Purpose:
Octogenarians are known to have less-favorable outcomes following ruptured abdominal aortic aneurysm (rAAA) repair compared with their younger counterparts. Accurate information regarding ...perioperative outcomes following rAAA-repair is important to evaluate current treatment practice. The aim of this study was to evaluate perioperative outcomes of octogenarians and to identify factors associated with mortality and major complications after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of a rAAA using nationwide, real-world, contemporary data.
Methods:
All patients that underwent EVAR or OSR of an infrarenal or juxtarenal rAAA between January 1, 2013, and December 31, 2018, were prospectively registered in the Dutch Surgical Aneurysm Audit (DSAA) and included in this study. The primary outcome was the comparison of perioperative outcomes of octogenarians versus non-octogenarians, including adjustment for confounders. Secondary outcomes were the identification of factors associated with mortality and major complications in octogenarians.
Results:
The study included 2879 patients, of which 1146 were treated by EVAR (382 octogenarians, 33%) and 1733 were treated by OSR (410 octogenarians, 24%). Perioperative mortality of octogenarians following EVAR was 37.2% versus 14.8% in non-octogenarians (adjusted OR=2.9, 95% CI=2.8–3.0) and 50.0% versus 29.4% following OSR (adjusted OR=2.2, 95% CI=2.2–2.3). Major complication rates of octogenarians were 55.4% versus 31.8% in non-octogenarians following EVAR (OR=2.7, 95% CI=2.1–3.4), and 68% versus 49% following OSR (OR=2.2, 95% CI=1.8–2.8). Following EVAR, 30.6% of the octogenarians had an uncomplicated perioperative course (UPC) versus 49.5% in non-octogenarians (OR=0.5, 95% CI=0.4–0.6), while following OSR, UPC rates were 20.7% in octogenarians versus 32.6% in non-octogenarians (OR=0.5, 95% CI=0.4–0.7). Cardiac or pulmonary comorbidity and loss of consciousness were associated with mortality and major complications in octogenarians. Interestingly, female octogenarians had lower mortality rates following EVAR than male octogenarians (adjusted OR=0.7, 95% CI=0.6–0.8).
Conclusion:
Based on this nationwide study with real-world registry data, mortality rates of octogenarians following ruptured AAA-repair were high, especially after OSR. However, a substantial proportion of these octogenarians following OSR and EVAR had an uneventful recovery. Known preoperative factors do influence perioperative outcomes and reflect current treatment practice.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Introduction
People with haemophilia suffer from haemophilic joint disease that may result in physical inactivity and overweight. Shared medical appointments (SMAs) might help limit the consequences ...of haemophilic arthropathy. SMAs are group meetings supervised by one or more healthcare professionals that can be utilized to improve lifestyle.
Aim
To evaluate the feasibility and efficacy of SMAs in people with haemophilia to improve physical activity and eating habits.
Methods
A multiple baseline single‐case design was used. Overweight people with haemophilia were eligible to participate. Seven weekly SMAs were conducted using multiple behavioural change techniques to improve physical activity and eating habits. Feasibility of SMAs was evaluated using (a) dropout rate, (b) occurrence of adverse events (AEs), (c) adherence rate and (d) patient satisfaction. During 13 weeks, physical activity was measured daily and eating habits were measured three times per week. The efficacy of SMAs was determined using randomization tests and visual data inspection.
Results
Out of the six men participating in the study, one participant dropped out. No study‐related AEs occurred. The adherence rate of SMAs was 80%, and participants reported to be ‘very satisfied’ with the SMAs. Randomization tests and visual analyses demonstrated (statistical) improvements in physical activity (p = .03). No effect was found in self‐reported eating habits (p = .55).
