Treatment outcomes and safety in children with rifampicin-resistant TB

BACKGROUND: The treatment of rifampicin-resistant TB (RR-TB) in children is evolving rapidly. As newer regimens are introduced into routine care, it is vital to compare their outcome and safety with well-characterised clinical cohorts treated with historical regimens.METHODS: Study sample comprised a prospective observational cohort of children on routine RR-TB treatment, enrolled from 2011 to 2015 in Cape Town, South Africa. Children were followed for safety, treatment response and outcome.RESULTS: Of 136 children included, 27 (19.9%) were living with HIV and 48 (37.8%) had severe TB. The median time-to-culture conversion in children with bacteriological confirmation (n = 44) was 28.5 days (IQR 14.5-45). Overall, 118/129 (91.5%) had favourable TB treatment outcomes. Of 106 (77.9%) children who received an injectable drug, 9 (8.5%) developed hearing loss and 7/136 (5.1%) developed other Grade 3 or higher adverse events likely related to treatment.CONCLUSIONS: In this cohort with a substantial proportion of children with severe manifestations of TB and with HIV, TB treatment outcomes were excellent. Apart from hearing loss, few children developed severe adverse events related to treatment. This study provides robust reference data for future evaluation of shorter, injectable-sparing regimens.

Treating peripheral arterial occlusive disease and acute limb ischemia during a COVID-19 pandemic in 2020

Background

For many surgeons the outbreak of SARS-CoV-2 meant a downscaling of surgical interventions. The aim of this study was to investigate the impact of the measures taken on the care for patients with peripheral arterial disease (PAOD) and acute limb ischemia (ALI).

Methods

A retrospective analysis of the vascular practices of 2 major teaching hospitals in the Netherlands was performed. All interventions and outpatient visits for PAOD or ALI in 2020 were included. Patients treated in 2018 and 2019 were to serve as a control group. Data were analysed using descriptive statistics.

Results

In 2020, a total of 1513 procedures were performed for PAOD or ALI. This did not differ significantly from previous years. Overall, Fontaine 2 and 4 were the most frequent indications for intervention. A significant increase in the number of major amputations was observed in 2020 compared to 2018 (P< 0.01). This was mainly due to patients suffering from PAOD Fontaine 4. Inversely, a reduction in the number of femoro-popliteal bypasses was observed between 2020 and 2018. The number of outpatient visit due to Fontaine 2 was significantly lower in 2020 compared to 2018.

Conclusions

The vascular practices of our hospitals were minimally influenced by the measures taken due to the outbreak of SARS-CoV-2. There was an increase in the number of amputation but an enormous surge in patients presenting with critical limb ischemia was not observed.

A Comparison of Health Status and Quality of Life in Patients with Intermittent Claudication

BACKGROUND

Patient reported outcome measures (PROMs) such as health status (HS) and quality of life (QOL) are frequently used interchangeably while they represent different outcomes. Whether a discrepancy exists in patients with intermittent claudication (IC) in changes over time between HS and QOL is unclear. This study aimed to investigate the strength and the direction of the association between HS and QOL over time in patients with IC that underwent supervised exercise therapy (SET).

MATERIAL AND METHODS

Patients were part of the ELECT multi-center prospective cohort study. One goal of this study was to obtain data on HS and QOL at different time intervals of patients with IC that underwent SET. HS (VascuQOL-6) and QOL (WHOQOL-BREF) were completed at baseline, 3 months, and 6 months follow up. Pearson's correlation coefficients and the associated common variances (R²) were calculated to measure the strength and the direction of the association between HS and QOL in changes between baseline and follow-up moments.

RESULTS

In total, 177 patients were included in data analyses. Only changes in physical QOL and overall QOL had a small correlation with changes over time in HS, at both 3- and 6 months follow up (respectively R²=.14; P < 0.001 and R² = 0.12; P < 0.001 for physical QOL and R² = 0.18; P < 0.001 and R² = 0.13; P < 0.001 for overall QOL).

CONCLUSIONS

This study showed that HS and QOL provide different outcomes in patients with IC that underwent SET. Future studies should be aware of these differences before PROMs are being incorporated as an outcome measure in clinical studies.

Effect of conservative treatment in aortoiliac occlusive disease

Objective: To determine the effect of primary conservative treatment without revascularization in patients with proven aortoiliac occlusive disease (AIOD) presenting with intermittent claudication (IC).Background: The initial treatment of IC should focus on supervised exercise therapy (SET) and pharmacotherapy. Nowadays, primary endovascular revascularization (EVR) has become increasingly popular in patients with all types of AIOD. But in daily practice, EVR is often performed without initially extensive exercise.Method: This is a single centre retrospective study from December 2012 to September 2017. Primary outcomes were maximum walking distance (MWD) and patient satisfaction. Secondary outcomes were revascularization rate and mortality.Results: Twenty-four patients were included. Mean age was 64 years (SD: 9). Mean follow-up was 28 months (SD: 17). Nineteen patients (80%) had SET. In 18 (75%) patients, the MWD was improved compared to the initial situation. In five (21%) patients, the MWD stayed the same. The MWD of one (4%) patient decreased. Overall satisfaction rate was 87%. Three patients (13%) were not satisfied with the conservative treatment and eventually got an EVR. There was no disease related death.Conclusions: Conservative treatment, especially with SET, has acceptable subjective symptom outcomes in selected patients with AIOD. It could be a good alternative treatment for certain patients with AIOD and IC.

