Platypnea-orthodeoxia due to osteoporosis and severe kyphosis: a rare cause for dyspnea and hypoxemia

Platypnea orthodeoxia is a rare disorder characterized by dyspnea and arterial desaturation, exacerbated by the upright position and relieved when the subject is recumbent. We report the case of a 79-year old woman admitted to hospital with dyspnea who was thought to have restrictive ventilatory impairment due to osteoporosis and severe kyphosis. Interestingly, the dyspnea was aggravated in the upright position, whereas the symptoms improved in the supine position. Arterial blood gas analysis confirmed orthodeoxia. The lung function test showed only a mild obstructive and restrictive ventilation disorder. Echocardiography revealed a patent foramen ovale and an aneurysm of the atrial septum protruding into the left atrium, despite normal right atrial pressure. Transesophageal echocardiography showed a prominent Eustachian valve guiding a blood flow from the inferior vena cava directly onto the atrial septum, thereby pushing open the patent foramen ovale. Contrast-enhanced echocardiography confirmed a spontaneous right-to-left shunt through the patent foramen ovale. It was assumed that the platypnea-orthodeoxia was caused by a prominent Eustachian valve redirected to the patent foramen ovale as a result of severe osteoporosis with subsequent thoracic kyphosis and a change in the position of the entire heart. The patient underwent permanent transcatheter closure of the patent foramen ovale after hemodynamic assessment had confirmed a significant right-to-left shunt through it. After the procedure the arterial oxygen pressure increased significantly in the upright position and dyspnea improved

Intraoperative flow measurements in gastroepiploic grafts using pulsed Doppler 1

Abstract Objective: The patency of a pedicled right gastroepiploic artery (RGEA) graft can be compromised by intraoperative twists, kinks or spasms. Therefore, a systematic flow assessment was made in RGEA grafts and was compared with similar measurements made in other types of bypass conduits. Methods: Intraoperative pulsed Doppler flowmeter measurements obtained in a series of 556 consecutive patients undergoing at least one coronary bypass grafting onto the right coronary system were studied. Eighty-five RGEA grafts were compared with 1427 bypass grafts implanted in the same group of patients and consisted of the following conduits: 442 left internal mammary (LIMA), 149 right internal mammary (RIMA), 831 greater saphenous vein (GSV) and five inferior epigastric (EPIG) grafts. Sequential grafts were excluded from the analysis. Results: Flow measurements and Doppler waveforms were abnormal and required graft repositioning, and the addition of a distal graft or intragraft papaverine injection (only in GSVs) in 29 cases (2.0% of all grafts). These graft corrections were necessary in 5.9% RGEAs, 3.4% LIMAs, 2.0% RIMAs, and 0.7% GSVs (P Ͻ 0.001). The relative risk for graft correction was eight times higher for RGEAs than for GSVs (P = 0.002). Flow increased from 8 ± 2 to 54 ± 5 ml/min (P Ͻ 0.0001). Flow data were significantly influenced by the type of run-off bed (P Ͻ 0.001), the measurements obtained in grafts implanted onto the right coronary artery and the left anterior descending artery being superior. Flows in RGEAs, however, were comparable with values obtained in other grafts implanted onto the same recipient coronary artery. Conclusions: A significantly higher incidence of graft malpositioning caused inadequate flows in RGEAs. However, normal flow values could be restored simply by assigning a better graft orientation under pulsed Doppler flowmeter control. Overall flow capacity of the RGEA did not differ from values obtained in other arterial and venous grafts implanted onto the same recipient arteries

Clinical profiles of patients colonized or infected with extended-spectrum beta-lactamase producing Enterobacteriaceae isolates: a 20 month retrospective study at a Belgian University Hospital

