How I do it: transapical cannulation for acute type-A aortic dissection

Aortic dissection is the most frequently diagnosed lethal disease of the aorta. Half of all patients with acute type-A aortic dissection die within 48 hours of presentation. There is still debate as to the optimal site of arterial cannulation for establishing cardiopulmonary bypass in patients with type-A aortic dissection

Early impact of aortic wrapping on patients undergoing aortic valve replacement with mild to moderate ascending aorta dilatation

<p>Abstract</p> <p>Background</p> <p>The management of mild to moderate dilatation of the ascending aorta of less than 5 cm is controversial, particularly when concomitant surgical correction of aortic valve is required. We investigate the impact of a simple method of aorta reduction using Dacron graft wrapping during aortic valve replacement on the rest of the aorta.</p> <p>Methods</p> <p>We studied 14 patients who had ascending aorta dilatation of 4-5 cm before undergoing aortic wrapping during their aortic valve replacement and compared with their post-operative imaging within a month.</p> <p>Results</p> <p>The diameters of the ascending aorta wrapped with the Dacron graft were significantly reduced within 4 weeks after surgery from 44.7 ± 2.6 to 33.6 ± 3.9 mm (p < 0.001). This was associated with significant reduction in the diameter of rest of ascending aorta: coronary sinuses (from 37.9 ± 4.9 mm to 33.3 ± 6.1 mm; p < 0.001), sinotubular junction (from 33.2 ± 4.7 mm to 30.6 ± 4.4 mm, p = 0.02), and aortic arch (from 34.7 ± 4.3 mm to 32.6 ± 4.1 mm, p = 0.03).</p> <p>Conclusions</p> <p>Reduction of ascending aortic dilatation by wrapping with a Dacron graft in this preliminary study is associated with favourable early reversed aortic remodelling. This supports the hypothesis that correction of mild-moderate dilatation of the ascending aorta with Dacron wrapping at the time of aortic valve surgery may prevent the progression of the dilatation, although the long-term study on a larger population is needed to confirm its benefits.</p

Measuring the effect of enhanced cleaning in a UK hospital : a prospective cross-over study

Increasing hospital-acquired infections have generated much attention over the last decade. There is evidence that hygienic cleaning has a role in the control of hospital-acquired infections. This study aimed to evaluate the potential impact of one additional cleaner by using microbiological standards based on aerobic colony counts and the presence of Staphylococcus aureus including meticillin-resistant S. aureus. We introduced an additional cleaner into two matched wards from Monday to Friday, with each ward receiving enhanced cleaning for six months in a cross-over design. Ten hand-touch sites on both wards were screened weekly using standardised methods and patients were monitored for meticillin-resistant S. aureus infection throughout the year-long study. Patient and environmental meticillin-resistant S. aureus isolates were characterised using molecular methods in order to investigate temporal and clonal relationships. Enhanced cleaning was associated with a 32.5% reduction in levels of microbial contamination at handtouch sites when wards received enhanced cleaning (P < 0.0001: 95% CI 20.2%, 42.9%). Near-patient sites (lockers, overbed tables and beds) were more frequently contaminated with meticillin-resistant S. aureus/S. aureus than sites further from the patient (P = 0.065). Genotyping identified indistinguishable strains from both handtouch sites and patients. There was a 26.6% reduction in new meticillin-resistant S. aureus infections on the wards receiving extra cleaning, despite higher meticillin-resistant S. aureus patient-days and bed occupancy rates during enhanced cleaning periods (P = 0.032: 95% CI 7.7%, 92.3%). Adjusting for meticillin-resistant S. aureus patient-days and based upon nine new meticillin-resistant S. aureus infections seen during routine cleaning, we expected 13 new infections during enhanced cleaning periods rather than the four that actually occurred. Clusters of new meticillin-resistant S. aureus infections were identified 2 to 4 weeks after the cleaner left both wards. Enhanced cleaning saved the hospital £30,000 to £70,000.Introducing one extra cleaner produced a measurable effect on the clinical environment, with apparent benefit to patients regarding meticillin-resistant S. aureus infection. Molecular epidemiological methods supported the possibility that patients acquired meticillin-resistant S. aureus from environmental sources. These findings suggest that additional research is warranted to further clarify the environmental, clinical and economic impact of enhanced hygienic cleaning as a component in the control of hospital-acquired infection

