Infection prevention strategies in a stem cell transplant unit: impact of change of care in isolation practice and routine use of high dose intravenous immunoglobulins on infectious complications and transplant related mortality

OBJECTIVE: Nursing in 'live islands' and routine high dose intravenous immunoglobulins after allogeneic hematopoietic stem cell transplantation were abandoned by many teams in view of limited evidence and high costs. METHODS: This retrospective single-center study examines the impact of change from nursing in 'live islands' to care in single rooms (SR) and from high dose to targeted intravenous immunoglobulins (IVIG) on mortality and infection rate of adult patients receiving an allogeneic stem cell or bone marrow transplantation in two steps and three time cohorts (1993-1997, 1997-2000, 2000-2003). RESULTS: Two hundred forty-eight allogeneic hematopoetic stem cell transplantations were performed in 227 patients. Patient characteristics were comparable in the three cohorts for gender, median age, underlying disease, and disease stage, prophylaxis for graft versus host disease (GvHD) and cytomegalovirus constellation. The incidence of infections (78.4%) and infection rates remained stable (rates/1000 days of neutropenia for sepsis 17.61, for pneumonia 6.76). Cumulative incidence of GvHD and transplant-related mortality did not change over time. CONCLUSIONS: Change from nursing in 'live islands' to SR and reduction of high dose to targeted IVIG did not result in increased infection rates or mortality despite an increase in patient age. These results support the current practice.

Oesophageal and gastric endoscopic foreign body removal: complications and follow-up of 102 dogs

OBJECTIVES: To assess complication rate, risk factors for complications and outcome in dogs with oesophageal and gastric endoscopic foreign body (FB) removal. METHODS: Medical records of 102 dogs undergoing endoscopic removal of oesophageal and/or gastric FBs from March 2001 to November 2006 were retrospectively reviewed. All owners were contacted by telephone to provide follow-up information. RESULTS: West Highland white terriers, Yorkshire terriers and Bernese mountain dogs were over-represented compared to the hospital population. Endoscopy alone was successful in 92/102 dogs (90.2 per cent), whereas gastrotomy (but no oesophagotomy) was required in 10 dogs (9.8 per cent). Complications in 13/102 dogs (12.7 per cent) were perforation (8), oesophageal stricture (1), oesophageal diverticula (1), perioesophageal abscess (1), pneumothorax and pleural effusion (1) and respiratory arrest (1). Six dogs (all weighing <10 kg) had complications resulting in death or euthanasia. Bone FBs, bodyweight of less than 10 kg, and oesophageal or gastric FB in place for more than three days were significant risk factors for complications. Of the dogs available for follow-up (75/96), 92 per cent had no complications after discharge. CLINICAL SIGNIFICANCE: Endoscopic FB removal is associated with a low overall complication rate with bone FBs and bodyweight of less than 10 kg as significant risk factors.

Bleeding complications following Nd:YAG laserassisted oral surgery vs conventional treatment in cardiac risk patients: a clinical retrospective comparative study

OBJECTIVE Thermal Nd:YAG laser energy is well known for the purpose of blood coagulation. However, little is known about the bleeding frequency following laser-assisted oral surgery in patients on coumarin drugs. Therefore, the purpose of this study was to compare retrospectively the frequency of bleeding complications following Nd:YAG laserassisted versus conventional local coagulation of blood in oral surgery. METHOD AND MATERIALS In October 2002, minor oral surgical interventions were found to be indicated in a total of 45 cardiac risk patients. In Group 1, blood coagulation was yielded in 24 patients with a Nd:YAG laser system, whereas in Group 2, treatment was performed in 21 patients with conventional means of local hemostasis. All therapies were performed continuing anticoagulant therapy between November 2002 and March 2003. Clinical data were recorded retrospectively from patient charts in May 2007. RESULTS In both Groups 1 and 2, a total of two bleeding complications were recorded. However, local re-interventions were sufficient for local hemostasis. CONCLUSION These results indicate that Nd:YAG laser-assisted local hemostasis was not able to prevent bleeding complications completely. Within the limitations of this retrospective study it was concluded that in patients with anticoagulant treatment undergoing minor oral surgery, Nd:YAG laser-assisted local hemostasis is not superior to conventional methods of blood coagulation with respect to the frequency of bleeding complications.