Caregiver strain on informal caregivers when providing care for older patients undergoing major abdominal surgery: a longitudinal prospective cohort study

Background

Health-care systems nowadays rely on complementary patient care by informal caregivers. The need for, and burden on, informal caregivers will likely increase in the upcoming years. This study aimed to examine the burden on caregivers when providing care for elderly patients undergoing major abdominal surgery.

Methods

A single-centre longitudinal cohort study was conducted between November 2015 and June 2018 in the Amphia hospital in Breda, the Netherlands. Patients aged 70+ undergoing elective surgery for colorectal carcinoma (CRC) or an abdominal aortic aneurysm (AAA) were included in this study. Informal caregiver burden was assessed and compared over time using the Caregiver Strain Index (CSI) at the outpatient clinic visit, at discharge, 2 weeks post-discharge and after 6 and 12 months. The effects of patient- and caregiver-related factors on the experienced caregiver strain were examined.

Results

CSI scores of 248 caregivers were significantly increased at discharge (3.5 vs 2.6; p < 0.001) and 2 weeks post-discharge (3.3 vs 2.6; p < 0.001). After 12 months, scores dropped below baseline scores (1.8 vs 2.6; p = 0.012). The highest strain was observed 2 weeks post-discharge for AAA patients and at discharge for CRC patients. Older age, physical or cognitive impairment and burden of comorbidity were associated with an increased caregiver strain at baseline. Type of surgery was independently associated with the change in mean CSI scores over time; a bigger change in caregiver burden is observed after open surgery.

Conclusion

In the early postoperative period, perceived caregiver strain was significantly increased. Psychological support for caregivers may be advisable, with timing of this support depending on diagnosis and patient-related factors.

Trial registration

This manuscript was retrospectively registered on 05-04-2016 in the Netherlands Trial Register (NTR5932). http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5932

Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands

OBJECTIVE

The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

METHODS

This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.

RESULTS

The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).

CONCLUSION

In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis

Introduction: Vulnerable or “frail” patients are susceptible to the development of delirium when exposed to triggers such as surgical procedures. Once delirium occurs, interventions have little effect on severity or duration, emphasizing the importance of primary prevention. This review provides an overview of interventions to prevent postoperative delirium in elderly patients undergoing elective surgery.

Methods: A literature search was conducted in March 2018. Randomized controlled trials (RCTs) and before-and-after studies on interventions with potential effects on postoperative delirium in elderly surgical patients were included. Acute admission, planned ICU admission, and cardiac patients were excluded. Full texts were reviewed, and quality was assessed by two independent reviewers. Primary outcome was the incidence of delirium. Secondary outcomes were severity and duration of delirium. Pooled risk ratios (RRs) were calculated for incidences of delirium where similar intervention techniques were used.

Results: Thirty-one RCTs and four before-and-after studies were included for analysis. In 19 studies, intervention decreased the incidences of postoperative delirium. Severity was reduced in three out of nine studies which reported severity of delirium. Duration was reduced in three out of six studies. Pooled analysis showed a significant reduction in delirium incidence for dexmedetomidine treatment, and bispectral index (BIS)-guided anaesthesia. Based on sensitivity analyses, by leaving out studies with a high risk of bias, multicomponent interventions and antipsychotics can also significantly reduce the incidence of delirium.

Conclusion: Multicomponent interventions, the use of antipsychotics, BIS-guidance, and dexmedetomidine treatment can successfully reduce the incidence of postoperative delirium in elderly patients undergoing elective, non-cardiac surgery. However, present studies are heterogeneous, and high-quality studies are scarce. Future studies should add these preventive methods to already existing multimodal and multidisciplinary interventions to tackle as many precipitating factors as possible, starting in the pre-admission period.

The Role of Delirium and Other Risk Factors on Mortality in Elderly Patients with Critical Limb Ischemia Undergoing Major Lower Limb Amputation

BACKGROUND

Delirium in patients with critical limb ischemia (CLI) is associated with increased mortality. The main goal of this study was to investigate the association between delirium and mortality in patients undergoing major lower limb amputation for CLI. In addition, other risk factors associated with mortality were analyzed.

METHODS

An observational cohort study was conducted including all patients aged ≥70 years with CLI undergoing a major lower limb amputation between January 2014 and July 2017. Delirium was scored using the Delirium Observation Screening Score in combination with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Risk factors for mortality were analyzed by calculating hazard ratios using a Cox proportional hazards model.

RESULTS

In total, 95 patients were included; of which, 29 (31%) patients developed a delirium during admission. Delirium was not associated with an increased risk of mortality (hazard ratio [HR] = 0.84; 95 % confidence interval [CI]: 0.51-1.73; P = 0.84). Variables independently associated with an increased risk of mortality were age (HR 1.1; 95% CI 1.0-1.1), cardiac history (HR 3.3; 95% CI 1.8-6.1), current smoking (HR 2.9; 95% CI 1.6-5.5), preoperative anemia (HR 2.8; 95% CI 1.1-7.2), and living in a nursing home (HR 2.2; 95% CI 1.1-4.4).

CONCLUSION

Delirium was not associated with an increased mortality risk in elderly patients with CLI undergoing a major lower limb amputation. Factors related to an increased mortality risk were age, cardiac history, current smoking, preoperative anemia, and living in a nursing home.