Aortic dissection at the University hospital of the West Indies: A 20-year clinicopathological study of autopsy cases

<p>Abstract</p> <p>Background</p> <p>An autopsy study of aortic dissection (AD) at our institution was previously reported. In the approximately 20 years since then, however, many aspects of diagnosis and treatment of this disease have changed, with a fall in mortality reported in many centers around the world. An impression amongst our pathologists that, there might be an increase in the prevalence of AD in the autopsy service at our hospital, since that earlier report, led to this repeated study, in an attempt to validate that notion. We also sought to identify any changes in clinicopathological features between the two series or any occurring during this study period itself.</p> <p>Findings</p> <p>All cases of AD identified at autopsy, during the 20-year period since the conclusion of the last study, were collected and pertinent clinical and pathological data were analyzed and compared, both within the two decades of this study period and against the results of the last study.</p> <p>Fifty-six cases comprised this study group including 36 males and 20 females, with a mean age of 63.9 years. There were, more patients in the second decade (n = 33; 59%) compared with the first decade (n = 23; 41%). Hypertension as a risk factor was identified in 52 (93%) cases and rupture occurred in 49 (88%) cases. A clinical diagnosis of AD was considered prior to surgery or autopsy in 25 (45%) cases overall, more during the second decade. Surgery was attempted in 25% of all cases with an increase in the second decade compared with the first.</p> <p>Conclusions</p> <p>Compared with the earlier review, a variety of changes in the profile of patients with AD in the autopsy service has been noted, including a reversal in the female predominance seen previously. Other observations include an increase in cases where the correct clinical diagnosis was considered and in which surgical treatment was attempted, changes also evident when the second decade of the present study was compared with the earlier decade. Overall, there were many positive trends. However, areas that could still be improved include an increased index of suspicion for the diagnosis of AD and perhaps in the initiation of treatment, earlier, in those cases where the correct diagnosis was considered.</p

Major bleeding during negative pressure wound/V.A.C.® - therapy for postsurgical deep sternal wound infection - a critical appraisal

Negative-pressure wound therapy, commercially known as vacuum-assisted closure (V.A.C.®) therapy, has become one of the most popular (and efficacious) interim (prior to flap reconstruction) or definite methods of managing deep sternal wound infection. Complications such as profuse bleeding, which may occur during negative-pressure therapy but not necessarily due to it, are often attributed to a single factor and reported as such. However, despite the wealth of clinical experience internationally available, information regarding certain simple considerations is still lacking. Garnering information on all the factors that could possibly influence the outcome has become more difficult due to a (fortunate) decrease in the incidence of deep sternal wound infection. If more insight is to be gained from fewer clinical cases, then various potentially confounding factors should be fully disclosed before complications can be attributed to the technique itself or improvements to negative-pressure wound therapy for deep sternal wound infection can be accepted as evidence-based and the guidelines for its use adapted. The authors propose the adoption of a simple checklist in such cases

Healing of surgical site after total hip and knee replacements show similar telethermographic patterns

