We report a patient, which we believe is the first, with a thoracoabdominal aortic aneurysm, Crawford type IV, caused by Q fever (Coxiella burnetii). Treatment consisted of antibiotic therapy started preoperatively and continued postoperatively and an open repair, including resection of the infected aneurysm, replacement with a rifampin-soaked polyester graft, and an omental wrap covering the grafts. After 13 months of follow-up, the patient had no signs of infection, and results of laboratory findings were normal.
In this prospective randomised controlled multicentre trial, gentamicin implants did not result in a significant overall reduction in surgical site infection following vascular surgery via inguinal incision. In a post hoc subgroup analysis comparing study sites with a low (<10%) and study sites with a high (>10%) infection rate in the control group, gentamicin implants significantly reduced surgical site infections in high risk centres. Therefore, preventive use of gentamicin implants cannot be routinely advised based on current evidence but may be considered in vascular centres with a high incidence of wound infections.Objective: The aim of this study was to assess the effectiveness of gentamicin containing collagen implants in the reduction of surgical site infections (SSIs) in patients undergoing an inguinal incision for vascular surgery. Methods: Prospective blinded randomised controlled multicentre trial (RCT), performed in four hospitals in The Netherlands and Belgium. This study included 288 patients who underwent an inguinal incision for primary arterial repair (femoral endarterectomy, femorofemoral or femoropopliteal bypass, aortobifemoral bypass, thrombectomy, embolectomy, endovascular aneurysm repair) between October 2012 and December 2015. Patients were randomised to receive a gentamicin implant (study group) or no implant (control group). The calculated sample sizes of 304 patients per group were not reached. Primary outcome was SSI incidence after six weeks. Secondary outcomes were time to onset of infection, length of hospital stay, allergic reactions, treatment with antibiotics, need for re-admission, re-operation and mortality. Results: One hundred fifty-one patients were allocated to the study group (mean age 69 AE 9.2 years) and 137 patients were allocated to the control group (mean age 70 AE 10.4 years). Both groups were homogeneous regarding baseline and intra-operative characteristics. Gentamicin implants did not result in a significant overall reduction of SSIs in the study group (7% vs. 12%, p ¼ .17). In a post hoc analysis comparing two study sites with low (<10%) and two study sites with high (>10%) infection rates in the control group, gentamicin implants significantly reduced SSIs in high risk centres (22% vs. 1%, p < .001), whereas there was no significant effect in low risk centres (13% vs. 7%, p ¼ .30). There were no allergic reactions and all secondary outcomes were comparable between groups. Conclusion: Gentamicin implants did not result in a significant overall reduction of SSIs in this RCT. Gentamicin implants did reduce the incidence of SSIs in high risk centres and may be a valuable adjunct to improve outcomes in such vascular centres with a high incidence of wound infections. However, the limitation of not reaching the calculated sample sizes should be considered.
BackgroundIn peripheral arterial disease (PAD), activation of the hemostatic system may contribute to atherosclerosis progression and atherothrombotic events.ObjectiveThis case–control study assesses the overall coagulation status in PAD patients by evaluating coagulation markers in combination with thrombin generation potential, whole blood (WB) clot formation, and fibrinolysis.MethodsIn blood from 40 PAD patients (n = 20 with cardiovascular event within 1 year after initial diagnosis, n = 20 without) and 40 apparently healthy controls, thrombin generation was determined in WB and platelet-poor plasma. Whole blood rotational thromboelastometry (ROTEM) measurements were triggered with tissue factor with/without tissue plasminogen activator.ResultsWe observed increased levels of erythrocyte sedimentation rate, leukocytes, eosinophil granulocytes, vWF antigen, fibrinogen, and D-dimer in PAD patients (p < 0.05). Markers of thrombin generation potential showed no difference between patients and healthy controls. In PAD patients with event compared to patients without, WB-thrombin generation showed a lower thrombin potential when triggered with 0 and 2.5 pM tissue factor. The ROTEM clotting assay showed significantly faster clot formation and increased clot firmness in PAD patients compared to controls. No significant differences were found for parameters of clot degradation.ConclusionThere are no significant differences between the thrombin generation profiles of PAD patients and healthy controls. Between PAD patients with and without cardiovascular event, the WB thrombin generation appears to differ. Mechanistically, PAD patients show an increased ability to form a stable clot in WB in comparison to healthy controls. This is most likely due to the increased fibrinogen levels related to the inflammation in atherosclerosis, confirming the importance of the inflammation-coagulation axis.
Backgrounds COVID-19 related reduction of surgical procedures jeopardizes learning on the job of surgical residents. Many educators resorted to digital resources in the search for alternatives. However, these resources are often limited to the extent they offer resident-surgeon interaction like a joint surgical performance does. Here we present a roadmap of livestreaming surgical procedures, and evaluate how surgical livestreams on human cadavers address the unmet educational needs of surgical residents in our Dutch nationwide initiative. Methods Technical and organizational feasibility, and definition of outcome deliverables for the livestream series and per livestream were essential in livestream development. Faculty selected interventions, lecture contents, and participant preparations. Appropriate location, technical setup, and support were imperative for a stable, high-quality stream with integrated interaction, while maintaining digital privacy. A survey was sent to livestream participants to evaluate each livestream, and allow for constant improvement during the broadcasting of the series. Only surveys which were completed by surgical residents were included in the analysis of this study. Results Each livestream attracted 139–347 unique viewers and a total of 307 surveys were completed by participants (response rate of 23–38% per livestream). Sixty percent of surveys ( n = 185) were completed by surgical residents. Livestreams were highly valued (appreciation 7.7 ± 1.1 and recommendation 8.6 ± 1.1), especially the live procedures combined with interaction and theoretical backgrounds. Criticized were technical difficulties and timing of the livestreams between 5 and 7 pm, which interfered with clinical duties. Conclusion Livestreaming surgical procedures on human cadavers is a valid and valued solution to augment resident education. Digital privacy and a stable, high-quality interactive stream are essential, as are appropriate moderation and relevant lectures. While livestreaming cannot replace hands-on training in the operating room, it enables surgeon-resident interaction which is key in education—and missed in pre-recorded surgical procedures which are currently available online.
We report a case where an integrated whole body F-fluorodeoxyglucose (F-FDG) positron emission tomography (PET)/magnetic resonance imaging (MRI) is performed in the diagnostic work-up of a saccular aortic aneurysm. The integrated whole body F-FDG PET/MRI study answered all relevant diagnostic questions, clearly marking an infected aortic aneurysm, depicting the extent of the infected area in relation to the aortic branch vessels, and indicating the aortic lesion as the primary site of infection. The patient was successfully treated by open type V TAAA repair and pericardial graft replacement. Aortic wall infection was proven in cultures of the surgical specimen.
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