Initiation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock during out of hours versus working hours is not associated with increased mortality.

BACKGROUND: Initiation of veno-arterial (VA) Extracorporeal Membrane Oxygenator (ECMO) is associated with severe complications. It is unknown whether these adverse consequences occur more often after initiations during out of hours service compared to working hours. METHODS: All patients receiving VA-ECMO for cardiogenic shock between 2009 and 2020 were categorized into a working hours group (between 8 am and 5 pm on weekdays) and an out of hours service group (between 5 pm and 8 am, or between Friday 5 pm and Monday 8 am). Primary outcome was all-cause mortality at 30 days. Secondary outcomes included vascular complications (including limb ischemia and/or bleeding), bloodstream infections and length of ICU stay. Propensity scores were used to adjust for potential confounding effects. RESULTS: Among 250 patients (median (IQR) age 56 (42-64) years) receiving VA-ECMO (median duration 3.5 (1.0-9.0) days), 160 (64%) runs were initiated between 5 pm and 8 am whereas the remainder (36%) started during working hours. Characteristic did not differ between the working hours- and out of hours-group. By day 30, 37 (41.1%), and 68 (42.5%) patients in either group had died, respectively (p = 0.831). VA-ECMO support duration and length of stay on the ICU did not differ significantly in both crude and adjusted analyses. More complications occurred during out of hours service (p = 0.039). CONCLUSIONS: Out of hours- versus working hours-initiation of VA-ECMO for cardiogenic shock was not associated with higher mortality, longer VA-ECMO support duration, or longer length of stay on the intensive care. Vascular complications were more common in the out of hours group.

Can routine chest radiography be used to diagnose mild COPD? A nested case-control study.

OBJECTIVES: To determine whether mild stage chronic obstructive pulmonary disease (COPD) can be detected on chest radiography without substantial overdiagnosis. METHODS: A retrospective nested case-control study (case:control, 1:1) was performed in 783 patients scheduled for cardiothoracic surgery who underwent both spirometry and a chest radiograph preoperative. Diagnostic accuracy of chest radiography for diagnosing mild COPD was investigated using objective measurements and overall appearance specific for COPD on chest radiography. Inter-observer variability was investigated and variables with a kappa >0.40 as well as baseline characteristics were used to make a diagnostic model which was aimed at achieving a high positive predictive value (PPV). RESULTS: Twenty percent (155/783) had COPD. The PPV of overall appearance specific for COPD alone was low (37-55%). Factors in the diagnostic model were age, type of surgery, gender, distance of the right diaphragm apex to the first rib, retrosternal space, sternodiaphragmatic angle, maximum height right diaphragm (lateral view) and subjective impression of COPD (using both views). The model resulted in a PPV of 100%, negative predictive value (NPV) of 82%, sensitivity of 10% and specificity of 100% with an area under the curve of 0.811. CONCLUSIONS: Detection of mild COPD without substantial overdiagnosis was not feasible on chest radiographs in our cohort.

Detection of Coxiella burnetii DNA in the environment during and after a large Q fever epidemic in the Netherlands.

AIM: To investigate the Coxiella burnetii DNA content in environmental samples that may contribute to the transmission of C. burnetii. METHODS AND RESULTS: During a large Q fever outbreak in the Netherlands, surface swabs and aerosol samples were collected inside stables and around six Q fever-affected ruminant farms, which are located in municipalities varying in Q fever incidence. After the outbreak in 2010, aerosol samples were collected in the same geographical areas. The use of an optimized multiplex qPCR for the detection of C. burnetii DNA revealed that all samples obtained inside stables were positive. In addition, the C. burnetii DNA content in aerosol samples collected in stables is significantly higher than in aerosol samples collected around the farms. Finally, the C. burnetii DNA content in aerosol samples collected in the same geographical locations was lower in 2010 in comparison with 2009. CONCLUSIONS: The reduction in C. burnetii DNA content in aerosol samples between 2009 and 2010 is in agreement with the reduction in Q fever incidence in the same geographical areas. SIGNIFICANCE AND IMPACT OF THE STUDY: The presence of C. burnetii DNA in environmental samples collected on and around ruminant farms supports the hypothesis that C. burnetii can be disseminated from ruminant farms to the surrounding areas.

Coxiella burnetii in sewage water at sewage water treatment plants in a Q fever epidemic area.

