Is the use of antibiotic-impregnated external ventricular drainage beneficial in the management of iatrogenic ventriculitis?

Background  

Profound evidence substantiates significantly reduced risk of catheter-related infections with prophylactic use of rifampin- and clindamycin-impregnated silicone catheters (Bactiseal?, Codman Johnson & Johnson, Raynham, MA, USA) for external ventricular drainage (EVD). However, whether Bactiseal?-EVD (B-EVD) influences the treatment of EVD-related ventriculitis remains controversial.     

What is the optimal anticoagulation in patients with a left ventricular assist device?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether there is an optimal antithrombotic management for patients supported with axial-flow left ventricular assist devices (LVADs). Altogether, more than 758 papers were found using the reported search, of which 17 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. These included seven prospective and three retrospective cohort studies with a total of 538 patients with axial-flow left ventricular assist device (LVAD) (HeartMate II, Jarvik 2000, INCOR, Thoratec assist device) implanted across the world as destination therapy or bridge to transplantation. We conclude that there is a substantial alteration of the prothrombotic profile in patients with axial-flow LVADs. These abnormalities appeared to be reversible with the removal of the device and are likely to be responsible for the high incidence of non-surgical bleeding episodes reported. Warfarin seems to offer a lower thromboembolic risk compared with unfractioned heparin or low molecular weight heparin. There are reports that suggest that managing axial-flow LVAD without anticoagulation, after major bleeding complications, is possible but in all probability, these papers are subject to publication bias as poor outcomes are unlikely to have been reported. All patients with axial-flow LVAD, showed severely impaired platelet function at point of care tests. The use of warfarin (INR target 2.5), in association with aspirin at 100?mg/day, or with point-of-care tests titrated antiplatelet therapy to inhibit 70%, seems to have the best bleeding-thrombosis, and in many cases a very small dose of aspirin of 25?mg twice a day and a dose of clopidogrel of 35?mg/day, were sufficient to achieve a reduction of the maximum aggregation to less than 30%. Finally, we would like to emphasize that such recommendations are addressed only to patients with axial-flow LVAD.     

Is there a need for the Fournier's gangrene severity index? Comparison of scoring systems for outcome prediction in patients with Fournier's gangrene

Study Type – Prognosis (prospective cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Fournier's gangrene (FG) is a rare but life‐threatening disease challenging the treating medical staff. Despite the fact that antibiotic therapy combined with surgery and intensive care surveillance are performed as standard treatment, mortality rates remain high. There have been efforts to develop a reliable tool to predict severity of the disease, not only to identify patients at highest risk of major complications or death but also to provide a target for medical teams and researchers aiming to improve outcome and to gather information for counselling patients. Laor et al. published the FG severity index (FGSI) in 1995 presenting a complex prediction score solely for patients with FG. Fifteen years later, Yilmazlar et al. suggested a new and supposedly more powerful scoring system, the Uludag FGSI (UFGSI), adding an age score and an extent of disease score to the FGSI. In the present study population we applied two scoring systems for outcome prediction that are solitarily applicable in patients with FG (FGSI, UFGSI), as well as two general scoring systems such as the established age‐adjusted Charlson Comorbidity Index (ACCI) and the recently introduced surgical Apgar Score (sAPGAR) to compare them and to test whether one system might be superior to the other. In addition, we identified potential prognostic factors in the study population. By contrast to many earlier studies, we performed a combined prospective and retrospective analysis and provided a 30‐day follow up. In the cohort of the present study, older patients with comorbidities as well as a need for mechanical ventilation and blood transfusion are at higher risk of lethal outcome. All scores are useful to predict mortality. Despite including more variables, the UFGSI does not seem to be more powerful than the FGSI. In daily routine we suggest applying ACCI and sAPGAR, as they are more easily calculated, generally applicable and well validated.

