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Sanne Klaphake,1,2 Kevin de Leur,1 Paul GH Mulder,1,3 Gwan H Ho,1 Hans G de Groot,1 Eelco J Veen,1 Hence JM Verhagen,2 Lijckle van der Laan1 1Department of Surgery, Amphia Hospital, Breda, 2Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, 3Amphia Academy, Amphia Hospital, Breda, the Netherlands Background: Owing to the aging population, the number of elderly patients with critical limb ischemia (CLI) has increased. The consequence of amputation is immense. However, at the moment, information about the mortality after amputation in the elderly vascular patients is unknown. For this reason, this study evaluated mortality rates and patient-related factors associated with mortality after a major amputation in elderly patients with CLI.Methods: From 2006 to 2013, we included patients aged >70 years who were treated for chronic CLI by primary or secondary major amputation within or after 3 months of initial therapy (revascularization or conservative management). Outcome measurements were mortality after major amputation and factors associated with mortality (age, comorbidity and timing of amputation).Results: In total, 168/651 patients (178 legs; 26%) underwent a major amputation. Patients were stratified by age: 70–80 years (n=86) and >80 years (n=82). Overall mortality after major amputation was 44%, 66% and 85% after 1, 3 and 5 years, respectively. The 6-month and 1-year mortality in patients aged 80 years or older was, respectively, 59% or 63% after a secondary amputation 3 months. Per year of age, the mortality rate increased by 4% (P=0.005). No significant difference in mortality after major amputation was found in the presence of comorbidity or according to Rutherford classification.Conclusion: Despite developments in the treatment of CLI by revascularization, amputation rates remain high and are associated with tremendous mortality rates. Secondary amputation after a failed attempt of revascularization causes a higher mortality. Further research concerning timing of amputation and patient-related outcome is needed to evaluate if selected patients might benefit from primary amputation. Keywords: peripheral arterial disease, aged, limb ischemia, primary amputation, octogenarians, patient selection

Willem A van Eijsden,1 Jelle W Raats,1 Paul GH Mulder,2 Lijckle van der Laan1 1Department of Surgery, 2Amphia Academy, Amphia Hospital, Breda, the Netherlands Objective: The primary objective was to identify possible risk factors for delirium in patients with critical limb ischemia undergoing surgery. The secondary objective was to study the effect of delirium on complications, the length of hospital stay, health care costs, and mortality. Methods: All patients 65 years or older with critical limb ischemia undergoing surgery from February 2013 to July 2014 at Amphia Hospital, were included and followed up until December 31, 2014. Delirium was scored using the Delirium Observation Screening Scale (DOSS). Perioperative risk factors (age, comorbidity, factors of frailty, operation type, hemoglobulin, and transfusion) were collected and analyzed using logistic regression. Secondary outcomes were the number of complications, total hospital stay, extra health care costs per delirium, and mortality within 3 months and 6 months of surgery Results: We included 92 patients with critical limb ischemia undergoing surgery. Twenty-nine (32%) patients developed a delirium during admission, of whom 17 (59%) developed delirium preoperatively. After multivariable analysis, only diabetes mellitus (odds ratio [OR] =6.23; 95% confidence interval [CI]: 1.11–52.2; P=0.035) and Short Nutritional Assessment Questionnaire for Residential Care (SNAQ-RC) ≥3 (OR =5.55; 95% CI: 1.07–42.0; P=0.039) was significantly associated with the onset of delirium. Delirium was associated with longer hospital stay (P=0.001), increased health care costs, and higher mortality after 6 months (P

Objectives The aim of the study was to test the antiviral efficacy of a triple nucleoside reverse transcriptase inhibitor ( NRTI) regimen, with potential beneficial metabolic effects, as maintenance therapy after induction with dual NRTIs and a boosted protease inhibitor ( PI). Methods An open-label, noninferiority study was carried out. Antiretroviral therapy ( ART)-naïve patients with CD4 count ≤ 350 cells/μL and HIV-1 RNA > 30 000 copies/mL ( n = 207) were treated with zidovudine/lamivudine and lopinavir/ritonavir. After achieving HIV-1 RNA < 50 copies/mL on two consecutive occasions between weeks 12 and 24 after baseline, 120 patients (baseline: median HIV-1 RNA 5.19 log10 copies/mL; median CD4 count 180 cells/μL) were randomized to receive abacavir/lamivudine/zidovudine ( ABC/3 TC/ ZDV) ( n = 61) or to continue the PI-based ART ( n = 59). Results For the proportions of patients (intention-to-treat; missing = failure) with HIV-1 RNA < 400 copies/mL ( PI group, 66%; ABC/3 TC/ ZDV group, 71%) and < 50 copies/mL ( PI group, 63%; ABC/3 TC/ ZDV group, 