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Objective: The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR)., Methods: This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests., Results: The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively)., Conclusion: In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair., (Copyright © 2020 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Evidence to guide management of postdissection abdominal aortic aneurysms (PDAAA) is lacking. This study describes the outcomes of open repair of PDAAA., Methods: A retrospective cohort study was conducted of all consecutive patients treated with open repair for PDAAA after a Stanford type A or type B thoracic aortic dissection between January 2006 and December 2017 in two vascular referral centers. Preceding type B dissection treatment could include conservative or surgical management. Primary outcomes were 30-day mortality, complication rates, survival, and reintervention-free survival. Survival and reintervention-free survival were analyzed using the Kaplan-Meier method. Reintervention was defined as any endovascular or surgical intervention after the index procedure., Results: Included were 36 patients (27 men [75%]) with a median age of 64 years (range, 35-81 years). The 30-day mortality was 2.7%. The median follow-up was 16 months (range, 0-88 months). The postoperative course was uneventful in 21 patients (58%). The most frequent complications were postoperative bleeding requiring repeat laparotomy (n = 4), pneumonia (n = 3), congestive heart failure (n = 2), new-onset atrial fibrillation (n = 2), mesenteric ischemia requiring left hemicolectomy (n=1), and ischemic cerebrovascular accident (n = 1). Renal failure requiring hemodialysis developed in one patient. The overall survival at 1 year was 88.8%. Reintervention-free survival was 95.5% after 1 year and 88.6% after 2 years., Conclusions: Open repair of PDAAA can be performed with a low mortality rate and an acceptable complication rate, comparable with elective open repair of abdominal aortic aneurysms without dissection., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

The ability to monitor the appropriateness of hospital antibiotic use is a key element of an effective antibiotic stewardship program. A set of 11 generic quality indicators (QIs) was previously developed to assess the quality of antibiotic use in hospitalized adults treated for a bacterial infection. The primary aim of the current study was to assess the clinimetric properties of these QIs (nine process and two structure indicators) in daily clinical practice. In a cross-sectional point-prevalence survey, performed in 2011 and 2012, 1890 inpatients from 22 hospitals in the Netherlands treated with antibiotics for a suspected bacterial infection were included, and data were extracted from medical records. In this cohort we tested the measurability, applicability, reliability, room for improvement and case mix stability of the previously developed QIs. Low applicability (≤10% of reviewed patients) was found for the QIs 'therapeutic drug monitoring', 'adapting antibiotics to renal function' and 'discontinue empirical therapy in case of lack of clinical and/or microbiological evidence of infection'. For the latter, we also found a low inter-observer agreement (kappa <0.4). One QI showed low improvement potential. The remaining seven QIs had sound clinimetric properties. Case-mix correction was necessary for most process QIs. For all QIs, we found ample room for improvement and large variation between hospitals. Establishing the clinimetric properties was essential, as four of the 11 previously selected QIs showed unsatisfactory properties in this practice test. Since the quality of antibiotic use and the process of documenting data is changing over time and may vary per country, QIs should always be tested in practice first., (Copyright © 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Background: Since the introduction of endovascular aneurysm repair (EVAR), long-term follow-up studies reporting single-device results are scarce. In this study, we focus on EVAR repair with the Talent stent graft (Medtronic, Santa Rosa, Calif)., Methods: Between July 2000 and December 2007, 365 patients underwent elective EVAR with a Talent device. Patient data were gathered prospectively and evaluated retrospectively. By American Society of Anesthesiologists category, 74% were categories III and IV. Postoperative computed tomography (CT) scanning was performed before discharge, at 3, 12 months, and yearly thereafter. Data are presented according to reporting standards for EVAR., Results: The mean proximal aortic neck diameter was 27 mm (range, 16-36 mm), with a neck length <15 mm in 31% (data available for 193 patients). Deployment of endografts was successful in 361 of 365 patients (99%). Initially, conversion to laparotomy was necessary in four patients. Primary technical success determined by results from computed tomography (CT) scans before discharge was achieved in 333 patients (91%). Proximal type I endoleaks were present in 28 patients (8%) during follow-up, and 14 of these patients needed additional treatment for type I endoleak. The 30-day mortality for the whole Talent group was 1.1% (4 of 365). Follow-up to 84 months is reported for 24 patients. During follow-up, 122 (33%) patients died; in nine, death was abdominal aortic aneurysm (AAA)-related (including 30-day mortality). Kaplan-Meier estimates revealed primary clinical success rates of 98% at 1 year, 93% at 2 years, 88% at 3 years, 79% at 4 years, 64% at 5 years, 51% at 6 years, and 48% at 7 years. Secondary interventions were performed in 73 of 365 patients (20%). Ten conversions for failed endografts were performed. Life-table yearly risk for AAA-related reintervention was 6%, yearly risk for conversion to open repair was 1.1%, yearly risk for total mortality was 8.9%, and yearly risk for AAA-related mortality was 0.8%., Conclusion: Initially, technical success of endovascular aneurysm repair (EVAR) using the Talent endograft is high, with acceptable yearly risk for AAA-related mortality and conversion. However, a substantial amount of mainly endovascular reinterventions is necessary during long-term follow-up to achieve these results., (Copyright © 2011 Society for Vascular Surgery. All rights reserved.)

