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Surgical site infections (SSIs) are the most common complication after surgery for ankle fractures. This retrospective study aimed to determine the pathogens cultured in SSI and their antimicrobial susceptibility patterns to provide a recommendation for empirical therapy. Patients who underwent surgical treatment for an ankle fracture were included. Cases were screened for the occurrence of SSI and divided into superficial (short course [total of <2 weeks] of oral antibiotics) and deep SSI (surgical debridement and long course [total of >2 weeks] antibiotics). Culture results, antimicrobial susceptibility patterns, empirical antibiotic regimen, type and timing of culture collection, and treatment strategies were collected from electronic health records. In total, 81 (9%) out of 931 patients developed an SSI (39 (48%) superficial SSI and 42 (52%) deep SSI). The most common pathogens in 16 superficial SSI and 37 deep SSI with positive cultures were Staphylococcus aureus , cultured in 11 (69%) superficial SSI and 23 (62%) deep SSI, and Enterobacter cloacae species, cultured in 5 (31%) superficial SSI and 12 (32%) deep SSI. Higher frequencies of gram-negative bacteria and polymicrobial infections were found in deep SSI. It is recommended to aim for empirical treatment at gram-positive and gram-negative microorganisms in the case of both superficial and deep SSI. Level of Evidence: Prognostic, Level 2: Retrospective., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

In patients who underwent surgical myectomy for hypertrophic obstructive cardiomyopathy (HOCM), additional mitral valve repair may offer additional benefits in terms of further reducing left ventricular outflow tract (LVOT) gradients, systolic anterior motion (SAM), and mitral regurgitation (MR). We performed a systematic review of the literature to evaluate the evidence of surgical myectomy with additional secondary chordal cutting in patients with HOCM. A systematic literature search in MEDLINE and EMBASE was performed until April 2024. The primary outcome studied was postoperative echocardiographic LVOT gradient. A random effects meta-analysis of means was performed for the primary outcome. The secondary outcomes studied were postoperative residual MR grade, 30-day new permanent pacemaker implantation, and in-hospital mortality. From 1,911 unique publications, a total of 6 articles fulfilled the inclusion criteria and comprised 471 patients with a pooled mean preoperative resting LVOT gradient of 84 mm Hg (95% confidence interval [CI]: 76-91). The postoperative pooled mean LVOT gradient was 11 mm Hg (95% CI: 10-12) with a low heterogeneity ( I 2  = 44%). The residual LVOT gradient exceeding 30 mm Hg was present in nine (1%) patients. MR grade 3 or 4 at hospital discharge was present in seven (1%) patients. The 30-day new permanent pacemaker implantation rate was 7% and the in-hospital mortality was 0.4%. This systematic review and meta-analysis demonstrate that combining surgical myectomy with secondary chordal cutting can be performed safely and effectively eliminate LVOT obstruction in HOCM patients. Further studies are needed to determine the additive effectiveness of additional secondary chordal cuttings., Competing Interests: None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Background: Infective endocarditis is a severe and potentially lethal cardiac disease. Recognition of the clinical features of endocarditis, such as distant embolisation, and adequate treatment should be initiated promptly given the grim perspective of upcoming virulent pathogens., Methods: We report on our registry-based experience with outcomes of consecutive patients with infective endocarditis with distant embolisation. We aimed to describe the patient characteristics of infective endocarditis complicated by distant organ embolisation and the safety aspects of continuing endocarditis treatment at home in these patients., Results: From November 2018 through April 2022, 157 consecutive patients were diagnosed with infective endocarditis. Of them, 38 patients (24%) experienced distant embolisation, either in the cerebrum (n = 18), a visceral organ (n = 5), the lungs (n = 7) or the myocardium (n = 8). Pathogens identified in blood cultures were predominantly streptococcal variants (43%), with only one culture-negative endocarditis case. Of the 18 patients with cerebral embolisation, 12 had neurological complaints and most often discrete abnormal findings on neurological examination. Six of the 8 cardiac embolism patients experienced chest pain before admission. Visceral organ and pulmonary embolism occurred silently. Of the 38 patients with distant embolisation, 17 could be discharged earlier by providing antibiotic treatment at home without complications., Conclusion: This registry-based single-centre experience showed an incidence of distant embolisation in daily care of 24%. Cerebral and coronary embolisation provoked symptoms, while visceral emboli remained silent. Pulmonary emboli may present with inflammatory signs. Distant embolisation was not in itself a contra-indication for outpatient endocarditis@home treatment., (© 2023. The Author(s).)