62%) at 96 weeks, switching to ABC/3 TC/ ZDV was noninferior compared with continuing the PI regimen; the difference in failure rate ( ABC/3 TC/ ZDV minus PI) was −4.4 percentage points [95% confidence interval ( CI) −21.0 to +12.3 percentage points] and +0.4 percentage points (95% CI −16.9 to +17.7 percentage points), respectively. In the per protocol analysis, the difference in virological failure for HIV-1 RNA > 400 copies/mL (0 of 39 patients in the PI group and two of 45 patients in the NRTI group) and for HIV-1 RNA > 50 copies/mL (two of 39 and three of 45 patients, respectively) was +4.4 percentage points (95% CI −2.1 to +11.0 percentage points) and +1.5 percentage points (95% CI −8.6 to +11.7 percentage points), respectively, also showing noninferiority. Serum lipids significantly improved in the NRTI group, but not in the PI arm. Conclusions A single-class NRTI regimen after successful induction with standard ART had similar antiviral efficacy compared to continuation of a PI-based regimen at 96 weeks after baseline, with improved serum lipids. [ABSTRACT FROM AUTHOR]

Maintenance with a triple nucleoside reverse transcriptase Inhibitor (NRTI) regimen after successful induction with a dual NRTI/protease inhibitor (PI) combination may be advantageous, because of low pill burden, favorable lipids, and less drug interactions. This strategy to become free of PI-related problems without losing viral efficacy has not been formally tested. We performed a randomized, open-label, multicenter, 96-week comparative study in antiretroviral therapy (ART)-naïve patients with CD4 <=350 cells/mm3 and HIV-1 RNA concentrations (viral load [VL]) greater than 30,000 copies per milliliter. Patients were randomized after reaching VL less than 50 copies per milliliter on two consecutive occasions between 12 and 24 weeks after start of zidovudine/lamuvidine and lopinavir/ritonavir combination. Eligible subjects switched to abacavir/lamivudine/zidovudine (TZV) or continued the PI-containing regimen. Here we present the 48-week data with virologic success rate (failure: VL > 50 copies per milliliter). Two hundred seven patients had similar baseline (BL) characteristics: median CD4 180 cells/mm3, median VL 5.19 log10 copies per milliliter. One hundred twenty subjects (58%) met randomization criteria. Baseline VL differed significantly between dropouts and randomized subjects (median 5.41 versus 5.06 log10 copies per milliliter, p = 0.017), as did CD4 cells (median 160 and 200 cells/mm3, p = 0.044). Sixty-one subjects received TZV and 59 subjects continued NRTIs/PI. At week 48, 2 patients in the TZV group and 5 in the PI group did not have a sustained virologic suppression (log rank test; p = 0.379). CD4 counts increased significantly in both arms. In ART-naïve patients, TZV maintenance had similar antiviral efficacy compared to continued standard ART at 48 weeks after baseline. Patients on successful standard ART can be safely switched to a NRTI-only regimen, at least for the tested time period. [ABSTRACT FROM AUTHOR]

Effects of perinatal exposure to polychlorinated biphenyls (PCBs) on auditory P300 latencies and amplitudes were evaluated in children from a Rotterdam cohort. From this cohort of healthy, term babies, the 26 lowest and 26 highest prenatally PCB-exposed children from the breastfed and the formula-fed groups (n=104) were invited for P300 assessment when they were 9 years of age. For P300 assessment an auditory simple odd-ball paradigm was used. In the 83 participating children, 60 assessments (32 males, 28 females) satisfied the measurement criteria and were included in the data analyses. After adjusting for confounding variables, children with high prenatal exposure were found to have longer P300 latencies than children with low prenatal exposure. Lactational exposure to PCBs through breastfeeding milk was not related to P300 latencies. P300 latencies were shorter in children breast-fed for at least 16 weeks than in children breastfed for 6 to 16 weeks and formula-fed children. P300 amplitudes were not related to perinatal PCB exposure nor breastfeeding. Results of this exploratory study suggest that prenatal exposure to environmental levels of PCBs and related compounds delays mechanisms in the central nervous system that evaluate and process relevant stimuli, whereas breastfeeding accelerates these mechanisms. [ABSTRACT FROM AUTHOR]