Bioavailability of two licensed paediatric rifampicin suspensions: implications for quality control programmes

SETTING

To assess the revised World Health Organization-recommended dose of 10-20 mg/kg rifampicin (RMP), we studied the steady state pharmacokinetics of RMP in South African children who received standard treatment for drug-susceptible tuberculosis (TB).

OBJECTIVE

To determine the formulation effect on the pharmacokinetics of RMP.

DESIGN

RMP plasma concentrations were characterised in 146 children (median age 1.4 years, range 0.2-10.2). The morning dose on the day of the pharmacokinetic evaluation was administered as one of two RMP single-drug oral suspensions.

RESULTS

While one formulation achieved 2 h concentrations in the range of those observed in adults (median 6.54 mg/l, interquartile range [IQR] 4.47-8.84), the other attained a median bioavailability of only 25% of this, with a median 2 h concentration of 1.59 mg/l (IQR 0.89-2.38).

CONCLUSION

RMP is a key drug for the treatment of TB. It is critical that the quality of RMP suspensions used to treat childhood TB is ensured.

Risk factors of post-operative delirium after elective vascular surgery in the elderly: A systematic review

BACKGROUND

Postoperative delirium is a common and serious adverse event in the elderly patient and is associated with significant morbidity and mortality. It is of great importance to identify patients at risk for delirium, in order to focus preventive strategies. The aim of this article is to systematically review current available literature on pre-operative risk factors for delirium after vascular surgery.

METHODS

A systematic literature search was conducted using PubMed and EMBASE, using the MeSH terms and key words "delirium", "surgery" and "risk factor". Studies were retained for review after meeting strict inclusion criteria that included only prospective studies evaluating risk factors for delirium in patients who had elective vascular surgery. Diagnosis of delirium needed to be confirmed using the Diagnostic and Statistical Manual of Mental Disorders (DSM) or ICD-10.

RESULTS

Fifteen articles were selected for inclusion, incidence of delirium across the studies ranged from 5% to 39%. Many factors have been associated with increased risk of delirium, including age, cognitive impairment, comorbidity, depression, smoking, alcohol, visual and hearing impairment, ASA-score, biochemical abnormalities, operative strategies and blood loss.

CONCLUSIONS

Delirium is a common complication after elective vascular surgery in elderly. The highest delirium incidence was observed after open aortic surgery as well as after surgery for critical limb ischemia. A picture starts to form of which predisposing factors lead to increased risk of delirium. The leading risk factors consistently identified in this systematic review were advanced age and cognitive impairment. Multi-disciplinary specialist-led interventions in the preoperative phase could decrease incidence and severity of delirium and should be focused on identified high-risk patients.

Pharmacokinetics of Rifampin, Isoniazid, Pyrazinamide, and Ethambutol in Infants Dosed According to Revised WHO-Recommended Treatment Guidelines

There are limited pharmacokinetic data for use of the first-line antituberculosis drugs during infancy (<12 months of age), when drug disposition may differ. Intensive pharmacokinetic sampling was performed in infants routinely receiving antituberculosis treatment, including rifampin, isoniazid, pyrazinamide, and ethambutol, using World Health Organization-recommended doses. Regulatory-approved single-drug formulations, including two rifampin suspensions, were used on the sampling day. Assays were conducted using liquid chromatography-mass spectrometry; pharmacokinetic parameters were generated using noncompartmental analysis. Thirty-nine infants were studied; 14 (36%) had culture-confirmed tuberculosis. Fifteen (38%) were premature (<37 weeks gestation); 5 (13%) were HIV infected. The mean corrected age and weight were 6.6 months and 6.45 kg, respectively. The mean maximum plasma concentrations (Cmax) for rifampin, isoniazid, pyrazinamide, and ethambutol were 2.9, 7.9, 41.9, and 1.3 μg/ml, respectively (current recommended adult target concentrations: 8 to 24, 3 to 6, 20 to 50, and 2 to 6 μg/ml, respectively), and the mean areas under the concentration-time curves from 0 to 8 h (AUC0-8) were 12.1, 24.7, 239.4, and 5.1 μg · h/ml, respectively. After adjusting for age and weight, rifampin exposures for the two formulations used differed inCmax(geometric mean ratio [GMR],2.55; 95% confidence interval [CI], 1.47 to 4.41;P= 0.001) and AUC0-8(GMR, 2.52; 95% CI, 1.34 to 4.73;P= 0.005). HIV status was associated with lower pyrazinamideCmax(GMR, 0.85; 95% CI, 0.75 to 0.96;P= 0.013) and AUC0-8(GMR, 0.79; 95% CI, 0.69 to 0.90;P< 0.001) values. No other important differences were observed due to age, weight, prematurity, ethnicity, or gender. In summary, isoniazid and pyrazinamide concentrations in infants compared well with proposed adult target concentrations; ethambutol concentrations were lower but similar to previously reported pediatric studies. The low rifampin exposures require further investigation. (This study has been registered at ClinicalTrials.gov under registration no. NCT01637558.).

Review: Quality of life in lower limb peripheral vascular surgery

PURPOSE

Vascular intervention studies generally consider patency and limb salvage as primary outcomes. However, quality of life is increasingly considered an important patient-oriented outcome measurement of vascular interventions. Existing literature was analyzed to determine the effect of different treatments on quality of life for patients suffering from either claudication or critical limb ischemia.