Objectives: The ELANA® Heart Bypass creates a standardized sutureless anastomosis. Hereby, we investigate the influence of arteriotomy and graft size on coronary hemodynamics., Methods: A computational fluid dynamics (CFD) model was developed. Arteriotomy size (standard 1.43 mm 2 ; varied 0.94 - 3.6 mm 2 ) and graft diameter (standard 2.5 mm; varied 1.5 - 5.0 mm) were independent parameters. Outcome parameters were coronary pressure and flow, and fractional flow reserve (FFR)., Results: The current size ELANA (arteriotomy 1.43 mm 2 ) presented an estimated FFR 0.65 (39 mL/min). Enlarging arteriotomy increased FFR, coronary pressure, and flow. All reached a maximum once the arteriotomy (2.80 mm 2 ) surpassed the coronary cross-sectional area (2.69 mm 2 , i.e. 1.85 mm diameter), presenting an estimated FFR 0.75 (46 mL/min). Increasing graft diameter was positively related to FFR, coronary pressure, and flow., Conclusion: The ratio between the required minimal coronary diameter for application and the ELANA arteriotomy size effectuates a pressure drop that could be clinically relevant. Additional research and eventual lengthening of the anastomosis is advised., (© 2023. The Author(s).)

Coronary artery disease is the most common type of cardiovascular disease, leading to high mortality rates worldwide. Although the vast majority can be treated effectively and safely by medical therapy, revascularization strategies remain essential for numerous patients. Outcomes of both percutaneous coronary intervention and coronary artery bypass grafting improve in a rapid pace, resulting from technical innovation and ongoing research. Progress has been achieved by technical improvements in coronary stents, optimal coronary target and graft selection, and the availability of minimally invasive surgical strategies. Besides technical progress, evidence-based patient-tailored decision-making by the Heart Team is the basic precondition for optimal outcome. The combination of fast innovation and long-term clinical evaluations creates a dynamic field. Research outcomes should be carefully interpreted according to the techniques used and the trial's design. Therefore, more and more trial outcomes suggest that revascularization strategies should be tailored towards the specific patient. Although the European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization date from 2018 and a large variety of trial outcomes on revascularization strategies in chronic coronary syndrome have been published since, we aim to provide an updated overview within this review., (© 2022 The Authors. European Journal of Clinical Investigation published by John Wiley & Sons Ltd on behalf of Stichting European Society for Clinical Investigation Journal Foundation.)

We have presented a case of a ruptured descending aortic aneurysm that was accompanied by extreme tortuosity and a pseudocoarctation at the level of the ligamentum arteriosum. We performed successful endovascular repair, covering the left subclavian artery, using a transapical-to-femoral artery (through-and-through) guidewire technique to overcome the tortuosity, with the option to perform balloon angioplasty in the case of an increased gradient over the coarctation. In the present case report, we have underlined the role of close collaborations with aortic expertise centers., (© 2022 The Author(s).)

Objectives: In patients with deep sternal wound infection (DSWI), primary closure of the sternal bone over high negative pressure Redon drains has shown to be a safe and feasible treatment method. Addition of local gentamicin could accelerate healing and improve clinical outcomes., Methods: We conducted a randomized controlled trial to evaluate the effectiveness of local gentamicin in the treatment of DSWI. In the treatment group, collagenous carriers containing gentamicin were left between the sternal halves during sternal refixation. In the control group, no local antibiotics were used. Primary outcome was hospital stay. Secondary outcomes were mortality, reoperation, wound sterilization time, time till removal of all drains and duration of intravenous antibiotic treatment., Results: Forty-one patients were included in the trial of which 20 were allocated to the treatment group. Baseline characteristics were similar in both groups. Drains could be removed after a median of 8.5 days in the treatment group and 14.5 days in the control group (P-value: 0.343). Intravenous antibiotics were administered for a median of 23.5 days in the treatment group and 38.5 days in the control group (P-value: 0.343). The median hospital stay was 27 days in the treatment group and 28 days in the control group (P-value: 0.873). Mortality rate was 10% in the treatment group and 9.5% in the control group (P-value: 0,959). No side effects were observed., Conclusions: This randomized controlled trial showed that addition of local gentamicin in the treatment of DSWI did not result in shorter length of stay., Clinical Trial Registration Number: 2014-001170-33., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: The ELANA Heart Bypass System is a new sutureless technique for coronary anastomoses. A titanium clip connects the graft with the coronary artery, whereafter the arteriotomy is performed by excimer laser. Since this anastomotic construction evidently differs from the standard hand-sewn anastomosis, we aim to evaluate the process of anastomotic healing and remodeling. Methods: Preclinical evaluation of anastomotic remodeling in 42 pigs who underwent off-pump left internal mammary artery to left anterior descending artery anastomosis by either the ELANA Heart Bypass ( n  = 24) or the hand-sewn ( n  = 18) technique. Anastomotic remodeling was evaluated by scanning electron microscopy and histology in short-term follow-up intervals up to 3 months. Anastomotic patency is determined by coronary angiography at latest follow-up before termination. Results: The nonendothelial surface of both the ELANA and the hand-sewn anastomoses were covered with neointima from 14 days onwards. Only half the amount of intima hyperplasia was present in the anastomotic surface of the patent ELANA anastomosis, compared with the hand-sewn anastomosis (98 [48-1358] vs 218 [108-296] µm, P  = 0.001). Yet patency of the ELANA was inferior to the hand-sewn anastomoses (79% vs 100%, P  = 0.06). Conclusions: This study shows the technical perioperative feasibility of the ELANA Heart Bypass System. Although limited intima hyperplasia was observed, hand-sewn anastomoses had superior patency during follow-up. The results of this trial suggest that an additional study with a new prototype is required before clinical implementation.

