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Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly being used for temporary bleeding control in patients with trauma with non-compressible truncal hemorrhage (NCTH). In recent years, the technique is gaining popularity in postpartum hemorrhage and non-traumatic cardiac arrest, although still underutilized. In other surgical fields, however, there is not yet much awareness for the possible advantages of this technique. Consequently, for non-trauma indications, limited data are available.Methods Description of the use of REBOA in two patients with hemorrhagic shock due to exsanguinating non-traumatic NCTH.Results In the first case, REBOA was deployed at the emergency department in a patient in their 80s presenting with hemorrhagic shock due to a ruptured abdominal aortic aneurysm. Hemodynamic stability was obtained and a CT scan was subsequently performed for planning of endovascular aneurysm repair. After successful placement of the endograft, the REBOA catheter was deflated and removed. In the second case, REBOA was performed in a patient with shock due to iatrogenic epigastric artery bleeding after an umbilical hernia repair to prevent hemodynamic collapse and facilitate induction of anesthesia for definitive surgery. During laparotomy, blood pressure-guided intermittent aortic balloon occlusion was used to preserve perfusion of the abdominal organs. Patient made a full recovery.Conclusion REBOA deployment was successful in achieving temporary hemorrhage control and hemodynamic stability in patients with non-traumatic NCTH. REBOA facilitated diagnostic work-up, transportation to the operating room and prevented hemodynamic collapse during definitive surgical repair. In the right patient and skilled hands, this relatively simple endovascular procedure could buy precious time and prove lifesaving in a variety of non-compressible hemorrhage.

Background: Training vascular access skills for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to emergency physicians (EPs) could contribute to better outcomes in patients with non-compressible truncal hemorrhage. This study aimed to determine whether a concise training program could train EPs to recognize anatomical structures and correctly visualize and identify the puncture site for percuta­neous REBOA catheter placement. Methods: Our training program included basic anatomy and training in access materials for REBOA. Participants underwent expert-guided practice on each other and were then tested on key skills: the identification of anatomical structures, anatomy knowledge, technical skills for vascular access imaging with a handheld ultrasound, and time to identify adequate puncture site of the common femoral artery (CFA). Consultant vascular surgeons functioned as expert controls. Results: Eleven EPs participated. They had a median overall technical skills score of 32.5 (27.0–35.0) and median time to identify the CFA puncture site of 52.9 s (35.6–63.7), which improved to 34.0 s (21.2–44.7) at the post-test (Z = –2.756, P = 0.006). Consultant vascular surgeons were significantly faster (P = 0.000). Conclusions: EPs are capable of visualizing the femoral artery and vein within 1 min. This speed improved rapidly after repetition. Our concise training program proved useful regardless of prior endovascular experience. This program, as a component of an expanded Endovascular Resuscitation and Trauma Management curriculum, in combination with realistic task training models (simulator, perfused cadaver, or live tissue) has the potential to provide effective training of the skills required to competently perform REBOA.

Background/Aims: Postoperative mortality after colon surgery is relatively infrequent. In order to evaluate the quality of colon surgery, post-mortem evaluation is useful. This study was performed to determine the value of a mortality register used at the Department of Surgery of the Red Cross Hospital. Methods: From 1991 to 2000, 882 colon resections were performed for both malignant and benign disorders, including elective and emergency surgery. Permission for autopsy was asked routinely. All cases were reviewed and categorized in a multidisciplinary meeting. Any discrepancy between the clinical and post-mortem diagnosis was determined by a pathologist. Results: The mortality rate of colon surgery was 8.0% (n = 71), 23% for emergency surgery and 6% for elective surgery (p < 0.001). For patients under 70 years of age the mortality rate was 4.3%, for patients over 70 years of age 11.2% (p < 0.001). Autopsy was performed in 62% (n = 44) of the patients. Discrepancy between clinical and post-mortem findings was documented in 14%. Conclusion: Postoperative mortality after colon surgery is influenced by the timing of surgery (elective or emergency procedure) and the age of the patient. A discrepancy of 14% between clinical cause of death and postmortem cause of death justifies the need for obtaining autopsy in this type of surgery. [ABSTRACT FROM AUTHOR]

Over the last decade, endovascular aneurysm repair (EVAR) has been used extensively for the elective treatment of infra-renal abdominal aneurysms. However, it remains unclear how specific devices perform and how they compare to others. We provide an overview of currently used endografts, and discuss the current evidence regarding device-specific outcomes. Published literature confirms differences in results according to endograft selection. These differences were more pronounced with older generations of devices, in comparison to newer models. Contemporary results are generally good and one should remember that no randomized data exist regarding individual device performance. Moreover, by the time there is enough follow-up to draw conclusions, the data is relatively obsolete due to constant improvements in endograft technology and design. Results from EVAR have been steadily improving and individualized device selection has shown to be valuable. It appears that patients with favorable anatomy do well with most modern endografts. Those with challenging anatomies may benefit more from a particular design, delivery and deployment feature requiring greater knowledge and experience for adequate device selection.