BASIC METHODS

A review of the literature was undertaken in the Medline library. A search was performed on quality of life in peripheral arterial disease. Results were stratified according to treatment groups.

PRINCIPAL FINDINGS

Twenty-one articles described quality of life in approximately 4600 patients suffering from peripheral arterial disease. Invasive treatment generally results in better quality of life scores (at a maximum of 2 years of follow-up), compared with non-invasive treatment. In patients with critical limb ischemia, successful revascularization improves quality of life scores. Only one study reported long-term results.

CONCLUSIONS

Increase in quality of life scores can be found for any intervention performed for peripheral arterial disease. However, there is scarce information on long-term quality of life after vascular intervention.

Pathophysiology and treatment of edema following femoropopliteal bypass surgery

Substantial lower-limb edema affects the majority of patients who undergo peripheral bypass surgery. Edema has impairing effects on the microvascular and the macrovascular circulation, causes discomfort and might delay the rehabilitation process of the patient. However, the pathophysiology of this edema is not well understood. The Cochrane Library and Medline were used to retrieve literature on edema following peripheral bypass surgery. Factors other than local wound healing alone are suggested in the literature to play a role, given the severity and duration of this edema. Hyperemia, microvascular permeability, reperfusion-associated inflammation and lymphatic disruptions are likely to facilitate the development of edema. Preventive methods could be lymphatic-sparing surgery, intraoperative antioxidative therapy and postoperative elevation. Successful treatment strategies to reduce postoperative edema are based on lymph massage and external compression. In conclusion, the pathophysiology of edema following peripheral surgery is not fully understood, although reperfusion-associated inflammation and lymphatic disruptions are likely to play a crucial role. When future less-invasive techniques prove to be successful, postoperative edema might be minimized. Until then, a careful lymphatic-sparing dissection should be executed when performing a peripheral bypass reconstruction. Postoperatively, the use of compression stockings and leg elevation are currently the golden standards.

Midterm results of autologous saphenous vein and ePTFE pre-cuffed bypass surgery in peripheral arterial occlusive disease

INTRODUCTION

The graft of choice in lower limb bypass surgery is the autologous saphenous vein (ASV). However, a prosthetic graft is needed in the absence of an ASV. In such situations, we used an expanded polytetrafluoroethylene (ePTFE) pre-cuffed Dynaflo graft as supragenicular bypass or Distaflo graft as infragenicular or femorocrural bypass. In respect to the expanding possibilities of percutaneous transluminal angioplasty (PTA), the indication for bypass surgery moved toward patients with advanced stages of peripheral arterial occlusive disease. For this reason, this study analyzed the current performances of these ePTFE grafts and ASV grafts with special attention to limb salvage.

METHODS

In a retrospective study all patients who underwent peripheral bypass surgery between 2004 and 2008 were included. Kaplan-Meier curves were used to express primary patency, secondary patency, and limb salvage rates at 1 and 3 years. Log-rank tests were performed to compare graft types.

RESULTS

A total of 272 grafts (ePTFE/ASV: 110/162) were performed in lower limb bypass surgery. The mean follow-up was 20.3 months. The secondary 3-year patency rates were for (n=78) supragenicular grafts (ePTFE/ASV: 45%/94%)*, for (n=124) infragenicular grafts (24%/74%), and 70 for femorocrural grafts (26%/52%). Limb salvage after 3 years was 59% in the ePTFE group versus 78% in the ASV group (P < .05).

CONCLUSION

In the current population of vascular patients where no PTA is possible and a peripheral bypass is necessary, the ASV remains the graft of first choice. However, the pre-cuffed ePTFE graft is a good alternative, especially in cases of critical limb ischemia, in respect to an acceptable limb salvage rate.

Reliability and reproducibility of a clinical application of a simple technique for repeated circumferential leg measurements

Objective

The aim of this study is to determine the reliability and reproducibility of repeated tape measurements to assess the leg circumference during a long period.

Methods

A tape measure is a simple instrument that is applicable in the presence of oedema. Measurements were performed by four observers on 11 volunteers. Four measurements were done in the first week (short term), a fifth measurement at two weeks (medium term) and a sixth measurement was done at 12 weeks (long term).

Results

The short-, medium- and long-term intra-class correlation coefficients for repeated measurements were 0.90, 0.89 and 0.78, respectively. The short-term and long-term reproducibility indices equalled 4.4% and 6.5%. If only a single observer would be involved, the short-term intra-class correlation coefficients would improve to 0.94 (reproducibility index 3.3%).

Conclusion

Tape measurements have been proved to be a reliable and reproducible method to asses the lower limb circumference.

Evaluation of A-V impulse technology as a treatment for oedema following polytetrafluoroethylene femoropopliteal surgery in a randomised controlled trial

OBJECTIVE

To investigate the efficacy of A-V impulse technology (A-V) for oedema prevention and treatment following PTFE femoropopliteal surgery.

DESIGN

Prospective randomized clinical trial.

MATERIALS

36 patients undergoing PTFE femoropopliteal bypass reconstructions, either being treated postoperatively with a compression stocking (CS) (Group-1, n = 19) or with A-V (Group-2, n = 17).

METHODS

Patients in treatment group-1 used a CS postoperatively during 1 week day and night, patients in group-2 were treated with A-V postoperatively at night during one week. The lower leg circumference was measured preoperatively and at five postoperative time points.