Abstract Objective To compare the incidence, symptomatology and course of mastocytosis with onset in childhood and in adults. Design Retrospective study of 101 patients with mastocytosis who were referred from 1980 to 1998. Patients Medical records of 65 cases of mastocytosis with onset in childhood and 36 in adulthood were analysed. The clinical course was assessed in a subgroup consisting of 33 subjects with childhood onset who were followed up until at least adolescence and 12 subjects with adult onset who were followed up for at least 10 years. Results The onset of the disease occurred before the age of 2 years in 50% and between the ages of 2 and 15 years in 14% of cases (childhood onset). In 36% of patients onset occurred at the age of 16 years and older (adult onset). An incidence peak of 60% was noted in the first year of life. Mast cell-mediated symptoms were not experienced by 21 of 36 adult onset mastocytosis patients nor by 27 of 65 childhood onset mastocytosis patients. Complete resolution was observed in five of 33 children. The majority of childhood onset cases (21 of 33) showed some improvement. Complete resolution was achieved in three of 12 adults. The majority of the remaining adults (eight of 12) showed no improvement. Conclusions We confirm the incidence of onset of mastocytosis previously reported in the literature. We conclude that childhood onset mastocytosis is much less transitory than generally is assumed, although improvement occurs in the majority of cases. Symptomatology and clinical course of adult onset mastocytosis is less severe than suggested in the literature. [ABSTRACT FROM AUTHOR]

We studied the feasibility of clinical tests in the diagnosis of syndesmotic injury of the ankle. 9 investigators examined 12 persons twice, including 2 patients with an arthroscopically-confirmed syndesmotic injury. They sat behind a curtain that exposed only the lower legs. We found a statistically significant relation between the final arthroscopic diagnosis and the squeeze, fibula translation, Cotton, and external rotation tests as well as for limited dorsal flexion. None of the syndesmotic tests was uniformly positive in chronic syndesmotic injury. The external rotation test had the fewest false-positive results, the fibula translation test the most. The external rotation test had the smallest inter-observer variance. The physical diagnosis was missed in one fifth of all examinations. When in accordance with medical history and physical examination, positive stress tests should raise a high index of suspicion of syndesmotic instability. The final diagnosis of such instability, however, should be made by additional diagnostic imaging and/or arthroscopy. [ABSTRACT FROM AUTHOR]

Objective: "Cerebellar mutis" and subsequent dysarthria (MSD) is a documented complication of posterior fossa surgery in children. In this prospective study the following risk factors for MSD were assessed: type, size and site of the tumour; hydrocephalus at presentation and after surgery, cerebellar incision site, postoperative infection, and cerebellar swelling.Methods: In a consecutive series of 42 children with a cerebellar tumour, speech and neuroradiological studies (CT and MRI) were systematically analysed preoperatively and postoperatively. Speech was assessed using the Mayo Clinic lists and the severity of dysarthria using the Michigan rating scale.Results: Twelve children (29%) developed MSD postoperatively. The type of tumour, midline localisation, and vermal incision were significant single independent risk factors. In addition, an interdependency of possible risk factors (tumour>5 cm, medulloblastoma) was found.Conclusion: MSD often occurs after paediatric cerebellar tumour removal and is most likely after removal of a medulloblastoma with a maximum lesion diameter>5 cm. [ABSTRACT FROM AUTHOR]

Objectives: To determine the prevalence, trends, and potential nosocomial transmission events of the hidden reservoir of rectal carriage of extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E)., Methods: From 2013 to 2022, yearly point prevalence surveys were conducted in a large Dutch teaching hospital. On the day of the survey, all admitted patients were screened for ESBL-E rectal carriage using peri-anal swabs and a consistent and sensitive selective culturing method. All Enterobacterales phenotypically suspected of ESBL production were analysed using whole genome sequencing for ESBL gene detection and clonal relatedness analysis., Results: On average, the ESBL-E prevalence was 4.6% (188/4,119 patients), ranging from 2.1 to 6.6% per year. The ESBL-prevalence decreased on average 5.5% per year. After time trend correction, the prevalence in 2016 and 2020 was lower compared to the other year. Among the ESBL-E, Escherichia coli (80%) and CTX-M genes (85%) predominated. Potential nosocomial transmission events could be found in 5.9% (11/188) of the ESBL-E carriers., Conclusions: The ESBL-E rectal carriage prevalence among hospitalized patients was 4.6% with a downward trend from 2013 to 2022. The decrease in ESBL-E prevalence in 2020 could have been due to the COVID-19 pandemic and subsequent countrywide measures as no nosocomial transmission events were detected in 2020. However, the persistently low ESBL-E prevalences in 2021 and 2022 suggest that the decline in ESBL-E prevalence goes beyond the COVID-19 pandemic, indicating that overall ESBL-E carriage rates are declining over time. Continuous monitoring of ESBL-E prevalence and transmission rates can aid infection control policy to keep antibiotic resistance rates in hospitals low., (© 2024. The Author(s).)