Conclusion
Shared medical appointments are feasible in people with haemophilia and appear to improve physical activity. The effect on improving eating habits could not be established. Scientific replication of our approach is warranted to confirm or refute the merit of SMAs in people with haemophilia.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Hypoxia, Hypoxia-Inducible Transcription Factor, and Macrophages in Human Atherosclerotic Plaques Are Correlated With Intraplaque Angiogenesis Judith C. Sluimer, Jean-Marie Gasc, Job L. van Wanroij, ...Natasja Kisters, Mathijs Groeneweg, Maarten D. Sollewijn Gelpke, Jack P. Cleutjens, Luc H. van den Akker, Pierre Corvol, Bradly G. Wouters, Mat J. Daemen, Ann-Pascale J. Bijnens Hypoxia was directly demonstrated in advanced atherosclerotic lesions of symptomatic patients with the use of pimonidazole administration before carotid endarterectomy. Hypoxia correlated with the presence of macrophages, angiogenesis, and a thrombus, and the expression of hypoxia-inducible transcription factor (HIF) and vascular endothelial growth factor. Also, the HIF pathway and microvessel density were associated with lesion progression and angiogenesis, suggesting the involvement of the HIF pathway in the response to hypoxia and the regulation of human intraplaque angiogenesis.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
OBJECTIVE
Conflicting evidence exists on the effects of hyperbaric oxygen therapy (HBOT) in the treatment of chronic ischemic leg ulcers. The aim of this trial was to investigate whether additional ...HBOT would benefit patients with diabetes and ischemic leg ulcers.
RESEARCH DESIGN AND METHODS
Patients with diabetes with an ischemic wound (n = 120) were randomized to standard care (SC) without or with HBOT (SC+HBOT). Primary outcomes were limb salvage and wound healing after 12 months, as well as time to wound healing. Other end points were amputation-free survival (AFS) and mortality.
RESULTS
Both groups contained 60 patients. Limb salvage was achieved in 47 patients in the SC group vs. 53 patients in the SC+HBOT group (risk difference RD 10% 95% CI −4 to 23). After 12 months, 28 index wounds were healed in the SC group vs. 30 in the SC+HBOT group (RD 3% 95% CI −14 to 21). AFS was achieved in 41 patients in the SC group and 49 patients in the SC+HBOT group (RD 13% 95% CI −2 to 28). In the SC+HBOT group, 21 patients (35%) were unable to complete the HBOT protocol as planned. Those who did had significantly fewer major amputations and higher AFS (RD for AFS 26% 95% CI 10–38).
CONCLUSIONS
Additional HBOT did not significantly improve complete wound healing or limb salvage in patients with diabetes and lower-limb ischemia.
Objective. The technical and clinical outcome of endovascular revascularization was analyzed in patients with suspicion of chronic splanchnic syndrome (CSS).
Methods. Medical history, duplex, ...angiography and exercise gastric tonometry suggested CSS in 97 patients. Twenty-seven of them were treated endovascular (one patient had 3-vessel, 12 patients had 2-vessels, 14 patients had 1-vessel CSS). Five patients received previous splanchnic revascularization. Twenty-three patients (85%) had severe co-morbidity: cardiac, pulmonary or cachexia. Endovascular treatment consisted of percutaneous transluminal angiography (PTA) of the coeliac artery (CA) or superior mesenteric artery (SMA) in three and primary balloon expandable stenting in 24 patients (13 CA and 10 SMA solitary, two CA and SMA both, 31 splanchnic arteries in total).
Results. Three patients showed procedure related complications (11%). Mean follow-up was 19, range 2–76 months. Two patients died during follow up, both not procedure or CSS related. Five patients had no improvement of symptoms, without evidence of re- or residual stenosis. The primary clinical success was 67%, secondary clinical success was 81%. The primary patency was 81% and secondary patency was 100%.
Conclusion. Endovascular treatment of CSS has a reasonable outcome. It is an alternative to operative treatment, especially in patients with high co-morbidity or limited life expectancy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Changes in the structure and chemistry of β-lactoglobulin (β-LG) play an important role in the processing and functionality of milk products. In model β-LG systems, there is evidence that the ...aggregates of heated β-LG are held together by a mixture of intermolecular non-covalent association and heat-induced non-native disulfide bonds. Although a number of non-native disulfide bonds have been identified, little is known about the initial inter- and intramolecular disulfide bond rearrangements that occur as a result of heating. These interchange reactions were explored by examining the products of heat treatment to determine the novel disulfide bonds that form in the heated β-LG aggregates. The native protein and heat-induced aggregates were hydrolyzed by trypsin, and the resulting peptides, before and after reduction with dithiothreitol, were separated by high-performance liquid chromatography and their identities confirmed by electrospray ionization mass spectrometry. Comparisons of these peptide patterns showed that some of the Cys160 was in the reduced form in heated β-LG aggregates, indicating that the Cys160−Cys66 disulfide bond had been broken during heating. This finding suggests that disulfide bond interchange reactions between β-LG non-native monomers, or polymers, and other proteins could occur largely via Cys160. Keywords: β-Lactoglobulin; disulfide bonding; heat-induced change; mass spectroscopy
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IJS, KILJ, NUK, PNG, UL, UM, UPUK
The technical and clinical outcome of endovascular revascularization was analyzed in patients with suspicion of chronic splanchnic syndrome (CSS).