BACKGROUND: Isolated reports indicate the efficacy of infrared thermography for monitoring wound healing and septic complications, but no long-term analysis has ever been performed on this, and there are no data on the telethermographic patterns of surgical site healing after uncomplicated total hip prosthesis and after knee prosthesis. MATERIALS AND METHODS: In this prospective, observational, nonrandomized cohort study, two groups with forty consecutive patients each, who were operated on respectively for total hip and for total knee replacements, underwent telethermographic examination of the operated and contralateral joints prior to and at fixed intervals for up to 1\ua0year after uncomplicated surgery. A digital, portable telethermocamera and dedicated software were used for data acquisition and processing. RESULTS: No thermographic difference was observed preoperatively between the affected side and the contralateral side in both groups. After the intervention, a steep increase in the temperature of the operated joint was recorded after total hip replacement and after knee replacement, with a peak mean differential temperature measured three days postoperatively between the operated and unoperated joint of 3.1\ua0\ub1\ua00.8\ub0C after total hip replacement, and 3.4\ua0\ub1\ua00.7\ub0C after total knee replacement. Thereafter, the mean differential temperature declined slowly to 0.7\ua0\ub1\ua01.1\ub0C and to 0.5\ua0\ub1\ua01.3\ub0C at 60\ua0days, and to 0.0\ua0\ub1\ua01.0\ub0C and -0.1\ua0\ub1\ua01.1\ub0C 90\ua0days post-operatively, respectively. No further changes were observed for up to 1\ua0year after surgery. Results were similar when comparing the average telethermographic values of an elliptical area where the main axis corresponded to the surgical wound. CONCLUSIONS: The surgical sites after uncomplicated total hip or total knee replacement show similar telethermographic patterns for up to 1\ua0year from surgery, and can easily be monitored using a portable, digital, telethermocamera

Plasmid-mediated Quinolone Resistance among Non-TyphiSalmonella enterica Isolates, USA

We determined the prevalence of plasmid-mediated quinolone resistance mechanisms among non-Typhi Salmonella spp. isolated from humans, food animals, and retail meat in the United States in 2007. Six isolates collected from humans harbored aac(6′)Ib-cr or a qnr gene. Most prevalent was qnrS1. No animal or retail meat isolates harbored a plasmid-mediated mechanism

Aortic stiffness in aortic stenosis assessed by cardiovascular MRI: a comparison between bicuspid and tricuspid valves

Objectives To compare aortic size and stiffness parameters on MRI between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients with aortic stenosis (AS). Methods MRI was performed in 174 patients with asymptomatic moderate-severe AS (mean AVAI 0.57 ± 0.14 cm2/m2) and 23 controls on 3T scanners. Valve morphology was available/analysable in 169 patients: 63 BAV (41 type-I, 22 type-II) and 106 TAV. Aortic cross-sectional areas were measured at the level of the pulmonary artery bifurcation. The ascending and descending aorta (AA, DA) distensibility, and pulse wave velocity (PWV) around the aortic arch were calculated. Results The AA and DA areas were lower in the controls, with no difference in DA distensibility or PWV, but slightly lower AA distensibility than in the patient group. With increasing age, there was a decrease in distensibility and an increase in PWV. After correcting for age, the AA maximum cross-sectional area was higher in bicuspid vs. tricuspid patients (12.97 [11.10, 15.59] vs. 10.06 [8.57, 12.04] cm2, p < 0.001), but there were no significant differences in AA distensibility (p = 0.099), DA distensibility (p = 0.498) or PWV (p = 0.235). Patients with BAV type-II valves demonstrated a significantly higher AA distensibility and lower PWV compared to type-I, despite a trend towards higher AA area. Conclusions In patients with significant AS, BAV patients do not have increased aortic stiffness compared to those with TAV despite increased ascending aortic dimensions. Those with type-II BAV have less aortic stiffness despite greater dimensions. These results demonstrate a dissociation between aortic dilatation and stiffness and suggest that altered flow patterns may play a role. Key Points • Both cellular abnormalities secondary to genetic differences and abnormal flow patterns have been implicated in the pathophysiology of aortic dilatation and increased vascular complications associated with bicuspid aortic valves (BAV). • We demonstrate an increased ascending aortic size in patients with BAV and moderate to severe AS compared to TAV and controls, but no difference in aortic stiffness parameters, therefore suggesting a dissociation between dilatation and stiffness. • Sub-group analysis showed greater aortic size but lower stiffness parameters in those with BAV type-II AS compared to BAV type-I