<p>Abstract</p> <p>Background</p> <p>Description of the clinical pictures of patients colonized or infected by ESBL-producing <it>Enterobacteriaceae </it>isolates and admitted to hospital are rather scarce in Europe. However, a better delineation of the clinical patterns associated with the carriage of ESBL-producing isolates may allow healthcare providers to identify more rapidly at risk patients. This matter is of particular concern because of the growing proportion of ESBL-producing <it>Enterobacteriaceae </it>species isolates worldwide.</p> <p>Methods</p> <p>We undertook a descriptive analysis of 114 consecutive patients in whom ESBL-producing <it>Enterobacteriaceae </it>isolates were collected from clinical specimens over a 20-month period. Clinical data were obtained through retrospective analysis of medical record charts. Microbiological cultures were carried out by standard laboratory methods.</p> <p>Results</p> <p>The proportion of ESBL-producing <it>Enterobacteriaceae </it>strains after exclusion of duplicate isolates was 4.5% and the incidence rate was 4.3 cases/1000 patients admitted. Healthcare-associated acquisition was important (n = 104) while community-acquisition was less frequently found (n = 10). Among the former group, two-thirds of the patients were aged over 65 years and 24% of these were living in nursing homes. Sixty-eight (65%) of the patients with healthcare-associated ESBL, were considered clinically infected. In this group, the number and severity of co-morbidities was high, particularly including diabetes mellitus and chronic renal insufficiency. Other known risk factors for ESBL colonization or infection such as prior antibiotic exposure, urinary catheter or previous hospitalisation were also often found. The four main diagnostic categories were: urinary tract infections, lower respiratory tract infections, septicaemia and intra-abdominal infections. For hospitalized patients, the median hospital length of stay was 23 days and the average mortality rate during hospitalization was 13% (Confidence Interval 95%: 7-19). <it>Escherichia coli</it>, by far, accounted as the most common ESBL-producing <it>Enterobacteriaceae </it>species (77/114; [68%]) while CTX-M-1 group was by far the most prevalent ESBL enzyme (n = 56).</p> <p>Conclusion</p> <p>In this retrospective study, the clinical profiles of patients carrying healthcare-associated ESBL-producing <it>Enterobacteriacae </it>is characterized by a high prevalence rate of several major co-morbidities and potential known risk factors. Both, the length of hospital stay and overall hospital mortality rates were particularly high. A prospective case-control matched study should be designed and performed in order to control for possible inclusion bias.</p

What's in a name : name suppression and the need for public interest

OBJECTIVES: Following two studies conducted in 2005 and 2011, a third prevalence survey of multidrug-resistant microorganisms (MDRO) was organised in Belgian nursing homes (NHs) using a similar methodology. The aim was to measure the prevalence of carriage of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), extended-spectrum β-lactamase producing Enterobacteriaceae (ESBLE) and carbapenemase-producing Enterobacteriaceae (CPE) in NH residents. Risk factors for MDRO carriage were also explored. METHODS: Up to 51 randomly selected residents per NH were screened for MDRO carriage by trained local nurses between June and October 2015. Rectal swabs were cultured for ESBLE, CPE and VRE, while pooled samples of nose, throat and perineum and chronic wound swabs were obtained for culture of MRSA. Antimicrobial susceptibility testing, molecular detection of resistance genes and strain genotyping were performed. Significant risk factors for MDRO colonization MDRO was determined by univariate and multivariable analysis. RESULTS: Overall, 1447 residents from 29 NHs were enrolled. The mean weighted prevalence of ESBLE and MRSA colonization was 11.3% and 9.0%, respectively. Co-colonization occurred in 1.8% of the residents. VRE and CPE carriage were identified in only one resident each. Impaired mobility and recent treatment with fluoroquinolones or with combinations of sulphonamides and trimethoprim were identified as risk factors for ESBLE carriage, while for MRSA these were previous MRSA carriage/infection, a stay in several different hospital wards during the past year, and a recent treatment with nitrofuran derivatives. Current antacid use was a predictor for both ESBL and MRSA carriage. CONCLUSIONS: In line with the evolution of MRSA and ESBL colonization/infection in hospitals, a decline in MRSA carriage and an increase in ESBLE prevalence was seen in Belgian NHs between 2005 and 2015. These results show that a systemic approach, including surveillance and enhancement of infection control and antimicrobial stewardship programs is needed in both acute and chronic care facilities

Low frequency of asymptomatic carriage of toxigenic Clostridium difficile in an acute care geriatric hospital: prospective cohort study in Switzerland

Abstract Background The role of asymptomatic carriers of toxigenic Clostridium difficile (TCD) in nosocomial cross-transmission remains debatable. Moreover, its relevance in the elderly has been sparsely studied. Objectives To assess asymptomatic TCD carriage in an acute care geriatric population. Methods We performed a prospective cohort study at the 296-bed geriatric hospital of the Geneva University Hospitals. We consecutively recruited all patients admitted to two 15-bed acute-care wards. Patients with C. difficile infection (CDI) or diarrhoea at admission were excluded. First bowel movement after admission and every two weeks thereafter were sampled. C. difficile toxin B gene was identified using real-time polymerase chain-reaction (BD MAXTMCdiff). Asymptomatic TCD carriage was defined by the presence of the C. difficile toxin B gene without diarrhoea. Results A total of 102 patients were admitted between March and June 2015. Two patients were excluded. Among the 100 patients included in the study, 63 were hospitalized and 1 had CDI in the previous year, and 36 were exposed to systemic antibiotics within 90 days prior to admission. Overall, 199 stool samples were collected (median 2 per patient, IQR 1-3). Asymptomatic TCD carriage was identified in two patients (2 %). Conclusions We found a low prevalence of asymptomatic TCD carriage in a geriatric population frequently exposed to antibiotics and healthcare. Our findings suggest that asymptomatic TCD carriage might contribute only marginally to nosocomial TCD cross-transmission in our and similar healthcare settings