During 2007-2010, over 4000 persons in The Netherlands contracted Q-fever, a zoonosis caused by the bacterium Coxiella burnetii. Goats and sheep are the main reservoir of C. burnetti and infected animals shed the bacterium with their urine, faeces and birth products. Human infections may occur through direct contact with infected animals, or through inhalation of contaminated dust particles or aerosols. Discharge of waste water from Q fever contaminated goat farms may result in the presence of C. burnetii in sewage water and aerosols at sewage water treatment plants (SWTPs) which may pose a health risk for workers or neighbouring residents. The objectives of this study were to determine the presence of C. burnetii at SWTPs and to optimize available detection methods. In March-July 2011, sewage influent and aeration tank samples from four SWTPs receiving discharge from Q fever positive goat farms were examined by using a multiplex real-time PCR detecting C. burnetii DNA by targeting IS1111 and com1 genes. Influent (44%; n=16/36) and active sludge (36%; n=13/36) samples were positive with low C. burnetii DNA content. Percentage positive samples per SWTP were 28-61%. Positive samples were most frequent in March 2011 and least frequent in May 2011. The presence of C. burnetii DNA in sewage water samples suggests that SWTPs receiving waste water from Q fever contaminated goat farms may contribute to the spread of C. burnetii to the environment. The low levels of C. burnetii DNA in sewage water during the decline of the Q fever outbreak in The Netherlands in 2011 indicate a low health risk for SWTP workers and residents.

Early mitral valve repair versus watchful waiting in patients with severe asymptomatic organic mitral regurgitation; rationale and design of the Dutch AMR trial, a multicenter, randomised trial.

BACKGROUND: Asymptomatic severe mitral valve (MV) regurgitation with preserved left ventricular function is a challenging clinical entity as data on the recommended treatment strategy for these patients are scarce and conflicting. For asymptomatic patients, no randomised trial has been performed for objectivising the best treatment strategy. METHODS: The Dutch AMR (Asymptomatic Mitral Regurgitation) trial is a multicenter, prospective, randomised trial comparing early MV repair versus watchful waiting in asymptomatic patients with severe organic MV regurgitation. A total of 250 asymptomatic patients (18-70 years) with preserved left ventricular function will be included. Intervention will be either watchful waiting or MV surgery. Follow-up will be 5 years. Primary outcome measures are all-cause mortality and a composite endpoint of cardiovascular mortality, congestive heart failure, and hospitalisation for non-fatal cardiovascular and cerebrovascular events. Secondary outcome measures are total costs, cost-effectiveness, quality of life, echocardiographic and cardiac magnetic resonance parameters, exercise tests, asymptomatic atrial fibrillation and brain natriuretic peptide levels. Additionally, the complication rate in the surgery group and rate of surgery in the watchful waiting group will be determined. IMPLICATIONS: The Dutch AMR trial will be the first multicenter randomised trial on this topic. We anticipate that the results of this study are highly needed to elucidate the best treatment strategy and that this may prove to be an international landmark study.

Detection of Coxiella burnetii DNA on small-ruminant farms during a Q fever outbreak in the Netherlands.

During large Q fever outbreaks in the Netherlands between 2007 and 2010, dairy goat farms were implicated as the primary source of human Q fever. The transmission of Coxiella burnetii to humans is thought to occur primarily via aerosols, although available data on C. burnetii in aerosols and other environmental matrices are limited. During the outbreak of 2009, 19 dairy goat farms and one dairy sheep farm were selected nationwide to investigate the presence of C. burnetii DNA in vaginal swabs, manure, surface area swabs, milk unit filters, and aerosols. Four of these farms had a positive status during the Coxiella burnetii bulk milk monitoring program in 2009 and additionally reported abortion waves in 2008 or 2009. Eleven farms were reported as having positive bulk milk only, and five selected (control) farms had a bulk milk-negative status in 2009 and no reported Q fever history. Screening by quantitative PCR (qPCR) revealed that on farms with a history of abortions related to C. burnetii and, to a lesser extent, on farms positive by bulk milk monitoring, generally higher proportions of positive samples and higher levels of C. burnetii DNA within positive samples were observed than on the control farms. The relatively high levels of C. burnetii DNA in surface area swabs and aerosols sampled in stables of bulk milk-positive farms, including farms with a Q fever-related abortion history, support the hypothesis that these farms can pose a risk for the transmission of C. burnetii to humans.

Detection of Coxiella burnetii in complex matrices by using multiplex quantitative PCR during a major Q fever outbreak in The Netherlands.

Q fever, caused by Coxiella burnetii, is a zoonosis with a worldwide distribution. A large rural area in the southeast of the Netherlands was heavily affected by Q fever between 2007 and 2009. This initiated the development of a robust and internally controlled multiplex quantitative PCR (qPCR) assay for the detection of C. burnetii DNA in veterinary and environmental matrices on suspected Q fever-affected farms. The qPCR detects three C. burnetii targets (icd, com1, and IS1111) and one Bacillus thuringiensis internal control target (cry1b). Bacillus thuringiensis spores were added to samples to control both DNA extraction and PCR amplification. The performance of the qPCR assay was investigated and showed a high efficiency; a limit of detection of 13.0, 10.6, and 10.4 copies per reaction for the targets icd, com1, and IS1111, respectively; and no cross-reactivity with the nontarget organisms tested. Screening for C. burnetii DNA on 29 suspected Q fever-affected farms during the Q fever epidemic in 2008 showed that swabs from dust-accumulating surfaces contained higher levels of C. burnetii DNA than vaginal swabs from goats or sheep. PCR inhibition by coextracted substances was observed in some environmental samples, and 10- or 100-fold dilutions of samples were sufficient to obtain interpretable signals for both the C. burnetii targets and the internal control. The inclusion of an internal control target and three C. burnetii targets in one multiplex qPCR assay showed that complex veterinary and environmental matrices can be screened reliably for the presence of C. burnetii DNA during an outbreak.