Background: Sutureless coronary anastomotic devices are intended to facilitate minimally invasive coronary artery bypass grafting (MICS-CABG) by easing and eventually standardizing the anastomotic technique. Within this systematic review and meta-analysis, we aim to determine patency and to evaluate safety outcomes for the sutureless anastomoses., Methods: CENTRAL, MEDLINE, and EMBASE were searched from database start till August 2021 in a predefined search strategy combining the key concepts: 'coronary artery bypass grafting', 'sutureless coronary anastomoses', and 'hand-sewn coronary anastomoses' by the Boolean operation 'AND'. Study characteristics, patient demographics, interventional details, and all available outcome data were extracted. A meta-analysis was performed on patency at longest follow-up. Safety outcomes were presented., Results: A total of eleven trials towards six sutureless anastomotic devices were included, comprising 3724 patients (490 sutureless and 3234 hand-sewn). There was no significant difference in patency at a mean follow-up duration of 546.3 (range 1.5-2691) days, with a risk ratio of 0.77 (95% CI 0.55-1.06). MACE was reported in 4.5% sutureless and 3.9% hand-sewn patients, including all-cause mortality (resp. 1.3 vs. 1.9%), myocardial infarction (resp. 1.6 vs. 1.7%), and coronary revascularization (resp. 1.8 vs. 0.5%). Incomplete hemostasis occurred in 24.8% of the sutureless anastomoses. Intra-operative device failure forced conversion to hand-sewn or redo-anastomosis in 5.8% of the sutureless cases., Conclusion: Based on the systematic review and meta-analysis including six devices, we conclude that sutureless coronary anastomotic devices appear safe and effective when used by well-trained and dedicated surgical teams.

Objective: This preclinical study determines the feasibility and 6-month patency rates of a new distal coronary connector, the Excimer Laser Assisted Nonocclusive Anastomosis (ELANA) Heart Bypass., Methods: Twenty Dutch Landrace pigs received either a hand-sewn ( n = 8) or an ELANA ( n = 12) left internal thoracic artery to left anterior descending artery anastomosis, using off-pump coronary artery bypass grafting. Six-month patency rates were demonstrated by coronary angiography and histological evaluation. Throughout, procedural details and complication rates were collected., Results: The ELANA Heart Bypass demonstrated 0% mortality and complication rates during follow-up. It was demonstrated feasible, with comparable perioperative flow measurements (ELANA vs hand-sewn, median [min to max], 24 [14 to 28] vs 17 [12 to 31] mL/min; P = 0.601) and fast construction times (3 [3 to 7] vs 31 [26 to 37] min; P < 0.001). Yet, an extra hemostatic stitch was needed in 25% of the ELANA versus 12.5% of the hand-sewn anastomoses. The 6-month patency rate of the ELANA Heart Bypass was 83.3% versus 100% in hand-sewn anastomoses. The 2 occluded ELANA-anastomoses were defined model-based errors., Conclusions: The ELANA Heart Bypass facilitates a sutureless distal coronary anastomosis. A design change is suggested to improve hemostasis and will be evaluated in future translational studies. This new technique is a potential alternative to hand-sewn anastomoses in (minimally invasive) coronary surgery.

Objective: To determine the prevalence of oral feeding problems in neonatal intensive care unit (NICU) graduates at 1 to 2 years, and to identify clinical risk factors during NICU admission., Study Design: Observational cohort study of 378 children, who received level III/IV NICU care for 4 days or more in 2011 to 2012, chromosomal abnormalities excluded. We detected feeding problems in four gestational age (GA) groups (<28, 28 to 31, 32 to 36 weeks, and term-borns) using the Dutch standardized Screeningslijst Eetgedrag Peuters, and collected clinical factors for logistic regression analyses., Results: The prevalence of feeding problems was higher in NICU (20.4%) than in reference (15.0%) population (P=0.024), but similar for all GA groups (P=0.468). Prolonged tube feeding, that is, >30 days (odds ratio (OR) 2.50, confidence interval (CI) 1.13 to 5.56) and being born small for GA (OR 4.79, CI 1.64 to 14.03) were the most prevalent risk factors in children with GA ⩾32 and GA <32 weeks, respectively., Conclusion: Feeding problems are more prevalent in NICU graduates, with prolonged tube feeding as most important risk factor.

