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Objectives Magnetic resonance venography (MRV) is underutilized in the evaluation of thrombus properties prior to endovascular treatment but may improve procedural outcomes. We therefore investigated the clinical impact of using a dedicated MRV scoring system to assess thrombus characteristics prior to endovascular intervention for iliofemoral deep vein thrombosis (DVT). Methods This is a post hoc analysis of data from the CAVA trial (Clinicaltrials.gov:NCT00970619). MRV studies of patients receiving ultrasound-accelerated catheter-directed thrombolysis (CDT) for iliofemoral DVT were reviewed. Thrombus age-related imaging characteristics were scored and translated into an overall score (acute, subacute, or old). MRV scores were compared to patient-reported complaints. MRV-scored groups were compared for CDT duration and success rate. Results Fifty-six patients (29 men; age 50.8 ± 16.4 years) were included. Using MRV, 27 thrombi were classified acute, 17 subacute, and 12 old. Based on patient-reported complaints, 11 (91.7%) of these old thrombi would have been categorized acute or subacute, and one (3.7%) of the acute thrombi as old. Average duration of CDT to > 90% restored patency differed significantly between groups (p < 0.0001): average duration was 23 h for acute thromboses (range: 19–25), 43 h for subacute (range: 41–62), and 85 h for old thromboses (range: 74–96). CDT was almost eleven times more successful in thromboses characterized as acute and subacute compared to old thromboses (OR: 10.7; 95% CI 2.1–55.5). Conclusion A dedicated MRV scoring system can safely discriminate between acute, subacute, and old thromboses. MRV-based selection is predictive of procedural duration and success rate and can help avoid unnecessary complications. Key Points • Thrombus age, characterized by MRV as acute, subacute, and old, can predict CDT duration and probability of success. • Accurate pre-interventional MRV-based thrombus aging has the potential to facilitate identification of eligible patients and may thus prevent CDT-related complications.

Background The CAVA trial did not show the anticipated risk reduction for postthrombotic syndrome (PTS) after thrombus removal via additional ultrasound-accelerated catheter-directed thrombolysis (UACDT) in patients with acute iliofemoral deep vein thrombosis (IFDVT). Difficulties in achieving an effective degree of recanalization through thrombolysis may have influenced outcomes. We therefore assessed whether successful UACDT (restored patency ≥ 90%) did reduce the development of PTS. Methods This CAVA trial post hoc analysis compared the proportion of PTS at 1-year follow-up between patients with successful UACDT and patients that received standard treatment only. In addition, clinical impact as well as determinants of successful thrombolysis were explored. Results UACDT was initiated in 77 (50.7%) patients and considered successful in 41 (53.2%, interrater agreement κ = 0.7, 95% confidence interval 0.47–0.83). PTS developed in 15/41 (36.6%) patients in the successful UACDT group versus 33/75 (44.0%) controls (p = 0.44). In this comparison, successful UACDT was associated with lower Venous Clinical Severity Score (3.50 ± 2.57 vs. 4.82 ± 2.74, p = 0.02) and higher EuroQOL-5D (EQ-5D) scores (40.2 ± 36.4 vs. 23.4 ± 34.4, p = 0.01). Compared with unsuccessful UACDT, successful UACDT was associated with a shorter symptom duration at inclusion (p = 0.05), and higher rates of performed adjunctive procedures (p Conclusion Successful UACDT was not associated with a reduced proportion of PTS 1 year after acute IFDVT compared with patients receiving standard treatment alone. There was, however, a significant reduction in symptom severity and improvement of generic quality of life according to the EQ-5D. Better patient selection and optimization of treatment protocols are needed to assess the full potential of UACDT for the prevention of PTS. Trial Registration Number ClinicalTrials.gov number, NCT00970619.

Background: A Bochdalek hernia is one of the most frequently occurring congenital diaphragmatic hernias, and it occurs in 1 out of 2,500 births. Clinical cases of adults with symptomatic Bochdalek hernias are very rare. We describe a patient with an incarcerated Bochdalek hernia who underwent emergency surgery and presented with a recurrence after three years. Comparable cases in the literature were reviewed. Case Presentation: A 56-year-old woman presented to the emergency department with acute dyspnea and pain in the epigastrium shortly after gastroscopy. A CT scan showed right sided intrathoracic herniation of the ascending colon and signs of perforation of a hollow viscus. During the operation, a suture repair of a cecal perforation as well as of a diagrammatic lesion was performed. The thorax and abdomen were lavaged and drained. The postoperative course was uneventful. After 3 years, the patient presented with colic pain in the upper abdominal quadrants. A small recurrence of the Bochdalek hernia was observed on a computed tomography scan and was managed with watchful waiting. A systematic search of comparable acute cases of Bochdalek hernias was performed. Conclusion: An incarcerated right colon with a perforation in a Bochdalek hernia is extremely rare; only 11 comparable cases of right sided Bochdalek hernia with acute symptoms are described in the literature. Recurrent Bochdalek hernias are even rarer. As a delay in the diagnosis or a missed diagnosis can ultimately lead to death, adequate imaging is warranted when considering a recurrence of a Bochdalek hernia.