We report the case of a 71-year-old man with acute back and left flank pain caused by a large pseudoaneurysm of the left renal artery. The pseudoaneurysm resulted from a complete fracture of a stent that had been placed at the origin of this vessel 10 months earlier. Because the left kidney had no residual function, the patient was treated by percutaneous occlusion of the left renal artery with a vascular plug. The symptoms rapidly subsided, and he remained symptom free at the 6-month follow-up. Stent fractures, their complications, and management are discussed.

The use of femoral artery closure devices to obtain hemostasis after percutaneous catheterization has become widespread because of their proven feasibility in combination with patient-related advantages. Since 2002 more than 6,500 patients have undergone either diagnostic angiography or therapeutic intervention via the femoral route with an Angioseal closure device in our hospital. We were faced with six cases of limb-threatening complications, which are described here. Most (5/6) complications were of obstructive origin due to traumatic dissection or occlusion of the artery mainly caused by malpositioning of the device. Recommendations are made in order to prevent or successfully overcome this certainly increasing problem in the vascular field.

Pressure sores are a frequent problem, especially in elderly patients. Nutritional status may influence the incidence, progression and severity of pressure sores, data, however, are contradictory (1). The purpose of this study was to determine the effect of supplemental feeding on the nutritional status and the development and severity of pressure sores. The effect of supplemental feeding overnight (tube +) on patients with a fracture of the hip and a high pressure-sore risk score, was studied in a randomized clinical trial. The control group (tube -) had no supplemental feeding. After informed consent, 140 patients were randomized, and 129 of these took part in the trial (62 tube +, and 67 tube -). Protein and energy intake, haemoglobin, serum albumin, total serum protein and pressure-sore grade were measured at admission and after 1 and 2 weeks. Of the 62 patients randomized for tube feeding (tube +), only 25 tolerated their tube for more than 1 week and 16 for 2 weeks. Nevertheless, energy and protein intake was significantly higher in the tube + group (P < 0.001). This, however, did not significantly influence total serum protein, serum albumin and development and severity of pressure sores after 1 and 2 weeks. Comparison of the actually tube fed group (n=25 at 1 week, n = 16 at 2 weeks) and the control group showed a 2-3 times higher protein and energy intake (P < 0.0001), and a significantly higher total serum protein and serum albumin after 1 and 2 weeks in the actually tube fed group (all P < 0.001). Pressure-sore development and severity were not significantly influenced in the actually tube fed group. We conclude that we were not able to show a significant decrease in development and severity of pressure sores, because the nasogastric tube for supplemental feeding was not well tolerated in this patient group. Nevertheless, tube feeding overnight does result in a significant higher protein and energy intake, and has a significant effect on nutritional status in the actually tube-fed group. Other means of supplemental feeding will have to be used in order to answer the question of whether supplemental feeding can decrease development and severity of pressure sores.

A vital characteristic of skin is its ability for wound repair in response to injury. A transient elevation of matrix metalloproteinases (MMP) in the epidermal and dermal compartments of healing wounds implicates the MMP family of enzymes in the regulation of events important to injury repair. Transgenic mice expressing human interstitial collagenase (MMP-1) in the epidermis were used to perturb the regulation of this proteinase in order to examine the role of epidermal collagenase during wound healing. The relative healing potential of collagenase transgenic mice and wild-type littermates was assessed by measurements of the wound area during closure of full-thickness wounds. Transgenic mice exhibited a 2-3 d delay in the time required to reach 50% closure of 6 mm wounds. Histologic analysis of the transgenic wound bed revealed the retarded migration of the epithelium across the open wound. The results are consistent with the hypothesis that control of collagenase (MMP-1) expression is important for re-epithelialization during wound healing and indicate that collagenase regulation is critical to the kinetics of normal wound closure.

Pressure sores are a problem, especially in elderly patients. Our study was designed to determine the effectiveness in pressure-sore prevention of a new interface-pressure decreasing mattress. In a prospective randomised controlled clinical trial we tested the Comfortex DeCube mattress (Comfortex, Winona, USA) against our standard hospital mattress in 44 patients with femoral-neck fracture and concomitant high pressure-sore risk score. In addition both groups were treated according to the Dutch consensus protocol for the prevention of pressure sores. On admission and 1 and 2 weeks after admission, pressure sores were graded. The two groups were similar in patient characteristics and pressure-sore risk factors. At 1 week, 25% of the patients nursed on the DeCube mattress and 64% of the patients nursed on the standard mattress had clinically relevant pressure sores (grade 2 or more). At 2 weeks the figures were 24% and 68%, respectively. The maximum score over the several body regions of the pressure-sore grading, measured on a 5-point sale, was significantly different in favour of the DeCube mattress at 1 week (p = 0.0043) and 2 weeks (p = 0.0067) postoperatively. We show that the occurrence of pressure sores and their severity can be significantly reduced when patients at risk are nursed on an interface-pressure decreasing mattress.