OBJECTIVE

• ? To compare four published scoring systems for outcome prediction (Fournier's gangrene severity index [FGSI], Uludag FGSI [UFGSI], age‐adjusted Charlson Comorbidity Index [ACCI] and surgical Apgar Score [sAPGAR]) and evaluate risk factors in patients with Fournier's gangrene (FG).

PATIENTS AND METHODS

• ? In all, 44 patients were analysed. The scores were applied.
• ? A Mann–Whitney U‐test, Fisher's exact test, receiver operator characteristic (ROC) analysis and Pearson correlation analysis were performed.

RESULTS

• ? The results of the present study show a significant association among FGSI (P= 0.002), UFGSI (P= 0.002), ACCI (P= 0.004), sAPGAR (P= 0.018) and death.
• ? The differences between the area under the receiver operating characteristic curve of the scores were not significant.
• ? Non‐survivors were older (P= 0.046), had a greater incidence of acute renal failure (P < 0.001) and coagulopathy (P= 0.041), were treated more often with mechanical ventilation (P= 0.001) and received more packed red blood cells (RBCs; P= 0.001).

CONCLUSION

• ? Older patients with comorbidities and need for mechanical ventilation and RBCs are at higher risk for death.
• ? In the present cohort, scores calculated easily at the bedside, such as ACCI and sAPGAR, seemed to be as good at predicting outcome in patients with FG as FGSI and UFGSI.

     

The application of a new regimen for short term sedation in the ICU (ketofol) – Case series

ObjectiveSedation is an effective component of care in ICU patients. The aim of this study was to evaluate the safety and efficacy of ketamine/propofol combination in short term sedation for the critically ill patients in ICU.DesignProspective case series study.SettingIntensive care unit (ICU) in a tertiary hospital (Kasr Al Aini).MethodsFourteen critically ill patients who were mechanically ventilated and were in need for sedation were included in this case series. An initial bolus dose (500 μg/kg) of ketamine/propofol 1:1 (ketamine 8 mg/ml and propofol 8 mg/ml) was given to all patients followed by a maintenance dose of 10 μg/kg/min and the infusion dose adjusted (in 5 μg/kg/min increments) to achieve Ramsay Sedation Scale of 4. Recorded parameters included heart rate, systolic blood pressure, Ramsay score, the need for use of noradrenalin and the recovery time from discontinuation of sedation.ResultsThe mean and standard deviation of the age of the patients was 60 ± 14.5 y and their APACHEII score ranged from 18 to 35. The median initial bolus dose of ketofol administered was 5 ml of aliquot with median infusion rate 6 ml/h (range: 4.8–7.5 ml/h) only three patients (21.4%) needed the infusion rate to be increased to achieve Ramsay score 4. Only one patient experienced hypotension due to hypovolemia secondary to internal hemorrhage.ConclusionContinuous intravenous infusion of ketofol may provide adequate and safe short term sedation (less than 24 h) for critically ill patients in the intensive care units, with rapid recovery and no clinically significant complications. Further studies with larger number of patients are required to evaluate and validate these findings.     

Gene expression analysis of human tissue from patients with cardiomyopathies: a new tool for guiding therapies in the future?

The complete sequencing of the human genome led to the development of a number of new molecular technologies. DNA microarrays represent an exciting new tool for gene expression analysis in human tissue. Measurements of the expressions of many thousands of genes in parallel is possible now. Microarrays may be used for various applications in medicine. They can be used to find novel prognostic and predictive markers as well as new disease classifications into clinically relevant subgroups. While there has been great progress in cancer research in this field, there are significantly less expression data available concerning the heart. In order to identify genes and pathways involved in the pathogenesis of cardiomyopathies, we have looked recently for alterations at cellular and molecular levels in heart tissue from cardiomyopathy patients. We showed that a special group of genes is differentially regulated in dilated cardiomyopathy. The first results in hypertrophic cardiomyopathy also showed similar findings. The surgeon's role in the clinical application of gene expression profiling is crucial. He provides a link between the patient and the laboratory scientists playing a significant role in focusing research on the clinically relevant problems. Gene expression profiles may help to better characterize the course and prognosis of the individual patient in the future. The long-term goal is to find a tool that will help to guide medical and surgical therapies in cardiomyopathies and other heart diseases.     