Epidemiology of extended-spectrum beta-lactamase-producing Enterobacteriaceae amongst old persons in the healthcare setting

Antimicrobial resistance is a major health concern in human medicine both in the healthcare setting and in the community. While the epidemiology of multidrug-resistant gram-positive bacteria has been extensively described in the medical literature, clinical data for multidrug-resistant gram-negative bacteria (MDR-GNB) have less frequently been reported. Since the eighties, extended-spectrum beta-lactamase production has been recognized as one of the most important mechanism of antibiotic resistance among Enterobacteriaceae (ESBLE). This work aimed to improve our understanding of the epidemiology of ESBLE with a special focus among older adults in the healthcare setting. Because asymptomatic colonization has been recognized as the first step before infection and as a potential reservoir for cross-transmission, our major aims were to define prevalence and clinical characteristics of patients colonized in the intestinal flora by ESBLE in three different settings: the hospital, nursing homes (NH) and the community. In certain parts of this work, we did also extend our focus to two other bacteria of interest, namely: methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enteroccci (VRE) in order to assess the risks of co-colonization and compare risk factors. The introduction (chapter 1) will define ESBLE and give some insights in the global trends of MDR-GNB. The second chapter reports data of a 20-month retrospective study performed at a Belgian University hospital between January 2008 and Augustus 2009. The global proportion of ESBLE recovered from clinical samples was 4.5%. Data from 114 consecutive patients colonized or infected by ESBLE were analysed. Among the 68 patients (65%) with a presumed healthcare-associated acquired infection, the four main diagnoses were urinary tract infection, lower respiratory tract infection, bloodstream infection and intra-abdominal infection. This study highlighted that ESBLE carriers (whether colonized or infected) had a high number of co-morbidities (for examples, diabetes and chronic renal insufficiency), bladder catheter, antibiotic exposure or previous hospitalization. We also reported an increase length of hospital stay and a higher intra-hospital mortality among this group of patients. Interestingly, two-thirds of the patients were aged over 65 years and were referred from a nursing home. The retrospective design and the lack of a control group were limiting factors, reasons why a prospective observational study was designed in a specific unit admitting old frail patients. The third chapter presents the results of a one year prospective cohort study performed amongst patients admitted to a geriatric evaluation and management unit between January 2010 and January 2011. The primary aim of that study was to determine the prevalence and potential predictors of ESBLE asymptomatic carriage amongst 337 consecutive patients admitted to the acute geriatric unit. The overall prevalence of ESBLE colonization was 11.6% (95% CI: 8.2-15.0), versus 7.5% for MRSA (95%CI: 4.6-10.4). The three main predictors of ESBLE carriage were: a low functional status, prior multiple contacts with the hospital within the previous year and the presence of a chronic catheter. Using a second set of screening samples at discharge, we reported an incidence density of 1.77 new cases of ESBLE colonization per 1000 patient-days. The rate of co-colonization was low, less than 1% and only 2 cases of VRE were observed. No increase of in-hospital mortality or of ESBLE-related nosocomial infection rate was observed but the study was probably underpowered. Low functional status was a common risk factor for ESBLE and MRSA colonization, highlighting the need to reinforce infection control measures and to reduce antibiotic selection pressure among this old frail population. In that study, patients referred from NH were four times more at risk to be colonized by MRSA while the risk to be ESBLE carriers was similar compared to patients admitted from the community. Nevertheless recent reports have suggested that NHs may account as a large reservoir of multi-drug resistant microorganisms (MDRO), although large variations in prevalence have been reported in the literature. The fourth chapter addresses the epidemiology of ESBLE among residents from a random sample of 60 Belgian NH. A point-prevalence survey was carried out between June 2011 and October 2011 in order to assess the prevalence and determinants of asymptomatic colonization by ESBLE, MRSA and VRE amongst 2791 NH residents. The weighted prevalence of ESBLE and MRSA carriage were 6.2% (95%CI: 5.6-6.9) and 12.2% (95%CI: 11.3-13.1), respectively. No cases of VRE were found. The best predictors of colonization by ESBLE were male gender, antibiotic exposure in the past 3 months and a low level of mobility. Risk factors for MRSA carriage included: male gender, a low functional status, pressure sores, antacid use and bladder catheter. The proportion of MRSA carriers decreased by 6.8% in comparison to a similar survey carried out in 2005. Furthermore, both MRSA and ESBLE carriage trends in NH were very similar to those observed in Belgian acute care hospitals over the same period in the setting of a national surveillance programme. These results emphasized the need for a global coordination of the surveillance of MDRO within and between chronic and acute care medical sectors. The fifth chapter reports the results from a point-prevalence survey in a sample of community-dwelling old persons aged over 80 years and recruited from the population-based BelFrail cohort study. During two study periods (2010 and 2011), 378 (67%) urinary samples were obtained from the 567 initially recruited participants in 2008. A total of 357 bacteria were isolated (212 samples), mainly Enterococcus spp., Escherichia coli (E. coli) and Staphylococcus spp. Among the 212 samples (56%) that grew with at least one bacteria, only 3 patients harboured an ESBL-producing E. coli (crude prevalence: 0.79% [95%CI: 0.16-2.30]). Due to the small number of patients carrying ESBLE, analysis with individual risk factors could not be performed. Results from published studies including patients from the community are reported at the end of this chapter. Chapter 6 summarizes the results of a one year prospective observational study, performed after hospital admission in a geriatric ward, with as primary goal to assess among MDRO colonized patients four geriatric outcomes: functional decline rate, nursing home admission rate, readmission to hospital and all-cause mortality. Among 320 followed patients through phone-calls, no increased risk for each individual selected outcome was noticed. Several limits when interpreting data are mentioned: the small sample size, the lack of repeated screening swabs during follow-up and the selected “high-risk” profile of included patients. Chapter 7 describes the use of a clinical score including five items aimed to identify, at admission to hospital, patients at risk of colonization by MRSA. The study was undertaken during a one year period (2006-2007) and included 221 patients admitted to a geriatric department. A crude prevalence of 10% (95%CI: 6-14%) was observed. The 5 criteria were: being aged over 87 years, known antecedents of previous MRSA carriage, multiple hospital stay(s) in the past year, chronic wounds, previous antibiotic exposure and long-term catheter use. Overall, the high negative predictive value (97%) of this simple clinical score was found as useful tool to avoid ordering laboratory test for screening MRSA colonization in patients with none of those 5 criteria upon admission to hospital. Similar data are reported for the prospective cohort study designed to detect ESBLE at admission in chapter 3. Chapter 8 reports that in a non-outbreak period, the prevalence of Clostridium difficile (CD) among asymptomatic patients was extremely low. The diagnostic method (rectal swabs in place of stool samples) that was used and pre-analytic problems may also explain in part this low rate. For these reasons, screening of CD carriage among the residents was finally not considered in the NH survey. The last chapter discusses and compares the results of our different surveys with those reported in other studies and by national or European surveillance networks. It critically describes the limitations of all studies and it aims to provide the reader with some practical clinical applications. Finally, a short perspective addresses the opportunities for further studies in the future.(MED 3) -- UCL, 201