Background: A radiographic fat pad sign after an elbow injury in children may indicate an occult fracture. Different incidences and locations of occult fractures have been reported. The primary objective of this meta-analysis was to assess the overall rate of occult fractures in children with a positive fat pad sign from the data of original studies. Secondary objectives were to assess the fracture types and to identify risk factors for sustaining an occult fracture., Methods: A systematic literature search of the Embase, MEDLINE, and Cochrane databases was performed according to PRISMA guidelines. Studies on pediatric populations with a positive fat pad sign identified using a lateral elbow radiograph and with follow-up imaging were included in this meta-analysis. Included studies were assessed for risk of bias with use of the MINORS (Methodological Index for NOn-Randomized Studies) instrument., Results: Ten studies with a total of 250 patients, of whom 104 had an occult fracture, were included. Accounting for heterogeneity between the studies, the overall occult fracture rate was 44.6% (95% confidence interval: 30.4% to 59.7%). The most common fracture locations were the supracondylar humerus (43%), proximal ulna (19%), proximal radius (17%), and lateral humeral condyle (14%). Definitions of a positive pad fad sign were not uniform among studies, and the follow-up imaging modality also varied (radiography, magnetic resonance imaging, or computed tomography). The average MINORS score was 10.1 for the 7 noncomparative studies and 18.7 for the 3 comparative studies, with both averages classified as moderate quality. We were not able to identify risk factors for an occult fracture in the presence of a positive fat pad sign., Conclusions: The occult fracture rate was 44.6% in pediatric elbow injuries with a positive fat pad sign. Supracondylar humeral fractures were the most frequently encountered type. The findings of this meta-analysis underline the potential clinical relevance of a positive fat pad sign in children and denote the opportunity for future studies to create evidence-based guidelines., Level of Evidence: Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A869)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Objective: To aid physicians in the process of shared decision-making, many predictive models for critical limb ischemia (CLI) have been constructed. However, none of these models is in widespread use. Predicting survival outcomes for a specific individual may be used to guide treatment selection. The aim of this study was to construct a 6-month survival-predicting model representative of elderly patients with CLI undergoing surgical or endovascular treatment., Methods: An observational cohort study including all patients with CLI aged ≥65 years who underwent surgical or endovascular treatment of CLI between January 2013 and June 2018 was conducted. The model to predict survival at 6 months was based on a multivariable Cox proportional hazards regression model and a penalized likelihood method. The performance of the model was judged by means of the area under the receiver operating characteristic curve., Results: In total, 449 patients were included in the study population. The median age was 76 years (range, 65-97 years), and 52.8% of the population was male. Surgical treatment was performed in 303 patients (67.5%), and 146 underwent endovascular treatment (32.5%). The estimated 30-day survival was 92.7% (standard error [SE], 1.2%); 6-month survival, 80% (SE, 1.9%); and 12-month survival, 71% (SE, 2.1%). Variables with the strongest association with 6-month mortality were age, living in a nursing home, physical impairment, and American Society of Anesthesiologists class. The area under the receiver operating characteristic curve of the 6-month mortality model was 0.81 (95% confidence interval, 0.76-0.85; P < .001)., Conclusions: A prediction model constructed for 6-month mortality of elderly patients undergoing surgical or endovascular treatment of CLI showed that age, living in a nursing home, physical impairment, and American Society of Anesthesiologists class have the highest association with an increase in mortality. These factors may be used to identify patients at risk for mortality in shared decision-making., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Delirium is associated with adverse outcomes, such as increased mortality and prolonged hospital stay. Information on the risk factors for delirium in elderly patients with critical limb ischaemia (CLI) is scarce. The aim of this study was to analyse the incidence of delirium and to identify risk factors for delirium in elderly patients undergoing surgical or endovascular treatment., Methods: A retrospective cohort study was conducted including patients aged ≥ 65 years undergoing surgical or endovascular treatment for CLI between January 2013 and June 2018. Delirium was scored using the DOSS (Delirium Observation Screening