Does the diagnosis of detrusor overactivity affect the long-term prognosis of patients treated with a retropubic midurethral sling?

Introduction and hypothesis

There are few long-term studies on the midurethral sling (MUS) procedure in patients with preoperative detrusor overactivity (DO) and there is debate regarding the usefulness of preoperative cystometry. This study was designed to provide long-term efficacy and safety data for the Advantage MUS and to compare the outcomes in patients with pure urodynamic stress incontinence (USI) with the outcomes in patients with mixed USI and DO.

Methods

This was a retrospective consecutive case series study of 100 patients with USI (USI-only group) matched to a consecutive group of a further 100 patients with preoperative USI and DO (mixed group) treated with a retropubic MUS. Outcomes were assessed using the King’s Health Questionnaire and Patient Global Impression of Improvement questionnaire.

Results

After a mean follow up of 6 years more patients in the USI-only group described themselves as “very much better” or “much better” (86 % USI-only group vs. 57 % mixed group; p?=?0.007). Quality of life was improved at 6 years from baseline in both groups. Patients in the mixed group were more likely to complain of urgency (69 % vs. 42 %; p?=?0.0007) which was more likely to be severe (34 % vs. 10 %; p?=?0.004). A repeat MUS procedure was needed in 1 % of patients and 0.6 % needed surgical removal of the MUS for persistent troublesome pain.

Conclusions

This study suggests that the preoperative diagnosis of DO affects the long-term patient-perceived outcome of the MUS procedure. However, most patients have significant long-term improvement in quality of life.

     

Optimal timing for heart transplantation in patients bridged with left ventricular assist devices: Is timing of the essence?

ObjectivesDue to the scarcity of donor hearts to meet recipient demands, more than 40% of heart transplants are performed in patients bridged to transplant (BTT) with a left ventricular assist device (LVAD). The objective of this study was to determine the effect of BTT duration with an LVAD on posttransplant outcomes.MethodsFrom 2009 to 2014, we identified 2639 fee-for-service Medicare patients who underwent a primary heart transplants with 1186 (45%) patients BTT with an LVAD. The LVAD patients were stratified as BTT ≤31 days (n = 28 [2.4%]), BTT 31-365 days (n = 748 [63.1%]), and BTT >365 days (n = 409 [34.5%]). Patients went directly to heart transplantation and were not bridged in 1453 cases (55%). LVAD duration was analyzed dichotomously and as a continuous variable with adjusted overall survival as the primary end point.ResultsAll-cause mortality was significantly worse in patients who were BTT <31 days. Survival at 30 days was 81.5% for BTT <31 days, 94% for BTT 31 to 365 days, 95% for BTT >365 days, and 94% for no BTT. At 1 year, survival was 74% for BTT <31 days, 85% for BTT 31 to 365 days, 88% for BTT >365 days, and 89% for no BTT (P = .018). When LVAD duration was analyzed as a continuous variable, patients BTT with an LVAD <34 days had significantly increased mortality.ConclusionsPatients who underwent heart transplantation within the first month of BTT with an LVAD had significantly increased mortality. However, there was no survival difference among patients who were BTT with an LVAD longer than 31 days.     

Should axillary ultrasound be used in patients with a preoperative diagnosis of ductal carcinoma in situ?