RESULTS

Limb circumference has increased postoperatively on day 1 (CS 1.5%/A-V 1.4%), on day 4 (5.7%/6.3%), on day 7 (6.6%/6.1%), on day 14 (7.9%/7.7%) and on day 90 (5.8%/5.2%). Differences between treatment groups were not significant. A re-operation gives a significant 3.9% increase in circumference as compared to a first operation (95% CI: 1.5-6.4%; p = 0.002).

CONCLUSION

No significant differences were found in the extent of developed edema between the groups following PTFE femoropopliteal bypass surgery. A redo peripheral bypass operation results in significantly more postoperative oedema than a first-time performed bypass operation.

[Diagnostic image (370). A boy with a painful groin]

A 14-year-old boy presented with a painful left inguinal region, after shooting a soccer ball. The pain was caused by an apophyseolysis of the left lesser trochanter.

[Abdominal pain as a symptom of a late complication following endovascular treatment of an aneurysm of the abdominal aorta]

A 72-year-old man presented with progressive pain in the left lower abdomen thought to be due to diverticulitis of the colon. Antimicrobial therapy had not reduced the symptoms. Four years before, during an endovascular procedure, the patient had been given a stent because of an abdominal aortic aneurysm (AAA). A CT scan showed a large retroperitoneal haematoma on the left side and an increased diameter of the AAA of 8.5 cm. X-rays showed a gap between the endovascular stent and the left iliac leg of the endoprosthesis. Due to the space between the two grafts, there was retroperitoneal leakage ofblood. In endovascular surgery this life-threatening situation is called a type III endoleak. The patient was operated immediately using the endovascular technique. Through the left femoral artery a new coated stent was positioned over the gap, which led to rapid recovery of the patient. Patients with abdominal pain and a history of a vascular endoprosthesis should be given a CT scan and plain radiography to exclude an endoleak.

Non invasive treatment of peri-aortic inflammation after endovascular graft

INTRODUCTION

Peri-aortitis is a rare and severe complication of endovascular treatment.

REPORT

Two cases of peri-aortic inflammation are reported after receiving an abdominal endoprosthesis as treatment for abdominal aneurysm. Both patients were successfully treated with high doses of prednisone and the grafts were left in situ.

DISCUSSION

High doses of prednisone may be the treatment of choice for post endovascular peri-aortitis.

[Retroperitoneal haematoma seen on CT scan in 2 patients with abdominal symptoms, aneurysm of the abdominal aorta and normal haemodynamics]

In 2 patients, men aged 73 and 66 undergoing physical and ultrasound examinations for complaints of abdominal pain, an aneurysm of the abdominal aorta (AAA) with a diameter of 7-8 cm was discovered. Both their blood pressure and heart rate were normal. The older man then underwent a CT scan as did the younger man after being observed overnight. They both proved to have a ruptured AAA. They were operated on and recovered well. It can be problematic to diagnose a ruptured AAA quickly in patients with abdominal and back pain, AAA on ultrasound and normal haemodynamic parameters. In this situation an emergency CT scan will visualize any retroperitoneal haematoma and the patient can undergo an emergency operation. If the CT scan does not show any rupture there is time for preoperative preparations before performing a semi-elective procedure.

[The central-venous compression syndrome: rare, but adequately treatable with endovascular stenting]

Two patients, women aged 30 and 29, had severe chronic pain in the left leg, and a woman aged 36 had pain in the left flank. On the grounds of the clinical symptoms, phlebography and venous-duplex ultrasonography, a central-venous compression syndrome was diagnosed: compression of the left common iliac vein between the crossing right common iliac artery and the body of the fifth lumbar vertebra (May-Thurner syndrome). The patient with left flank pain also had haematuria. Angiography, computed tomography and phlebography revealed that these symptoms were due to compression of the left renal vein between the abdominal aorta and the superior mesenteric artery (nutcracker phenomenon). The treatment of all 3 patients consisted of venous endovascular stenting. At follow-up after 12, 30 and 15 months, respectively, the complaints had subsided considerably.

Leg muscle reflexes mediated by cutaneous A-beta fibres are normal during gait in reflex sympathetic dystrophy

OBJECTIVES

Reflex sympathetic dystrophy (RSD) is, from the onset, characterized by various neurological deficits such as an alteration of sensation and a decrease in muscle strength. We investigated if afferent A-beta fibre-mediated reflexes are changed in lower extremities affected by acute RSD.

METHODS

The involvement of these fibres was determined by analyzing reflex responses from the tibialis anterior (TA) and biceps femoris (BF) muscles after electrical stimulation of the sural nerve. The reflexes were studied during walking on a treadmill to investigate whether the abnormalities in gait of the patients were related either to abnormal amplitudes or deficient phase-dependent modulation of reflexes. In 5 patients with acute RSD of the leg and 5 healthy volunteers these reflex responses were determined during the early and late swing phase of the step cycle.

RESULTS

No significant difference was found between the RSD and the volunteers. During early swing the mean amplitude of the facilitatory P2 responses in BF and TA increased as a function of stimulus intensity (1.5, 2 and 2.5 times the perception threshold) in both groups. At end swing the same stimuli induced suppressive responses in TA. This phase-dependent reflex reversal from facilitation in early swing to suppression in late swing occurred equally in both groups.

CONCLUSIONS

In the acute phase of RSD of the lower extremity there is no evidence for abnormal A-beta fibre-mediated reflexes or for defective regulation of such reflexes. This finding has implications for both the theory on RSD pathophysiology and RSD models, which are based on abnormal functioning of A-beta fibres.