Scale) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. Risk factors for delirium were analysed using logistic regression. The discriminative ability of the model was calculated using the area under the receiver operating characteristics (AUROC) curve., Results: In total, 392 patients were included, of which 70 (17.9%) developed delirium. Factors associated with an increased risk of delirium were: age, odds ratio (OR) 1.05 (95% confidence interval (CI) 1.0-1.1), history of femoral endarterectomy, OR 4.7 (95% CI 1.5-15), physical impairment, OR 2.2 (95% CI 1.1-4.5), history of delirium, OR 2.7 (95% CI 1.4-5.3), general anaesthesia, OR 2.6 (95% CI 1.2-5.7) and pre-operative anaemia, OR 5.9 (95% CI 2.3-15). The AUROC was .82 (95% CI 0.76-0.87, p < .001). Delirium was associated with more respiratory, renal and surgical complications, as well as a prolonged hospital stay and a more frequent discharge to a nursing home., Conclusion: Delirium occurs frequently in patients with critical limb ischaemia undergoing any type of invasive treatment. This study identified multiple risk factors for delirium that may be helpful to delineate patients susceptible to its development., (Copyright © 2019 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Delirium in patients with critical limb ischemia (CLI) is associated with increased mortality. The main goal of this study was to investigate the association between delirium and mortality in patients undergoing major lower limb amputation for CLI. In addition, other risk factors associated with mortality were analyzed., Methods: An observational cohort study was conducted including all patients aged ≥70 years with CLI undergoing a major lower limb amputation between January 2014 and July 2017. Delirium was scored using the Delirium Observation Screening Score in combination with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Risk factors for mortality were analyzed by calculating hazard ratios using a Cox proportional hazards model., Results: In total, 95 patients were included; of which, 29 (31%) patients developed a delirium during admission. Delirium was not associated with an increased risk of mortality (hazard ratio [HR] = 0.84; 95 % confidence interval [CI]: 0.51-1.73; P = 0.84). Variables independently associated with an increased risk of mortality were age (HR 1.1; 95% CI 1.0-1.1), cardiac history (HR 3.3; 95% CI 1.8-6.1), current smoking (HR 2.9; 95% CI 1.6-5.5), preoperative anemia (HR 2.8; 95% CI 1.1-7.2), and living in a nursing home (HR 2.2; 95% CI 1.1-4.4)., Conclusion: Delirium was not associated with an increased mortality risk in elderly patients with CLI undergoing a major lower limb amputation. Factors related to an increased mortality risk were age, cardiac history, current smoking, preoperative anemia, and living in a nursing home., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Rib fractures are common in ageing people after trauma and delirium is a complication often seen in acutely hospitalized elderly patients. For both conditions, elderly have an increased risk for institutionalization, morbidity, and mortality. This study is the first to investigate risk factors of delirium in elderly patients with rib fractures after trauma., Methods: A retrospective chart review was performed on patients ≥65 years admitted with rib fractures after blunt chest wall trauma to the Amphia hospital Breda, the Netherlands, between July 2013 and June 2018. Baseline patient, trauma- and treatment-related characteristics were identified. The main objectives were identification of risk factors of delirium and investigation of the effect of delirium on outcomes after rib fractures. Outcomes were additional complications, length of hospital stay, need for institutionalization and mortality within six months., Results: Forty-seven (24.6%) of 191 patients developed a delirium. Independent risk factors for delirium were increased age, physical impairment (lower KATZ-ADL score), nutritional impairment (higher SNAQ score) and the need for a urinary catheter, with odds ratios of 1.07, 0.78, 1.53 and 8.53 respectively. Overall, more complications were observed in patients with delirium. Median ICU and hospital length of stay were 4 and 7 days respectively, of which the latter was significantly longer for delirious patients (p < 0.001). Significantly more patients with delirium were discharged to a nursing home or rehabilitation institution (p < 0.001). The 6-month mortality in delirious patients was nearly twice as high as in non-delirious patients; however, differences did not reach statistical significance., Conclusion: Delirium in elderly patients with rib fractures is a serious and common complication, with a longer hospital stay and a higher risk of institutionalization as a consequence. Increased awareness for delirium is imperative, most importantly in older patients, in physically or nutritionally impaired patients and in patients in need of a urinary catheter.