New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications

OBJECTIVES To review the incidence, clinical presentation, definite management and 1-year outcome in patients with aorto-oesophageal fistulation (AOF) following thoracic endovascular aortic repair (TEVAR). METHODS International multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2011 with a total caseload of 2387 TEVAR procedures (17 centres). RESULTS Thirty-six patients with a median age of 69 years (IQR 56-75), 25% females and 9 patients (19%) following previous aortic surgery were identified. The incidence of AOF in the entire cohort after TEVAR in the study period was 1.5%. The primary underlying aortic pathology for TEVAR was atherosclerotic aneurysm formation in 53% of patients and the median time to development of AOF was 90 days (IQR 30-150). Leading clinical symptoms were fever of unknown origin in 29 (81%), haematemesis in 19 (53%) and shock in 8 (22%) patients. Diagnosis could be confirmed via computed tomography in 92% of the cases with the leading sign of a new mediastinal mass in 28 (78%) patients. A conservative approach resulted in a 100% 1-year mortality, and 1-year survival for an oesophageal stenting-only approach was 17%. Survival after isolated oesophagectomy was 43%. The highest 1-year survival rate (46%) could be achieved via an aggressive treatment including radical oesophagectomy and aortic replacement [relative risk increase 1.73 95% confidence interval (CI) 1.03-2.92]. The survival advantage of this aggressive treatment modality could be confirmed in bootstrap analysis (95% CI 1.11-3.33). CONCLUSIONS The development of AOF is a rare but lethal complication after TEVAR, being associated with the need for emergency TEVAR as well as mediastinal haematoma formation. The only durable and successful approach to cure the disease is radical oesophagectomy and extensive aortic reconstruction. These findings may serve as a decision-making tool for physicians treating these complex patients.

Early troponin T and prediction of potentially correctable in-hospital complications after coronary artery bypass grafting surgery

BACKGROUND Peak levels of troponin T (TnT) reliably predict morbidity and mortality after cardiac surgery. However, the therapeutic window to manage CABG-related in-hospital complications may close before the peak is reached. We investigated whether early TnT levels correlate as well with complications after coronary artery bypass grafting (CABG) surgery. METHODS A 12 month consecutive series of patients undergoing elective isolated CABG procedures (mini-extra-corporeal circuit, Cardioplegic arrest) was analyzed. Logistic regression modeling was used to investigate whether TnT levels 6 to 8 hours after surgery were independently associated with in-hospital complications (either post-operative myocardial infarction, stroke, new-onset renal insufficiency, intensive care unit (ICU) readmission, prolonged ICU stay (>48 hours), prolonged need for vasopressors (>24 hours), resuscitation or death). RESULTS A total of 290 patients, including 36 patients with complications, was analyzed. Early TnT levels (odds ratio (OR): 6.8, 95% confidence interval (CI): 2.2-21.4, P=.001), logistic EuroSCORE (OR: 1.2, 95%CI: 1.0-1.3, P=.007) and the need for vasopressors during the first 6 postoperative hours (OR: 2.7, 95%CI: 1.0-7.1, P=.05) were independently associated with the risk of complications. With consideration of vasopressor use during the first 6 postoperative hours, the sum of specificity (0.958) and sensitivity (0.417) of TnT for subsequent complications was highest at a TnT cut-off value of 0.8 ng/mL. CONCLUSION Early TnT levels may be useful to guide ICU management of CABG patients. They predict clinically relevant complications within a potential therapeutic window, particularly in patients requiring vasopressors during the first postoperative hours, although with only moderate sensitivity.

The influence of body mass index on injury pattern in polytrauma: thorax as the main source of complications