Background: Phaeochromocytomas and paragangliomas are neuro-endocrine tumours that occur sporadically and in several hereditary tumour syndromes, including the phaeochromocytoma-paraganglioma syndrome. This syndrome is caused by germline mutations in succinate dehydrogenase B (SDHB), C (SDHC), or D (SDHD) genes. Clinically, the phaeochromocytoma-paraganglioma syndrome is often unrecognised, although 10-30% of apparently sporadic phaeochromocytomas and paragangliomas harbour germline SDH-gene mutations. Despite these figures, the screening of phaeochromocytomas and paragangliomas for mutations in the SDH genes to detect phaeochromocytoma-paraganglioma syndrome is rarely done because of time and financial constraints. We investigated whether SDHB immunohistochemistry could effectively discriminate between SDH-related and non-SDH-related phaeochromocytomas and paragangliomas in large retrospective and prospective tumour series., Methods: Immunohistochemistry for SDHB was done on 220 tumours. Two retrospective series of 175 phaeochromocytomas and paragangliomas with known germline mutation status for phaeochromocytoma-susceptibility or paraganglioma-susceptibility genes were investigated. Additionally, a prospective series of 45 phaeochromocytomas and paragangliomas was investigated for SDHB immunostaining followed by SDHB, SDHC, and SDHD mutation testing., Findings: SDHB protein expression was absent in all 102 phaeochromocytomas and paragangliomas with an SDHB, SDHC, or SDHD mutation, but was present in all 65 paraganglionic tumours related to multiple endocrine neoplasia type 2, von Hippel-Lindau disease, and neurofibromatosis type 1. 47 (89%) of the 53 phaeochromocytomas and paragangliomas with no syndromic germline mutation showed SDHB expression. The sensitivity and specificity of the SDHB immunohistochemistry to detect the presence of an SDH mutation in the prospective series were 100% (95% CI 87-100) and 84% (60-97), respectively., Interpretation: Phaeochromocytoma-paraganglioma syndrome can be diagnosed reliably by an immunohistochemical procedure. SDHB, SDHC, and SDHD germline mutation testing is indicated only in patients with SDHB-negative tumours. SDHB immunohistochemistry on phaeochromocytomas and paragangliomas could improve the diagnosis of phaeochromocytoma-paraganglioma syndrome., Funding: The Netherlands Organisation for Scientific Research, Dutch Cancer Society, Vanderes Foundation, Association pour la Recherche contre le Cancer, Institut National de la Santé et de la Recherche Médicale, and a PHRC grant COMETE 3 for the COMETE network.

Background: The groin incision after arterial reconstructive surgery is most likely at risk for infectious or lymphatic wound complications. Theoretically; sparing lymphatic tissue by a lateral approach to the femoral artery should minimize these. The aim of this study was to assess the incidence of wound complications after the lateral versus the direct approach of the common femoral artery., Methods: The study population included all patients who underwent an exploration of the common femoral artery between May 2002 and December 2005., Results: After 6 weeks, no statistical differences in the occurrence of wound complications could be shown. A wound infection was present after 6 weeks in 6.1% in the direct group versus 6.0% in the lateral group. Lymphorrhea was persistent in 3.1% in the direct group versus 5.0% in the lateral group., Conclusions: Using a lateral vertical incision for the approach of the common femoral artery did not decrease the incidence of postoperative wound complications.

Successful cryopreservation is essential for a large-scale dispersal of bovine in vitro produced (IVP) embryos that have been shown to be more sensitive to cryopreservation than their in vivo counterparts. On the other hand, the use of animal proteins in freezing media increases sanitary risks. We first replaced animal proteins, such as bovine serum albumin (BSA) in the freezing medium by plant-derived peptides (vegetal peptones). A batch of wheat peptones was selected after a preliminary experiment showing the absence of toxicity of concentrations<18 mg/mL on in vitro bovine blastocysts. Increasing concentrations of peptones were then added in the freezing medium. The surviving and hatching rates were not affected by comparison with those observed with BSA. No significant difference was observed between groups either for the total number of cells or for the ratio ICM/Total cell, nor for the rate of apoptosis in surviving embryos. When embryos were cryopreserved in 1.8 mg/mL peptone, the hatching rate and embryo quality as assessed at 48 h post-thawing were not significantly different from those of unfrozen embryos. In a second experiment two additives were added in this animal protein-free freezing medium containing 1.8 mg/mL peptones. No beneficial effect of adding 1 mg/mL sodium hyaluronate or 100 microM beta-mercaptoethanol was observed on embryo survival or quality. In conclusion, we have demonstrated that vegetal peptones can replace BSA in freezing media without affecting blastocyst survival and quality.

Objective: To develop a safe and accurate method for the administration in the neonatal intensive care unit of several potent medications as a continuous infusion without overloading the infant, especially the very low birth weight (VLBW) infant by diluents., Method: The method designed is based on a weight-adapted solution limiting the diluent administration and allowing for a versatile modulation of dose administration. As this method was initially designed for VLBW infants, the point of departure of this method is a standard maximal fluid load of 0.3 ml/h for each medication, delivered in a low compliant circuit with a high-precision syringe driver. Solutions are made for 24 h, which is a compromise between drug stability and repeated pressure drops in the circuit when changing the syringe and administration set. To translate a prescription into a solution a conversion factor is calculated. In addition to the calculation principle, this conversion factor is given for a number of commonly used drugs in neonatal care., Conclusions: In our experience, the method described adds to the safety and accuracy of continuous drug administration in neonatal care.

The fracture aspects of impact twisted human femurs and tibias have been studied in their wet condition. The main tool used to correlate fracture behaviour with bone structure was the scanning electron microscope. Supplementary data were obtained from macroscopic fracture pattern analyses and stress coat experiments on slowly tested dried bone. The interest of the data reported concerns two major points. Firstly the analysis of the fractographic results leads to the conclusion that the fracture has presumably been initiated by shearing parallel with the torsion axis. The fracture propagates along so called spiral and oblique fracture lines. Secondly, the correlation of the macroscopic fracture pattern with microscopic fracture aspects indicates that the fracture is initiated along the cement lines, which can be considered as the weak matrix in an osteon-cement lining composite. The fracture propagates along the cement lines as well as through osteons and lamellae. Throughout the impact fracture surfaces ductile and brittle fracture aspects were observed, although the brittle fracture mode was predominant during propagation.