire stenting after RSFAE for long segment occlusions (mean length 25 cm). Follow-up was by duplex scanning at 1-, 6-, 12- and 18-months. Primary, primary-assisted and secondary patency rates were analysed. RESULTS: The median follow-up was 17 (range 2-34) months. A mean of 1.3 stents (range 1-3) were deployed with a median stent diameter of 7 mm (range 6-9). There were one early and 24 late failures. At 18-months the cumulative primary, primary-assisted and secondary patency rates were 60, 70 and 72%, respectively. There were no device related adverse events, such as kinking or fracturing and no stent migrations. CONCLUSIONS: The aSpire stent and the delivery system are both safe and feasible in combination with RSFAE. The mid term follow-up appears favourable in view of the long segment occlusions treated. Further follow-up is required to compare the mid- and long-term outcomes with current stents and conventional femoropopliteal bypass.

[Heart and androgens]. / Coeur et androgènes.

Beyond sexual function regulation, male steroids are operative in several physiologic homeostastic systems including the cardiovascular system. By ways of specific androgen receptors,testosterone can mediate cardiomyocyte trophycity, in physiologic states as in diseases involving cardiac hypertrophy. Androgenic hormones also regulate pathologic levels of inflammatory cytokines as 11-6 or TNF, in advanced heart failure. They also mediate vascular resistance with, in vitro and in vivo, proved coronary vasodilatation. Reduced free testosterone serum levels (age-mediated or in premature coronary artery disease patients (CAD) promote a pro-atherogenic lipid profile expressed as HDL-cholesterol decrease and up-regulation of triglycerids levels). The latter observation has relevant clinical significance for evaluation and treatment of CAD disease. As most of normal and diseased cardiovascular system functions are influenced by androgens, we can foresee an increasing interest for further evaluation of their physiologic implications as well as for large and rigourous studies of their therapeutic potential in two leading disabling pathologies, CAD and heart failure.

[The heart and androgens]. / Coeur et androgènes.

Beyond regulation of sexual function, male steroids play an important role in many physiological homeostasis systems, including the cardiovascular system. Via a specific androgen receptor, testosterone mediates cardiomyocyte trophicity both in physiological situations and in hypertrophy-related cardiac diseases. Androgens also regulate pathological levels of inflammatory cytokines such as Il-6 or TNF in advanced heart failure. They also mediate vascular resistance since coronary vasodilatation has been proven both in vitro and in vivo. Reduced free testosterone serum levels (age-mediated or premature coronary artery disease) promote a pro-atherogenic lipid profile expressed as lower serum HDL-cholesterol and up-regulation of triglyceride levels. This observation has relevant clinical implications for the evaluation and treatment of coronary artery disease. As most of normal and diseased cardiovascular system functions are influenced by androgens, further evaluation of their physiological implications should be undertaken as well as large-scale rigorous studies of the therapeutic implications in two disabling diseases, coronary heart disease and heart failure.