Background: Obesity is a growing problem in industrial nations. The aim of this study was to determine the relationship between the body mass index (BMI) and the pattern of injury after polytrauma. Methods: This retrospective study included 651 patients with an injury severity score (ISS) ≥16 and aged ≥16 years who were subdivided into three groups: BMI < 25 kg/m2, BMI 25–30 kg/m2, and BMI > 30 kg/m2. The Abbreviated Injury Scale (AIS) was used to quantify the injuries in the different anatomical regions. The Murray score was assessed at admission and at its maximum during hospitalization to evaluate pulmonary problems. Data are presented as means ± standard errors of the means. One way analysis of variance, χ2 test and Kruskal-Wallis test were used for the analyses and the significance level was set at p < 0.05. Results: The AIS of the thorax was 3.2 ± 0.1 in the BMI < 25 kg/m2 group, 3.3 ± 0.1 in the BMI 25–30 kg/m2 group, and 2.8 ± 0.2 in the BMI > 30 kg/m2 group; p < 0.05. The Murray score at admission increased significantly with increasing BMI (0.8 ± 0.8 for BMI < 25 kg/m2, 0.9 ± 0.9 for BMI 25–30 kg/m2, and 1.0 ± 0.8 for BMI > 30 kg/m2; p < 0.05) as was the maximum Murray score during hospitalization (1.2 ± 0.9 for BMI < 25 kg/m2, 1.6 ± 1.0 for BMI 25–30 kg/m2, and 1.5 ± 0.9 for BMI > 30 kg/m2; p < 0.001). The number of ventilator days was also elevated significantly with increasing BMI (5.9 ± 0.4 for BMI < 25 kg/m2, 7.7 ± 0.8 for BMI 25–30 kg/m2, and 7.9 ± 1.6 for BMI > 30 kg/m2; p < 0.05). Conclusion: Overweight and obesity lead to a higher incidence of thoracic trauma in a polytrauma situation and may additionally handicap ventilation in an obstructive manner.

Restrictive deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy reduces postoperative complications and hospitalization time: a randomized clinical trial.

BACKGROUND Anesthetics and neuraxial anesthesia commonly result in vasodilation/hypotension. Norepinephrine counteracts this effect and thus allows for decreased intraoperative hydration. The authors investigated whether this approach could result in reduced postoperative complication rate. METHODS In this single-center, double-blind, randomized, superiority trial, 166 patients undergoing radical cystectomy and urinary diversion were equally allocated to receive 1 ml·kg·h of balanced Ringer's solution until the end of cystectomy and then 3 ml·kg·h until the end of surgery combined with preemptive norepinephrine infusion at an initial rate of 2 µg·kg·h (low-volume group; n = 83) or 6 ml·kg·h of balanced Ringer's solution throughout surgery (control group; n = 83). Primary outcome was the in-hospital complication rate. Secondary outcomes were hospitalization time, and 90-day mortality. RESULTS In-hospital complications occurred in 43 of 83 patients (52%) in the low-volume group and in 61 of 83 (73%) in the control group (relative risk, 0.70; 95% CI, 0.55-0.88; P = 0.006). The rates of gastrointestinal and cardiac complications were lower in the low-volume group than in the control group (5 [6%] vs. 31 [37%]; relative risk, 0.16; 95% CI, 0.07-0.39; P < 0.0001 and 17 [20%] vs. 39 [48%], relative risk, 0.43; 95% CI, 0.26-0.60; P = 0.0003, respectively). The median hospitalization time was 15 days [range, 11, 27d] in the low-volume group and 17 days [11, 95d] in the control group (P = 0.02). The 90-day mortality was 0% in the low-volume group and 4.8% in the control group (P = 0.12). CONCLUSION A restrictive-deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy and urinary diversion significantly reduced the postoperative complication rate and hospitalization time.

Risk factors associated with cast complications in horses: 398 cases (1997-2006)

OBJECTIVE To determine the frequency of and risk factors for complications associated with casts in horses. DESIGN Multicenter retrospective case series. ANIMALS 398 horses with a half-limb or full-limb cast treated at 1 of 4 hospitals. PROCEDURES Data collected from medical records included age, breed, sex, injury, limb affected, time from injury to hospital admission, surgical procedure performed, type of cast (bandage cast [BC; fiberglass tape applied over a bandage] or traditional cast [TC; fiberglass tape applied over polyurethane resin-impregnated foam]), limb position in cast (flexed, neutral, or extended), and complications. Risk factors for cast complications were identified via multiple logistic regression. RESULTS Cast complications were detected in 197 of 398 (49%) horses (18/53 [34%] horses with a BC and 179/345 [52%] horses with a TC). Of the 197 horses with complications, 152 (77%) had clinical signs of complications prior to cast removal; the most common clinical signs were increased lameness severity and visibly detectable soft tissue damage Cast sores were the most common complication (179/398 [45%] horses). Casts broke for 20 (5%) horses. Three (0.8%) horses developed a bone fracture attributable to casting Median time to detection of complications was 12 days and 8 days for horses with TCs and BCs, respectively. Complications developed in 71%, 48%, and 47% of horses with the casted limb in a flexed, neutral, and extended position, respectively. For horses with TCs, hospital, limb position in the cast, and sex were significant risk factors for development of cast complications. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that 49% of horses with a cast developed cast complications.