Adjuvant physical therapy versus occupational therapy in patients with reflex sympathetic dystrophy/complex regional pain syndrome type I

OBJECTIVE

To investigate the effectiveness and cost of physical therapy (PT) or occupational therapy (OT) in patients with reflex sympathetic dystrophy (RSD).

DESIGN

Prospective randomized controlled trial, with 1 year follow-up.

SETTING

Two university hospitals.

PATIENTS

One hundred thirty-five patients who had been suffering from RSD of one upper extremity for less than 1 year.

INTERVENTIONS

Patients were assigned to PT, OT, or a control group (social work).

MAIN OUTCOME MEASURES

Improvement in impairment level sumscore (ISS) over 1 year (Student's t test). A difference of 5 ISS points between the groups was defined as being clinically relevant. Furthermore, severity of disability and handicap was measured and tested exploratively (Wilcoxon; alpha = .05), and cost-effectiveness of the groups was calculated.

RESULTS

PT and, to a lesser extent, OT resulted in a significant and also more rapid improvement in the ISS as compared with controls (6 and 4 ISS points, respectively). On a disability level, a positive trend was found in favor of OT. On a handicap level, no differences were found between the groups. PT had an advantage over OT regarding the cost-effectiveness ratio.

CONCLUSION

In different ways PT and OT each contribute to the recovery from RSD of the upper extremity.

The Symptom Checklist-90 Revised questionnaire: no psychological profiles in complex regional pain syndrome-dystonia

Complex regional pain syndrome (CRPS) is a syndrome usually localized in the extremities, mostly occurring after a preceding trauma or operation. Dystonia is present in a minority of CRPS patients, but, when present, leads to severe disability. Various pathological factors have been postulated to present in CRPS-dystonia, such as involvement of the sympathetic system, reorganization of the central nervous system, and psychological distress. In the present study, we investigated the involvement of psychological distress in CRPS-dystonia with the aid of the Symptom Checklist-90 Revised (SCL-90R) questionnaire. The SCL-90R is a multidimensional self-report inventory covering various dimensions of psychological distress. In a population of 1006 CRPS patients, we analyzed the SCL-90R scores of 27 patients with CRPS-dystonia (23 female and 4 male) and compared the scores to sample scores of a control female (n = 577) and a control rehabilitation population (n = 56). Insomnia scored significantly higher in the female CRPS-dystonia population, as compared to the control female population (P < 0.001), and in the total CRPS-dystonia population, as compared to the rehabilitation population (P < 0.01). Remarkable was the significantly higher score of somatization in the rehabilitation population, as compared to the CRPS-dystonia population (P = 0.006). For the other dimensions of psychological distress of the SCL-90R, the scores of the CRPS-dystonia and control populations were similar. With regard to the SCL-90R scores, we conclude that specific psychological profiles are not present in CRPS-dystonia.

A comparison of free radical-induced vascular and skeletal muscle damage in immunocompetent and neutropenic rats

BACKGROUND

Intraarterial infusion of the free radical donor tert. -butyl-hydroperoxide (tert.-BuOOH) into one extremity of the rat induces vascular permeability and considerable skeletal muscle damage. However, it remains unclear what the role of polymorphonuclear neutrophils (PMNs) is in oxidative stress-related processes. Therefore, we investigated possible differences between neutropenic and normal animals in this model.

METHODS

Neutropenia was induced in male rats by intraperitoneal administration of cyclophosphamide. tert.-BuOOH was continuously infused intraarterially into one hindlimb of normal or neutropenic nonanesthetized rats for 24 h. The control neutropenic rats were infused with the same volume of saline. After the infusion, 99mTc-IgG was administered intravenously followed by scintigraphic imaging analysis of the left/right uptake ratio of the hindlimbs and by gamma counting of the tissue samples of the gastrocnemius and gluteus maximus muscles. Samples of these muscles were analyzed by light microscopy.

RESULTS

The uptake ratios were significantly increased in the normal and neutropenic tert.-BuOOH-infused animals as compared with the saline-infused neutropenic rats (P < 0.05). The uptake ratios were significantly higher in normal than in neutropenic tert.-BuOOH-infused rats (P < 0.05). Histological analysis of the saline infused skeletal muscles showed unaffected skeletal muscles with intact arterioles and arteries. In the gastrocnemius and gluteus maximus muscles of the normal tert. -BuOOH-infused and neutropenic rats, similar morphological damage was observed.

CONCLUSIONS

PMNs can increase, to some extent, the vascular permeability of the free radical damaged small arteries and arterioles of a tert.-BuOOH-infused hindlimb. However, in the present animal model, tert.-BuOOH alone can induce oxidative stress-related abnormalities with skeletal muscle tissue damage that is mainly independent of the presence of PMNs.

Complex regional pain syndrome type I (RSD): pathology of skeletal muscle and peripheral nerve

BACKGROUND

Reflex sympathetic dystrophy (RSD) (recently reclassified as complex regional pain syndrome type I) is a syndrome occurring in extremities and, when chronic, results in severe disability and untractable pain. RSD may be accompanied by neurologic symptoms even when there is no previous neurologic lesion. There is no consensus as to the pathogenic mechanism involved in RSD. To gain insight into the pathophysiology of RSD, we studied histopathology of skeletal muscle and peripheral nerve from patients with chronic RSD in a lower extremity.