Magnetic resonance venography (MRV) is underutilized in the evaluation of thrombus properties prior to endovascular treatment but may improve procedural outcomes. We therefore investigated the clinical impact of using a dedicated MRV scoring system to assess thrombus characteristics prior to endovascular intervention for iliofemoral deep vein thrombosis (DVT).This is a post hoc analysis of data from the CAVA trial ( Clinicaltrials.gov :NCT00970619). MRV studies of patients receiving ultrasound-accelerated catheter-directed thrombolysis (CDT) for iliofemoral DVT were reviewed. Thrombus age-related imaging characteristics were scored and translated into an overall score (acute, subacute, or old). MRV scores were compared to patient-reported complaints. MRV-scored groups were compared for CDT duration and success rate.Fifty-six patients (29 men; age 50.8 ± 16.4 years) were included. Using MRV, 27 thrombi were classified acute, 17 subacute, and 12 old. Based on patient-reported complaints, 11 (91.7%) of these old thrombi would have been categorized acute or subacute, and one (3.7%) of the acute thrombi as old. Average duration of CDT to90% restored patency differed significantly between groups (p0.0001): average duration was 23 h for acute thromboses (range: 19-25), 43 h for subacute (range: 41-62), and 85 h for old thromboses (range: 74-96). CDT was almost eleven times more successful in thromboses characterized as acute and subacute compared to old thromboses (OR: 10.7; 95% CI 2.1-55.5).A dedicated MRV scoring system can safely discriminate between acute, subacute, and old thromboses. MRV-based selection is predictive of procedural duration and success rate and can help avoid unnecessary complications.• Thrombus age, characterized by MRV as acute, subacute, and old, can predict CDT duration and probability of success. • Accurate pre-interventional MRV-based thrombus aging has the potential to facilitate identification of eligible patients and may thus prevent CDT-related complications.

OBJECTIVES: This study sought to compare heparin-bonded endografts with femoropopliteal bypass, including quality of life, using general health and disease-specific questionnaires as well as patency rates.BACKGROUND: Endovascular treatment continues to advance and is gaining acceptance as primary treatment for long occlusive or stenotic lesions in the superficial femoral artery. Heparin-bonded expanded polytetrafluoroethylene endografts have been related to outcomes comparable to bypass surgery, but this has not been tested in a randomized fashion.METHODS: A multicenter randomized-controlled trial was performed comparing femoropopliteal bypass with heparin-bonded expanded polytetrafluoroethylene endografts. Data were analyzed on an intention-to-treat and per-protocol manner.RESULTS: A total of 129 patients were randomized and 125 patients were treated, 63 in the endoluminal and 62 in the surgical group (42 venous, 20 prosthetic). Enrollment was terminated before reaching the predefined target number for patency. Baseline characteristics and anatomical data were similar. Patients were treated for critical limb ischemia in 38.1% and 32.2% in the endoluminal and surgical arms, respectively. Mean lesion length was 23 cm in both groups and lesions were largely TransAtlantic Inter-Society Consensus II D. Hospitalization time and 30-day morbidity were significantly lower in the endoluminal group, without differences in serious adverse events (n = 5 each; surgical: 4 venous and 1 polytetrafluoroethylene bypass). There were no significant differences in Rutherford category between groups at any time point. At 30 days the endoluminal group showed a greater improvement in quality-of-life scores. At 1 year, these differences had largely disappeared and no differences in primary (endoluminal: 64.8%; surgical: 63.6%), assisted primary (endoluminal: 78.1%; surgical: 79.8%), secondary patency (endoluminal: 85.9%; surgical: 83.3%), and target vessel revascularization (endoluminal: 72.1%; surgical: 71.0%) were observed. Limb salvage rate was 100% in both groups.CONCLUSIONS: Heparin-bonded endoluminal bypass for long segment lesions shows promising results (less morbidity, faster recovery, and improvement in quality of life with indistinguishable patency rates at 1 year) compared with surgical bypass. Long-term results have to be awaited.