Retinoids bearing azido photoaffinity-labeling groups (azidoretinoids) have potential as probes for investigating the molecular mechanisms of action of all-trans-retinoic acid (RA) as mediated by its cellular retinoic acid-binding protein (CRABP) and nuclear receptor proteins. Two new azidoretinoids, 3-azido-4-[2-(5,6,7,8-tetrahydro-5,5,8,8-tetramethyl-2-naphthalenyl)-1E- propen-1-yl]-benzonic acid and 4-(4-azido-5,6,7,8-tetrahydro-5,5,8,8-tetramethyl-2-anthracenyl)be nzoic acid were synthesized, and evaluated for their in vitro biological potency, and binding affinity for CRABP. Like RA, these aromatic azides had significant activity in modulating cell differentiation in retinoid-deficient hamster tracheal organ culture (ED500.02 nM and 0.03 nM, respectively) and in the inhibition of the induction of ornithine decarboxylase in mouse epidermis (ED50 7.0 nmol and 0.5 nmol, respectively). They also possessed high binding affinity for CRABP (ID50 0.9 microM and 0.85 microM, respectively). The tritiated aromatic azides were further evaluated for their ability to bind covalently to CRABP after photolysis. On photolysis at -78 degrees C, the two radiolabeled azidoretinoids formed stable adducts with CRABP. Treatment of the adducts with either RA or p-chloromercuriphenylsulfonic acid (CMPS) and subsequent dialysis did not cause any dissociation, indicating the formation of a covalent bond. In contrast, treatment of the unirradiated complexes with RA or CMPS led to dissociation of the complex. Synthesis of affinity labels and characterization of CRABP-retinoid complexes should provide useful information on the ligand-binding regions and insights into the mechanism of action of RA.

Four human squamous carcinoma cell (SCC) lines (SCC-9, SCC-13, SCC-15, and SCC-25) were studied to characterize their relative ability to control proliferation and differentiation. These experiments were based on previous data that established that in normal human keratinocytes three distinct and sequential steps are involved in the integrated control of proliferation and differentiation: 1) reversible growth-arrest at a predifferentiation state, 2) irreversible loss of proliferative potential, and 3) terminal differentiation. The current results show that SCC can show changes in the culture conditions required to undergo reversible growth-arrest and SCC can express partial or complete defects in their ability to irreversibly growth-arrest or terminally differentiate. For example, SCC-9 and SCC-25 cannot irreversibly growth-arrest or terminally differentiate, SCC-13 can irreversibly growth-arrest but cannot terminally differentiate, and SCC-15 can irreversibly growth-arrest and terminally differentiate to a moderate extent. These results therefore extend previous data by establishing that the malignant transformation of human epithelial cells does not simply result from defects in the control of terminal differentiation but rather from a combination of complex defects in the regulation of proliferation and differentiation.

Normal human keratinocytes can be grown in serum-free medium, and the integrated control of their proliferation and differentiation can be modulated experimentally. The growth of cultured human keratinocytes can also be specifically arrested at either reversible or irreversible growth arrest states. Reversible growth arrest is induced by culture in medium containing TGF-beta or ethionine or in medium deficient of isoleucine. Irreversible growth arrest is induced by culture in razoxane-containing medium or by routine passage of keratinocytes until senescence results. The current studies were performed to determine from which growth arrest states keratinocyte differentiation occurs. Cells were therefore growth-arrested at each state, and they were then incubated in several different differentiation-promoting culture conditions. The results show that differentiation, as determined by morphologic, cytochemical, and immunofluorescent assays, can be induced from multiple reversible and irreversible growth arrest states by a series of complex biologic mechanisms. More specifically, at least three distinct stages appear to be involved in the process of keratinocyte differentiation. First, cells arrest their growth at a reversible predifferentiation state. Second, cells irreversibly lose their proliferative potential. Finally, cells express the terminally differentiated keratinocyte phenotype.

Rapidly growing normal human neonatal prokeratinocytes (HPK) cultured in serum-free medium can be induced to undergo either reversible or irreversible growth arrest at distinct cell cycle states. Reversible G1 arrest was induced by culture of low-density cells in human lymphocyte conditioned medium, by culture in high-density stationary phase conditioned medium, and by culture in isoleucine-deficient medium. Irreversible arrest of HPK growth predominantly in G1 was induced by culture in growth factor-deficient medium. Irreversible arrest of HPK growth in G1 and G2 was also induced by culture in suspension in methylcellulose prepared in complete MCDB 153 medium or by culture in serum-containing medium. Finally, the drug razoxane was employed to induce irreversible arrest of HPK in G2. These data establish that there are 2 distinct classes of growth arrest states for HPK and suggest that each arrest mechanism may serve a unique role in the control of keratinocyte differentiation in normal cells. It is also possible that the development of selective defects in either of these processes could be of etiologic significance in certain epidermal disease states.