Bio-impedance Sensor Technology for Robot-Assisted Vitreo-retinal Surgery

At present, vitreoretinal surgery is performed purely manually by highly specialized, welltrained surgeons. The surgeons need superior handeye coordination and precise positioning. When applying even small forces tangential to the surface of the eye, e.g. by means of the inserted instruments, the eye rotates and a different part of the eye becomes visible under the microscope. Microsurgeons are trained to pivot the instruments around the incision point so as to keep the eye from rotating. However, there is a limit to the surgeon's ability to perform pure pivotal motion. Furthermore small vibrations by the surgeon's hand (physiological tremor) are amplified by the leverage effect, resulting in larger vibrations of the instrument tip. It is thus extremely difficult to maintain a stable position down at the retinal surface. All targets are extremely small - ranging from 5 to 500 microns - and fragile. Tremor not only complicates reaching the required precision, it also causes the eye to rotate undeliberately, which results in surgeons aiming on a moving target. Furthermore, the surgeon is forced to work under very tight spatial constraints. Overall the surgeons are under very stringent requirements on safety and reliability as damage to the delicate retina leads to blind spots in the patient's vision and causes partial or full blindness. Within the framework of this PhD robotassisted technology will be developed to improve vitreoretinal surgery in terms of reliability and performance. More in particular the focus is on the development of sensorbased control algorithms that making use of sensory inputs such as e.g. force, proximity, oct, stereocamera, provide various operating modes that allow microsurgeons to operate in a comfortable and reliable manner. Shared control algorithms will be developed specifically for this pplications. Through these methods guidance and motion compensation is offered to the surgeon. Maximal use of surgical skill is possible as the envisioned shared control methods are fully compatible with surgeon input commands. Apart from sensordevelopment and sensorintegration, this work will progress humanrobot interaction and surgical skill in a realistic and demanding scenario. The work foresees in ample clinical validation on exvivo setups.status: publishe