METHODS

In eight patients with chronic RSD, an above-the-knee amputation was performed because of a nonfunctional limb. Specimens of sural nerves, tibial nerves, common peroneal nerves, gastrocnemius muscles, and soleus muscles were obtained from the amputated legs and analyzed by light and electron microscopy.

RESULTS

In all patients, the affected leg showed similar neurologic symptoms such as spontaneous pain, hyperpathy, allodynia, paresis, and anesthesia dolorosa. The nerves showed no consistent abnormalities of myelinated fibers. In four patients, the C-fibers showed electron microscopic pathology. In all patients, the gastrocnemius and soleus muscle specimens showed a decrease of type I fibers, an increase of lipofuscin pigment, atrophic fibers, and severely thickened basal membrane layers of the capillaries.

CONCLUSION

In chronic RSD, efferent nerve fibers were histologically unaffected; from afferent fibers, only C-fibers showed histopathologic abnormalities. Skeletal muscle showed a variety of histopathologic findings, which are similar to the histologic abnormalities found in muscles of patients with diabetes.

Clinical signs and symptoms of acute reflex sympathetic dystrophy in one hindlimb of the rat, induced by infusion of a free-radical donor

The acute phase of reflex sympathetic dystrophy (RSD) is characterized by the classical signs and symptoms of inflammation (rubor, calor, dolor, tumor and impaired function). As free radicals are involved in acute inflammation, we studied the effects of free radicals in an animal model, especially as to signs and symptoms found in acute RSD. Awake rats were given continuous intra-arterial infusion (1 ml/h) in the left hindlimb, with saline (n = 6) or the free-radical donor tert-butylhydroperoxide (tert-BuOOH, 25 mM, n = 6). During a 24-h infusion period the skin temperature, volume, skin color, function and pain reactions of the paws were observed. After 24 h the rats were killed and both gastrocnemius muscles were histologically analyzed. Infusion with tert-BuOOH induced in the left paw an increased skin temperature, increased volume, redness of the plantar skin, impaired function and increased pain sensation, while these acute RSD signs and symptoms were absent in the saline infused animals. The alterations in pain sensation (spontaneous, mechanical and thermal pain) were similar to findings in the neuropathic animal model. The gastrocnemius muscles of the saline infused rats and the contralateral gastrocnemius muscle of the tert-BuOOH infused rats showed no histological tissue damage. In the left gastrocnemius muscle free-radical-related damage was visible. Induction of free-radical formation in one hindlimb of awake rats mimics the acute signs and symptoms of acute RSD, with alterations in pain sensation as found in the classical neuropathic animal model of RSD, as well as in acute RSD patients.

Severe complications of reflex sympathetic dystrophy: infection, ulcers, chronic edema, dystonia, and myoclonus

OBJECTIVE

To determine the prevalence, type of complication, predisposing factors, and treatment for severe complications in a population of reflex sympathetic dystrophy (RSD) patients.

DESIGN

Retrospective analysis of the data from RSD patients collected over a 12-year period, to investigate the involvement of predisposing factors in an RSD population without severe complications compared with an RSD population with severe complications.

SETTING

Outpatient clinic of a department of surgery of a university hospital.

PATIENTS

A total of 1,006 patients with the diagnosis of RSD established according to prospectively defined criteria.

MAIN OUTCOME MEASURES

The signs and symptoms of every RSD patient who visited the department were prospectively documented in the medical history; these data were retrospectively analyzed with special regard to RSD with severe complications-infection, ulcers, chronic edema, dystonia, and/or myoclonus-for prevalence, type of complication, and treatment.

RESULTS

Seventy-four RSD patients who were mostly young and female developed severe complications. More than one complication occurred in 91% of the affected extremities. Severe complications developed more frequently in the lower extremity (65%). In patients in whom the acute RSD started with a decreased skin temperature of the affected extremity, severe complications developed significantly more often than in acute RSD patients with a warm skin temperature of the extremity from the onset of the disease (p < .001).

CONCLUSIONS

It is important to recognize "cold" RSD immediately at the onset of the disease because this group of RSD patients has a higher risk of developing a severe complication, mostly followed by a severe disability that is resistant to therapy.

NADH videofluorimetry to monitor the energy state of skeletal muscle in vivo

BACKGROUND

Reduction of the cellular energy state during ischemia of the limbs is an important determinant for development of necrosis. Since energy conversion in the mitochondria is based on electron transport from NADH to molecular O2, the NADH/NAD+ redox couple reflects the mitochondrial redox state and cellular O2 requirement. The applicability of NADH videofluorimetry to monitor noninvasively changes in the energy state of intact resting skeletal muscle as a function of oxygenation was investigated in a rat model.

MATERIALS AND METHODS

In mechanically ventilated rats (n = 6), NADH fluorescence images of the gracilis muscle were recorded under different oxygenation conditions. Induction of anoxic and ischemic hypoxia were verified by simultaneous measurement of tissue oxygen pressure and afferent blood flow.

RESULTS

Anoxic hypoxia and ischemic hypoxia increased the NADH fluorescence intensity by 46.0 +/- 15.0 and 30.8 +/- 26.4%, respectively. The response time of NADH fluorescence intensity, tissue oxygen pressure, and afferent blood flow was similar during development of anoxic and ischemic hypoxia. Upon reperfusion and reoxygenation, however, NADH fluorescence intensity changed significantly earlier than tissue oxygen pressure as measured by an oxygen needle electrode.