BackgroundWe evaluated the usefulness of axillary ultrasound (US) in patients with core biopsy–proven ductal carcinoma in situ (DCIS).MethodsPreoperative axillary US, fine-needle aspiration (FNA), and sentinel lymph node (SLN) data from women with DCIS were reviewed.ResultsEighty-two women with DCIS underwent axillary US. In 16 women (19.5%) US was abnormal; however, FNA was negative in all cases. Sixty-one women (74%) underwent SLN surgery; 2 were positive for macrometastasis (3%) and 1 had isolated tumor cells. None of them had an abnormal US. Axillary US did not change the management in any of the cases.ConclusionsAxillary US and FNA did not change the management in any of the 82 cases. In women with a core biopsy diagnosis of DCIS, positive nodes are uncommon and unlikely to be detected by axillary US. Routine preoperative axillary US is not recommended for pure DCIS on core biopsy.     

Ready for the frontline: is early thoracoscopic decortication the new standard of care for advanced pneumonia with empyema?

Video-assisted thoracoscopic decortication (VATD) has been established as an effective and potentially less morbid alternative to open thoracotomy for the management of empyema. However, the timing and role of VATD for advanced pneumonia with empyema is still controversial. In assessing surgical outcome, the authors reviewed their VATD experience in children with empyema or empyema with necrotizing pneumonia. The charts of 42 children who underwent VATD at our institution between July 2001 and July 2005 were retrospectively reviewed for surgical outcome. For purposes of analysis, patients were cohorted into four classes with increasing severity of pneumonia: 1 (-) intraoperative pleural fluid cultures, (-) necrotizing pneumonia, 18 (43%); 2 (+) pleural fluid cultures, (-) necrotizing pneumonia, 10 (24%); 3 (-) pleural fluid cultures, (+) necrotizing pneumonia, 6 (14%); 4 (+) pleural fluid cultures, (+) necrotizing pneumonia, 8 (19%). A P value of < 0.05 via Student's t test or Fischer's exact analysis was considered an indicator of significant difference in the comparison of group outcomes. VATD was successfully completed in all 42 patients with no mortality and without significant morbidity (82% had less than 20 cc blood loss). There was found to be no significant difference (p = NS) in time to surgical discharge (removal of chest tube) among all groups. Hospital length of stay postsurgery was found to be significantly increased between 1 and 4 (6 days vs 9 days; P = 0.038). 14/14 (100%) of children with necrotizing pneumonia were found to have evidence of lung parenchymal preservation with improved aeration on follow-up CT scan and/or chest x-rays. The authors conclude that early VATD in children with advanced pneumonia with empyema is indicated to avoid unnecessarily lengthy hospitalization and prolonged intravenous antibiotic therapy. Furthermore, early VATD can be safely performed in various stages of advanced pneumonia with empyema, promoting lung salvage, and accelerating clinical recovery.     

Does the Banff rejection activity index predict outcome in patients with early acute cellular rejection following liver transplantation?

The Banff schema incorporates a semiquantitative scoring system for grading of acute cellular rejection (ACR) of the liver allograft. The Banff rejection activity index (RAI) comprises 3 components scored from 0 to 3: venous endothelial inflammation (E); bile duct damage (B); and portal inflammation (P); the scores are combined to an overall score (the RAI). The purpose of this research was to determine the prognostic value of the Banff RAI score in predicting the response to increased immunosuppression and the long-term outcome of the graft. A retrospective study was done of patients undergoing primary liver transplantation between January 2000 and October 2004 with tacrolimus-based immunosuppression; 495 patients were included, 231 had histologically-confirmed ACR, 193 responded to 1 cycle of high-dose steroids. There was no correlation between the total RAI score and response to steroids, resistant rejection, development of chronic rejection, or graft survival. The E score was related to patient survival, a lower score being associated with a worse outcome (P = 0.048). In multivariable analysis, serum bilirubin, serum aspartate aminotransferase, and E score were significant predictors of death (P = 0.012). In univariable analysis, B score and bilirubin were significantly related to "resistant rejection" (P = 0.018 and 0.002, respectively), but only bilirubin was significant in multivariable analysis (logistic regression). In conclusion, although the Banff RAI score is a useful marker of the severity of rejection, neither the total RAI score nor any of the individual components correlated with response to steroids or graft survival.