Medical history, duplex, angiography and exercise ...gastric tonometry suggested CSS in 97 patients. Twenty-seven of them were treated endovascular (one patient had 3-vessel, 12 patients had 2-vessels, 14 patients had 1-vessel CSS). Five patients received previous splanchnic revascularization. Twenty-three patients (85%) had severe co-morbidity: cardiac, pulmonary or cachexia. Endovascular treatment consisted of percutaneous transluminal angiography (PTA) of the coeliac artery (CA) or superior mesenteric artery (SMA) in three and primary balloon expandable stenting in 24 patients (13 CA and 10 SMA solitary, two CA and SMA both, 31 splanchnic arteries in total).
Three patients showed procedure related complications (11%). Mean follow-up was 19, range 2-76 months. Two patients died during follow up, both not procedure or CSS related. Five patients had no improvement of symptoms, without evidence of re- or residual stenosis. The primary clinical success was 67%, secondary clinical success was 81%. The primary patency was 81% and secondary patency was 100%.
Endovascular treatment of CSS has a reasonable outcome. It is an alternative to operative treatment, especially in patients with high co-morbidity or limited life expectancy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract only
Intraplaque neovascularization is linked to plaque instability and thought to be stimulated by hypoxia. However, hypoxia has not been demonstrated yet in human atherosclerosis. The ...hypoxia marker pimonidazole was administrated intravenously 2 hours prior to carotid endarterectomy in 6 symptomatic patients to evaluate the presence of hypoxia. Subsequent immunohistochemistry of the operatively removed atherosclerotic plaques demonstrated the presence of hypoxia, especially in the macrophage-rich center of the lesions. Notably, two hypoxic gradients were observed:
hypoxia was very strong in the center of the plaque, but almost absent close to the main artery lumen and in the media.
hypoxia was most intense in segments with advanced atheroma and almost absent in segments containing only diffuse intimal thickening.
Hypoxia strongly correlated with CD68 immunoreactivity (ρ= 0.7, p=0.000), neovascularization (ρ= 0.6, p=0.000) and the presence of a thrombus (ρ= 0.4, p=0.009). In addition, hypoxia co-localized with expression of HIF1α and VEGF . To exclude that pimonidazole immunoreactivity in the atherosclerotic plaque was the result of surgery-induced ischemia, arterial wall segments were collected at two time-points: directly after incision of the carotid artery and directly following excision of the plaque. Pimonidazole immunoreactivity in these two pieces was not different, suggesting that hypoxia and pimonidazole adducts were already present in the plaques before surgery . To show that pimonidazole reactivity was hypoxia-specific and independent of reactive oxygen species, human THP-1 macrophages were exposed to normoxia (20% O
2
), hypoxia (0.2% O
2
) and/or H
2
O
2
(100 μM) in the presence of pimonidazole. Indeed, flow cytometry only showed pimonidazole-positive cells after hypoxic exposure. This is the first study proving direct evidence of the existence of hypoxia in advanced human atherosclerotic lesions, most prominently in the macrophage-rich center. Also, hypoxia was associated with the expression of HIF1α, VEGF and intraplaque microvessels, suggesting its involvement in the regulation of human intraplaque neovascularization.
The authors retrospectively report the results of surgical treatment of spinal cord tumours in the Department of Neurosurgery, University Hospital Utrecht, Holland and review the recent literature. ...Twenty-eight patients were operated on for an intramedullary spinal cord tumour between 1981 and 1990. The mean follow-up period was 31 months. Neurological evaluation was done using the grading system described by Cooper and Epstein, immediately postoperatively and after 6 months. A total or subtotal resection could be performed in 22 (79%) of the 28 patients. Postoperatively, the neurological function of the legs improved or remained stable in 21 of the 28 patients, and the function of the arms in 26 of the 28 patients. After six months the neurological function in arms and legs had improved or remained stable in 19 of 21 patients. The most frequently occurring tumour, ependymoma, could be radically resected more often (82%) than astrocytoma (33%). Postoperative morbidity is closely related to the level of involvement. Microsurgical exploration at the cervical level is far less dangerous than has always been believed. Surgical mortality was 0%. Radical resection of intramedullary tumours should be attempted and can be achieved with stabilisation or improvement of neurological deficit in the majority of patients.
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