Molecular detection methods, such as quantitative PCR (qPCR), have found their way into clinical microbiology laboratories for the detection of an array of pathogens. Most routinely used methods, however, are directed at specific species. Thus, anything that is not explicitly searched for will be missed. This greatly limits the flexibility and universal application of these techniques. We investigated the application of a rapid universal bacterial molecular identification method, IS-pro, to routine patient samples received in a clinical microbiology laboratory. IS-pro is a eubacterial technique based on the detection and categorization of 16S-23S rRNA gene interspace regions with lengths that are specific for each microbial species. As this is an open technique, clinicians do not need to decide in advance what to look for. We compared routine culture to IS-pro using 66 samples sent in for routine bacterial diagnostic testing. The samples were obtained from patients with infections in normally sterile sites (without a resident microbiota). The results were identical in 20 (30%) samples, IS-pro detected more bacterial species than culture in 31 (47%) samples, and five of the 10 culture-negative samples were positive with IS-pro. The case histories of the five patients from whom these culture-negative/IS-pro-positive samples were obtained suggest that the IS-pro findings are highly clinically relevant. Our findings indicate that an open molecular approach, such as IS-pro, may have a high added value for clinical practice., (Copyright © 2016, American Society for Microbiology. All Rights Reserved.)

Background: Immunodeficiency in end-stage renal disease (ESRD) can be aggravated by haemodialysis (HD). This results in an increased incidence of reactivation of tuberculosis (TB) in HD patients. The tuberculin skin test to detect a latent TB infection (LTBI) has its limitations in these patients because of a high rate of false negative results due to anergy of T cells. Data on the influence of HD on the performance of interferon-gamma release assays are limited. The aim of this study was to determine the effect of HD on the performance of the QuantiFERON-TB Gold (QFT-G) assay in ESRD patients before, during and after the HD session., Methods: In HD patients older than 18 years without immunosuppressive medication or other immunocompromising conditions, the QFT-G assay was performed just before starting HD, 30 minutes after start and immediately after the finish of the HD session., Results: Twenty patients were included. No statistically significant differences were found in interferon-gamma production in the nil- and antigen tubes between pre-HD, during and after HD. In 1 patient the predialysis result was indeterminate (one of 60 samples, 1.67%). In all 3 patients with a history of LTBI, the QFT-G test tube results were positive at all time points. In the other 16 patients, all test tubes showed negative results., Conclusions: The QFT-G assay could be a useful test for the evaluation of the immunological response against Mycobacterium tuberculosis in HD patients. The time point of blood sampling does not seem to affect the interpretation of test results.

For patients with community-acquired pneumonia (CAP), clinical response during the first days of treatment is predictive of clinical outcome. As risk assessments can improve the efficiency of pneumonia management, a prospective cohort study to assess clinical, biochemical and microbiological predictors of early clinical failure was conducted in patients with severe CAP (pneumonia severity index score of >90 or according to the American Thoracic Society definition). Failure was assessed at day 3 and was defined as death, a need for mechanical ventilation, respiratory rate >25/min, PaO2 <55 mm Hg, oxygen saturation <90%, haemodynamic instability, temperature >38 degrees C or confusion. Of 260 patients, 80 (31%) had early clinical failure, associated mainly with a respiratory rate >25/minute (n = 34), oxygen saturation <90% (n = 28) and confusion (n = 20). In multivariate logistic regression analysis, failure was associated independently with altered mental state (OR 3.19, 95% CI 1.75-5.80), arterial PaH <7.35 mm Hg (OR 4.29, 95% CI 1.53-12.05) and PaO2 <60 mm Hg (OR 1.75, 95% CI 0.97-3.15). A history of heart failure was associated inversely with clinical failure (OR 0.30, 95% CI 0.10-0.96). Patients who failed to respond had a higher 28-day mortality rate and a longer hospital stay. It was concluded that routine clinical and biochemical information can be used to predict early clinical failure in patients with severe CAP.

Patients who have not received previous antiretroviral treatment (ART) have a high failure rate on the combination treatment of abacavir, lamivudine, and tenovir. We assessed the virological failure rate in eight patients with HIV-1 who switched to this combination after having complete virological suppression from their previous long-term ART (median 8.0 months, range 7.5-18.0). Five of the eight patients showed virological failure. Four of these five patients had either the K65R mutation, the M184V/I mutation, or both. This combination of drugs cannot therefore be recommended as alternative treatment in patients with HIV-1 who are fully virologically suppressed.