Intra- and postoperative complications of navigated and conventional techniques in percutaneous iliosacral screw fixation after pelvic fractures: Results from the German Pelvic Trauma Registry

Background: Percutaneous iliosacral screw placement following pelvic trauma is a very demanding technique involving a high rate of screw malpositions possibly associated with the risk of neurological damage or inadequate stability. In the conventional technique, the screw’s correct entry point and the small target corridor for the iliosacral screw may be difficult to visualise using an image intensifier. 2D and 3D navigation techniques may therefore be helpful tools. The aim of this multicentre study was to evaluate the intra- and postoperative complications after percutaneous screw implantation by classifying the fractures using data from a prospective pelvic trauma registry. The a priori hypothesis was that the navigation techniques have lower rates of intraoperative and postoperative complications. Methods: This study is based on data from the prospective pelvic trauma registry introduced by the German Society of Traumatology and the German Section of the AO/ASIF International in 1991. The registry provides data on all patients with pelvic fractures treated between July 2008 and June 2011 at any one of the 23 Level I trauma centres contributing to the registry. Results: A total of 2615 patients were identified. Out of these a further analysis was performed in 597 patients suffering injuries of the SI joint (187 � with surgical interventions) and 597 patients with sacral fractures (334 � with surgical interventions). The rate of intraoperative complications was not significantly different, with 10/114 patients undergoing navigated techniques (8.8%) and 14/239 patients in the conventional group (5.9%) for percutaneous screw implantation (p = 0.4242). Postoperative complications were analysed in 30/114 patients in the navigated group (26.3%) and in 70/239 patients (29.3%) in the conventional group (p = 0.6542). Patients who underwent no surgery had with 66/197 cases (33.5%) a relatively high rate of complications during their hospital stay. The rate of surgically-treated fractures was higher in the group with more unstable Type-C fractures, but the fracture classification had no significant influence on the rate of complications. Discussion: In this prospective multicentre study, the 2D/3D navigation techniques revealed similar results for the rate of intraoperative and postoperative complications compared to the conventional technique. The rate of neurological complications was significantly higher in the navigated group.

Systematic review of the survival rate and incidence of biologic, technical, and esthetic complications of single implant abutments supporting fixed prostheses

Purpose: To assess the 5-year survival rate and number of technical, biologic, and esthetic complications involving implant abutments. Materials and Methods: Electronic (Medline) and hand searches were performed to assess studies on metal and ceramic implant abutments. Relevant data from a previous review were included. Two reviewers independently extracted the data. Failure and complication rates were analyzed, and estimates of 5-year survival proportions were calculated from the relationship between event rate and survival function. Multivariable robust Poisson regression was used to compare abutment characteristics. Results: The search yielded 1,558 titles and 274 abstracts. Twenty-four studies were selected for data analysis. The survival rate for ceramic abutments was 97.5% (95% confidence interval [CI]): 89.6% to 99.4%) and 97.6% (95% CI: 96.2% to 98.5%) for metal abutments. The overall 5-year rate for technical complications was 11.8% (95% CI: 8.5% to 16.3%), 8.9% (95% CI: 4.3% to 17.7%) for ceramic and 12.0% (95% CI: 8.5% to 16.8%) for metal abutments. Biologic complications occurred with an overall rate of 6.4% (95% CI: 3.3% to 12.0%), 10.4% (95% CI: 1.9% to 46.7%) for ceramic, and 6.1% (95% CI: 3.1% to 12.0%) for metal abutments. Conclusions: The present meta-analysis on single-implant prostheses presents high survival rates of single implants, abutments, and prostheses after 5 years of function. No differences were found for the survival and failure rates of ceramic and metal abutments. No significant differences were found for technical, biologic, and esthetic complications of internally and externally connected abutments.