Background: Surgical site infections (SSIs) cause considerable morbidity and deaths among patients undergoing vascular surgery. Pre-operative screening and subsequent treatment of nasal Staphylococcus aureus carriers with mupirocin and chlorhexidine reduces the risk of SSIs in cardiothoracic and orthopedic surgery. The aim of this study was to investigate the effect of this screen-and-treat strategy on the development of SSI in patients undergoing aortoiliac surgery., Methods: A prospective study was performed that enrolled an intervention cohort comprising all patients undergoing aortoiliac surgery from February 2013 to December 2016. Before surgery, patients were screened for S. aureus nasal carriage and, if positive, were treated with mupirocin nasal ointment and chlorhexidine body washes. The presence of SSI was recorded on the basis of the criteria of the U.S. Centers for Disease Control and Prevention. A historic control group was used, consisting of aortoiliac surgery patients in 2010 who tested positive for S. aureus but received no treatment., Results: A total of 374 patients in the study cohort were screened of whom 75 (20.1%) tested positive for S. aureus. Of these patients, 68 were given eradication therapy. In the 2010 cohort, 22 patients (15.7%) were positive. The incidence of S. aureus infection was 0 of 75 in the treatment group versus 3 of 22 (13.6%) in the control group (p = 0.021). Both the 30-day mortality rate (1.3% vs. 13.6%; p = 0.035) and the rate of re-interventions (12.0% vs. 31.8%) were significantly lower in the treated group., Conclusion: We conclude that S. aureus nasal screening and eradication with mupirocin and chlorhexidine reduces S. aureus SSI and its complications after aortoiliac surgery.

Background: Cosmetic result in breast cancer surgery is gaining increased interest. Currently, some 30-40% of the patients treated with breast conserving surgery (BCS) are dissatisfied with their final cosmetic result. In order to prevent disturbing breast deformity oncoplastic surgical techniques have been introduced. The extent of different levels of oncoplastic surgery incorporated in breast conserving surgery and its value with regard to cosmetic outcome, patient satisfaction and quality of life remains to be defined. The aim of this prospective cohort study is to investigate quality of life and satisfaction with cosmetic result in patients with breast cancer, undergoing standard lumpectomy versus level I or II oncoplastic breast conserving surgery., Methods: Female breast cancer patients scheduled for BCS, from 18 years of age, referred to our outpatient clinic from July 2015 are asked to participate in this study. General, oncologic and treatment information will be collected. Patient satisfaction will be scored preceding surgery, and at 1 month and 1 year follow up. Photographs of the breast will be used to score cosmetic result both by the patient, an independent expert panel and BCCT.Core software. Quality of life will be measured by using the BREAST-Q BCT, EORTC-QLQ and EQ-5D-5 L questionnaires., Discussion: The purpose of this prospective study is to determine the clinical value of different levels of oncoplastic techniques in breast conserving surgery, with regard to quality of life and cosmetic result. Analysis will be carried out by objective measurements of the final cosmetic result in comparison with standard breast conserving surgery. The results of this study will be used to development of a clinical decision model to guide the use oncoplastic surgery in future BCS., Trial Registration: Central Commission of Human Research (CCMO), The Netherlands: NL54888.015.15. Medical Ethical Commission (METC), Maxima Medical Centre, Veldhoven, The Netherlands: 15.107. Dutch Trial Register: NTR5665 , retrospectively registered, 02-25-2016.