CONCLUSION

These results demonstrate that changes in NADH fluorescence intensity reflect oxygenation changes in intact skeletal muscle in vivo. Since NADH videofluorimetry, in contrast to oxygen needle electrode measurements, noninvasively visualizes temporal and regional changes in the energy state of skeletal muscle, this technique has the potential to improve clinical evaluation of ischemia/reperfusion injury and tissue viability.

Soft tissue repair capacity after oxygen-derived free radical-induced damage in one hindlimb of the rat

Oxygen-derived free radicals are suspected to play an important role in the pathogenesis of inflammation and ischemia/reperfusion of an extremity. In this study we investigated the repair capacity of a free radical-damaged hindlimb of the rat and the effect of the anti-oxidant N-acetyl-L-cysteine (NAC). In nonanesthetized rats (n = 39), the left hindlimb was continuously infused intra-arterially (1 ml/hr) for 24 hr with the free radical donor tert-butylhydroperoxide (tert-BuOOH, 25 mM). Subsequently the infusion system was disconnected and the repair of soft tissue damage was observed with special attention to various pain tests, vascular permeability ((99m)Tc-IgG scintigraphy), and histology for a maximum period of 6 weeks. In 12 of these tert-BuOOH-infused rats the antioxidant NAC was injected intraperitoneally. Six of the NAC-treated rats were killed after 24 hr of infusion, while the remaining 6 rats were disconnected, reinjected with NAC, and observed for 1 week. Tert-BuOOH infusion for 24 hr led to significantly increased pain sensations, vascular permeability, and histological damage. Treatment with NAC significantly reduced pain sensations and vascular permeability, though not to control levels. One week after disconnection, tissue damage was almost completely repaired in the NAC-treated rats. In the untreated rats, repair took longer but histology and vascular permeability were completely normalized within the observation period. Soft tissue damage, induced by 24-hr infusion of the free radical donor tert-BuOOH, showed spontaneous repair within 6 weeks. The antioxidant NAC significantly reduced the soft tissue damage and shortened the repair period.

Reflex sympathetic dystrophy. An exaggerated regional inflammatory response?

Reflex sympathetic dystrophy (RSD) is a syndrome affecting an extremity after a minor trauma or operation. Currently, there is no consensus about the pathogenesis of RSD. The authors performed various clinical and experimental investigations, including studies of the effects of anti-inflammatory treatment, that support the hypothesis that RSD is the result of an exaggerated inflammatory response to injury or surgery.

A novel animal model to evaluate oxygen derived free radical damage in soft tissue

We present a novel animal model which allows the continuous intra-arterial infusion in one hindlimb of non-anaesthetized rats, without inducing ischemia. Using this model the effect of continuous infusion (1 ml/h) for 24 h with tert-butylhydroperoxide (tert-BuOOH) at a concentration of 25 mM on soft tissue of the left hind limb was studied and compared to the effect of saline infusion (control group). The tert-BuOOH-infused foot showed increased skin temperature, increased circumference, redness of the plantar skin, impaired function and increased pain sensation, while in the contralateral foot and in rats only perfused with saline these signs of inflammation were absent (p < 0.01). Histological analysis of the left gastrocnemius muscle showed edema, muscle cell degeneration with a patchy distribution pattern and vascular damage. All these features increased in severity from 4 to 24 h tert-BuOOH infusion. After 24 h of tert-BuOOH infusion infiltration of neutrophils in the interstitium was observed. Vascular permeability, expressed as left to right gastrocnemius muscle 99mTc-IgG uptake ratio, was similarly increased after 4 h (2.09 +/- 0.26) and 12 h (2.04 +/- 0.08) of tert-BuOOH infusion compared to saline (1.05 +/- 0.08) (p < 0.001), and further increased after 24 h (3.84 +/- 0.13): (p < 0.001). In this animal model free radical-related soft tissue damage was induced, by continuous infusion of tert-BuOOH, followed by increasing necrosis and vascular permeability in skeletal muscle coinciding with neutrophilic infiltration.

[Sudeck's syndrome. Was Sudeck right?]

Reflex sympathetic dystrophy (RSD) is a syndrome affecting an extremity after a minor trauma or operation. At the moment there is no consensus about the pathogenesis of RSD. In 1942 Paul Sudeck suggested that the signs and symptoms of RSD may be provoked by an exaggerated inflammatory response to injury or operation of an extremity. His theory found no disciples, as most physicians believe that RSD is initiated by an hyperactive sympathetic system. We performed various clinical and experimental investigations, including the effects of antiinflammatory treatment. The results of these studies support the theory of Paul Sudeck.

Reflex sympathetic dystrophy after a burn injury

Reflex sympathetic dystrophy (RSD) is a disease that can appear after minor trauma or operation to an extremity. The injury may vary from a simple contusion to a fracture. The prevalence of burns as a cause of RSD, within a population of 829 patients with RSD, was studied retrospectively. Prospectively, we documented the medical history, signs and symptoms of all patients with RSD, seen by our department during the period from January 1984 to 31 December 1994. Four patients had developed RSD after a burn injury, resulting in a prevalence of 0.5 per cent. Though the clinical signs of early RSD are similar to those of a (thermal) burn, alertness to recognize inflammatory signs, in combination with the increase in complaints after exercise, is necessary for early diagnosis and treatment of the complicating RSD.