Long-term treatment with Pilogel/beta-blocker in glaucoma patients.

In a multicentre clinical trial thirteen patients with primary open angle glaucoma or ocular hypertension were followed during at least six months while selfinstilling Pilogel (once daily) and topical beta-blocker (twice daily). After six months of combination therapy there was an average decrease in intra-ocular pressure (IOP) of 33.6% 9.5 hours after Pilogel administration and an IOP decrease of 23.4% 22.5 hours after Pilogel administration. With topical beta-blocker alone, an average IOP decrease of 15% was measured. Throughout the study we observed in six patients (46.1%) a superficial punctate keratitis which mostly spontaneously cleared. We did not see any serious side-effects after six months of combination therapy.

Efficacy and safety of the combination therapy Pilogel/beta-blocker: interim results.

The interim results of a multicentered clinical trial with the combination therapy therapy Pilogel/topical beta-blocker (twice daily) in patients with primary open angle glaucoma or ocular hypertension are discussed. Six patients were treated with Pilogel and a topical beta-blocker for one month. Four out of six patients responded well to the combination therapy. Most patients experienced some difficulty in applying the gel and their eyelids stuck together on awakening. In two patients a superficial punctate keratitis was observed. We found an average decrease in intra-ocular pressure (IOP) of 22.5% 22.5 hours after Pilogel administration, but there was some tendency towards higher evening values compared to morning values. In view of the appearance of a corneal haze as described by Johnson et al. during long-term treatment, longer follow-up is necessary.

The influence of oxybuprocaine (Novesine) on the intraocular pressure.

Patients with raised intraocular pressure often have lower tension during hospital admissions than on out-patient measurement, even though the therapy is the same. A prospective study on 18 volunteers and 10 glaucoma patients was set up to find out whether oxybuprocaine eyedrops or repeated applanation tonometry could have anything to do with this. The tension was measured at least 3 times a day with the non-contact tonometer (NCT). In the case of the volunteers oxybuprocaine was instilled into the eye 3 times a day for one week. In the case of the patients the tension in one eye was measured with the Goldmann tonometer on several days after the application of oxybuprocaine drops. No reduction in intraocular pressure was found during the observation period, nor was there an obvious difference between the test eyes and the control eyes. In hospital, patients had at 11 o'clock in the morning intraocular pressure which was on the average 2.2 +/- 1.5 mmHg lower than that measured at out-patient checks, in spite of receiving the same therapy.

The Ocuplot semi-automatic visual field screener--technical evaluation and clinical results.

The perimetric concept and the technical construction of the Ocuplot were evaluated. The mechanical and electrical construction of the instrument we tested was poor. The manufacturer claims improvements in newer specimens. We examined 87 eyes of patients and normal subjects with the Ocuplot and learned that the test-strategy is not efficient and yields a high proportion of false positive results. Clinical results of the patient-examinations are presented.

Glaucoma as a problem in intraocular lens implantation.

The literature has been investigated on the prevalence of preexisting and complicating glaucoma in intraocular lens surgery. Few exact data are available. The problem of the management of preexisting primary or postoperative secondary glaucoma in pseudophakia is discussed, in particular the inevitable restrictions the intraocular lens imposes on medical therapy and eventual glaucoma surgery. Preexisting glaucoma should therefore be a relative contraindication to intraocular lens surgery.

Long-term results of Vidian neurectomy.

A number of publications appeared in the sixties claiming success of Vidian neurectomy in patients with chronic vasomotor rhinitis and recurrent polyposis nasi. During the period from October 1970 through February 1975, a total of 27 Vidian neurectomies was performed in 14 patients (seven males and seven females). Two groups of seven patients each were operated on; seven patients with chronic vasomotor rhinitis and seven patients with recurrent polyposis nasi and rhinitis. Symptoms were quantitatively recorded pre- and postoperatively and patients were followed up 15--66 months. The Rotterdam results appear in the long run inferior to those published in the literature.

Experiences with laser trabeculopuncture.

54 eyes with glaucoma simplex and 21 eyes with secondary chronic glaucoma were treated once by laser trabeculopuncture and followed up for at least 1 year. The results in the first group were encouraging, in the second group disappointing. L.T.P. appears to be a technique with which, in the majority of cases of glaucoma simplex, a sustained moderate decrease in pressure can be obtained.