Background: The treatment of critical limb ischemia (CLI) in the elderly patients is challenging because of the comorbidity and fragility of these patients. We analyzed survival in relation to different treatment options and estimated life expectancy of our study group by age and gender., Methods: All patients aged ≥70 years, presenting with chronic CLI, between 2006 and 2013 were included. The treatment was conservative, endovascular, surgical, or by primary major amputation. The interest was in the effect of conservative versus nonconservative treatment on survival. Furthermore, we compared mortality and life expectancy between the study population to the overall Dutch population by age and gender., Results: In total, 686 legs in 651 patients were treated. Initial treatment of patients was conservative (n = 181), endovascular (n = 259), surgical (n = 169), or amputation (n = 42). The overall 1-year mortality was 29%. Patients were stratified by age: 70-79 (n = 350) years and ≥80 (n = 301) years. Higher mortality rate ratios (RR) were found in octogenarians compared with patients aged 70-79 years, in the endovascular (P < 0.001) and surgical (P < 0.001) group. The mortality RRs of conservative relatively to nonconservative treatment was 0.84 (95% confidence interval: 0.65-1.09; P = 0.19), not significantly differing between both age groups (P = 0.74). The mortality RR of 3.72 of our study population to the Dutch general population was high, with an excess mortality of 272%. Life expectancy at the age of 70 years was substantially decreased by 9 and 8 years for, respectively, the male and female population., Conclusions: Mortality rates in elderly patients with CLI are high, corresponding with a decreased life expectancy, regardless of the type of intervention. Revascularization is associated with high periprocedural mortality, especially in octogenarians. Conservative treatment is noninferior to nonconservative treatment in terms of mortality and should be considered as the treatment in octogenarians with substantial comorbidity., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Theoretical advantages of bipolar over monopolar radial head arthroplasty include better accommodation of radiocapitellar malalignment, reduction of capitellar abrasion, and reduction of stress at the bone-to-cement and cement-to-implant interfaces. Our purpose was to report the midterm results of cemented bipolar radial head arthroplasty., Methods: Twenty-five patients were treated by cemented bipolar radial head arthroplasty for acute fracture of the radial head, earlier treatment that had failed, or posttraumatic sequelae. One patient refused follow-up after surgery. Results are presented for the remaining 24 patients., Results: At a mean follow-up of 50 months (range, 24-72 months), 1 prosthesis (4%) had been removed 2 years after implantation for dissociation of the prosthesis due to failure of the snap-on mechanism. There were 2 (8%) additional radiologic failures in the subluxated position: 1 prosthesis due to malalignment of the radius onto the capitellum and another due to ulnohumeral erosion. The average flexion-extension arc was 129° (range, 80°-140°), and the average pronation-supination arc was 131° (range, 40°-180°). According to the Mayo Elbow Performance Score, the combined excellent and good results accounted for 83%. In 8 patients, the bipolar design compensated for radiocapitellar malalignment., Conclusions: The overall midterm outcome of this series of 25 cemented bipolar radial head arthroplasties can be considered favorable. There was 1 (4%) revision and 2 (8%) additional radiologic failures. The bipolar design was able to compensate for radiocapitellar malalignment. We suggest considering a cemented bipolar radial head prosthesis in case of concerns about radiocapitellar alignment., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Despite the expanding body of literature on radial head arthroplasty, the increasing understanding of elbow anatomy, biomechanics, and kinetics, and the evolution of surgical techniques and prosthesis designs, there is currently no evidence to support one type of radial head prosthesis over another. The purposes of the present report were to review the literature and to explore the association between prosthesis design variables and the timing of surgery and the outcome of modern radial head arthroplasty., Methods: The literature search was limited to studies involving skeletally mature patients. Major databases were searched from January 1940 to May 2015 to identify studies relating to functional and subjective outcomes and radiographic results after radial head arthroplasty., Results: Thirty articles involving 727 patients were included. Seventy percent of the implants were made of cobalt-chromium, 15% were made of pyrocarbon, 9% were made of titanium, and 6% were made of Vitallium. Seventy percent were monopolar, and 30% were bipolar. Twenty-one percent were cemented in place, 32% were press-fit, 32% were intentionally loose-fit, and 15% were fixed with an expandable stem. The weighted average duration of follow-up was 45 months. The rate of revision ranged from 0% to 29% among studies. The incidence of revision was 8% during 2,714 person-years of follow-up across all 727 patients, yielding a crude overall revision rate of 2.06 per 100 person-years of follow-up. The revision rate was not significantly affected by prosthesis polarity, material, or fixation technique, nor was it significantly affected by the delay of treatment. There was also no significant effect of prosthesis polarity, material, or fixation technique on postoperative range of motion. The Mayo Elbow Performance Score was only reported for half of the overall patient population, but, among those patients, the combined rate of excellent and good results was 85%. Seven percent of the overall patient population underwent secondary surgery about the elbow other than revision surgery. Twenty-three percent were reported to have 1 or more complications., Conclusions: On the basis of our analysis of the peer-reviewed English-language literature on radial head arthroplasty from January 1940 to May 2015, there seems to be no evidence to support one type of radial head prosthesis over another. The only exception is that silicone prostheses have been shown to be biologically and biomechanically insufficient., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Peripheral arterial disease has become an increasing problem in the aging population of the western world with a prevalence of 10-14%. This will result in a growing group of nonagenarians being referred to vascular surgeons, with an estimated growth of 2.5 times the number of nonagenarians between 2015 and 2040. Outcome results of nonagenarians suffering from critical limb ischemia (CLI) are scarce, which can cause difficulties in choosing superior therapy options. We propose that the life expectancy of nonagenarians suffering CLI compared to the overall population of nonagenarians is valuable information required in clinical decision-making., Methods: Between January 2012 and October 2015, all patients suffering from CLI were retrospectively reviewed in the Amphia Hospital, Breda, The Netherlands. Patients aged ≥90 years at admission were exclusively included. The main outcome result of this study is the life expectancy of nonagenarians suffering from CLI. Closely related to life expectancy is the primary end point of mortality. Secondary end points were adverse events, reoperations, and limb salvage., Results: A total of 36 patients were included in this study of which 27 were women. The median age was 92 years. Conservative therapy was performed in 61% of the patients. Based on 24 deaths (of which 19 were women), the mortality rate ratio of the study group relative to the Dutch population was 3.13 (95% confidence interval [CI], 2.00-4.66; P < 0.000001), adjusted for age and gender. Life expectancy in years of the total Dutch population at age 90 years in 2013 was 3.83 for men and 4.54 for women in contrast to, respectively, 1.23 (95% CI, 0.50-5.69) and 2.70 (95% CI, 1.76-3.74) years in our patient group., Conclusions: CLI is a severe disease in nonagenarians with a dreadful life expectancy of 1.23 and 2.7 years for men and women, respectively, corresponding with an age- and gender-adjusted mortality rate ratio of 3.13 relative to the Dutch population. Individual factors such as preoperative status, arterial occlusive lesion, and especially predicted postoperative quality of life are important parameters in clinical decision-making. Results of conservative therapy might be acceptable in selected patients, but more focus on quality of life is needed to be conclusive., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Current diagnostics for community-acquired pneumonia (CAP) include testing for a wide range of pathogens, which is costly and not always informative. We compared clinical and laboratory parameters of patients with CAP caused by different groups of pathogens to evaluate the potential for targeted diagnostics and directed treatment. In a prospective study, conducted between April 2008 and April 2009, adult patients with CAP were tested for the presence of a broad range of possible respiratory pathogens using bacterial cultures, PCR, urinary antigen testing and serology. Of 408 patients with CAP, pathogens were detected in 263 patients (64.5%). Streptococcus pneumoniae and influenza A virus were the most frequently identified bacterial and viral pathogens, respectively. Age had a significant effect on the prediction of aetiology (P = 0.054), with an increase in the relative contribution of viruses with advancing age. Multivariate analyses further showed that the presence of cough increased the likelihood of detecting a viral pathogen [odds ratio (OR) 5.536, 95% confidence interval (CI) 2.130-14.390], the presence of immunodeficiency decreased the likelihood of detecting a bacterial pathogen (OR 0.595, 95 % CI 0.246-1.437) and an increase in pneumonia severity index score increased the likelihood of detecting a pathogen in general. Although several variables were independently associated with the detection of a pathogen group, substantial overlap meant there were no reliable clinical predictors to distinguish aetiologies. Therefore, testing for common respiratory pathogens is still necessary to optimize treatment.

Both rhesus and cynomolgus macaques have been used as animal models for measles vaccination and immunopathogenesis studies. A number of studies have suggested that experimental measles virus (MV) infection induces more-characteristic clinical features in rhesus than in cynomolgus monkeys. In the present study, both macaque species were infected with two different wild-type MV strains and clinical, virological and immunological parameters were compared. The viruses used were a genotype C2 virus isolated in The Netherlands in 1991 (MV-Bil) and a genotype B3 virus isolated from a severe measles case in Sudan in 1997 (MV-Sudan). Following infection, all rhesus monkeys developed a skin rash and conjunctivitis, which were less obvious in cynomolgus monkeys. Fever was either mild or absent in both species. Virus reisolation profiles from peripheral blood mononuclear cells and broncho-alveolar lavage cells and the kinetics of MV-specific IgM and IgG responses were largely identical in the two animal species. However, in animals infected with MV-Sudan, viraemia appeared earlier and lasted longer than in animals infected with MV-Bil. This was also reflected by the earlier appearance of MV-specific serum IgM antibodies after infection with MV-Sudan. Collectively, these data show that cynomolgus and rhesus macaques are equally susceptible to wild-type MV infection, although infection in the skin seems to follow a different course in rhesus macaques. MV-Sudan proved more pathogenic for non-human primates than MV-Bil, which may render it more suitable for use in future pathogenesis studies.