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

Seawater solutions of environmentally relevant organosulfur compounds, commercial humic acid (HA), and natural dissolved organic matter (DOM) were incubated with and without UV light in order to determine the carbonyl sulfide (COS) producing capabilities of these compounds. COS dark- and photo-production rate constants were determined for dilute solutions of the organosulfur compounds (μmol l−1) and HA/DOM (mg l−1). Dissolved COS was determined using a purge and cryogenic trap method followed by GC/FPD detection. COS was produced in considerable amounts both non-photochemically and photochemically from the reduced form of free acid of glutathione (GSH) and photochemically from cysteine (CYS). Other organosulfur compounds yielded little or no COS. Photosensitizers, such as commercial HA and natural DOM, photo-catalyzed COS production from several of the chemicals tested and from unknown COS precursors in the seawater samples. HA itself was found to contain COS precursors. We propose that reactions of thiyl radicals with carbonyl compounds play an important role in COS formation from the organosulfur compounds studied.

During the EGAMES (Evasion of GAses from the MEditerranean Sea) expedition in the Aegean and eastern Ionian Sea in July 1993, we measured atmospheric and sea surface concentrations of carbonyl sulfide (COS). The surface waters were found to be supersaturated with respect to the atmosphere at all times with an average saturation ratio of 2.6 in open ocean areas and 5.2 in coastal areas. Using air-sea exchange coefficients based on the empirical model by Liss and Merlivat (1986), we estimated an average COS flux of 55 nmol m−2 day−1 from the ocean into the atmosphere. Although the supersaturation of COS was twice as high in coastal areas, during our cruise the flux was not different from open ocean areas because of extremely low windspeeds encountered at coastal areas. We observed a clear diel cycle for coastal area averages and open ocean averages of COS. This cycle could be described using an empirical model including terms for photoproduction, dark production, hydrolysis and air-sea exchange. The in situ COS photoproduction rates were found to be 0.12 fmol l−1 s−1 W−1 m2 for coastal areas and 0.03 fmol 1−1 s−1 W−1 m2 for open ocean areas. After correction to surface light intensities, the coastal and open ocean photoproduction rates were 0.99 and 0.08 fmol l−1 s−1 W−1 m2. Our model provides a satisfactory fit to the open ocean field measurements only if a dark production term is included. The dark production rates were 0.38 and 0.55 fmol l−1 s−1, for coastal and open ocean areas, respectively. From incubation experiments with open ocean waters carried out on board the R.V. Aegaio we found average photoproduction rates of 0.09 fmol l−1 s−1 W−1 m2 and dark production rates of 0.42 fmol 1−1 s−1, which are very close to the values found in sea surface open ocean waters. Finally, we observed photo decomposition of methyl mercaptane (MeSH) at a rate between 0.41 and 1.7 fmol l−1 s−1 W−1 m2 suggesting MeSH as a potential precursor of COS.

Item does not contain fulltext Redo femoropopliteal bypass surgery is associated with increased morbidity and related to a poorer outcome than primary procedures. Endografts might provide an alternative, avoiding dissection of a previously operated groin. Patients treated with a polytetrafluoroethylene-covered stents for superficial femoral artery occlusive disease between February 2009 and September 2011 were prospectively gathered. Demographics, clinical status, procedural aspects, and follow-up were retrieved. Seventy-four patients were included of which 5 (7%) were treated before with a femoropopliteal bypass. Indication for intervention was Rutherford category 3 in all patients and the median ankle-brachial index (ABI) was 0.68. Technical success was achieved in all cases. The postoperative course was uneventful in all and the ABI increased to 0.95. After a follow-up period of 18 months, 4 of 5 endografts remained patent. The use of endografts after failed femoropopliteal bypass surgery is feasible and safe and could be used to avoid or minimize a difficult and hazardous dissection of a previously operated area. 01 mei 2012

Intra-abdominal abscesses are a potential source of recurrent or residual infection after surgical intervention for secondary peritonitis. The development of therapies requires a model which combines low mortality with the formation of persisting abscesses and which is also suitable to study the local inflammatory response. Male Wistar rats were injected intraperitoneally with a mixture of sterile rat faeces, increasing doses of E. coli (10(4)-10(8) cfu/ml) and a fixed dose of B. Fragilis (10(4) cfu/ml). After one h a laparotomy was performed and the peritoneal cavity was debrided. Blood samples were taken under anaesthesia after 6 and 24 h. Abdominal fluid samples were collected (by laparotomy) after 24 and 72 h. The rats were killed after 5 days and the abdomen was inspected for abscesses. Mortality was 90% in the two groups with the highest doses of E. coli and 30% in those with the two lowest doses. In the latter groups all surviving rats but one showed intraabdominal abscesses and bacteremia was encountered frequently, especially after 24 h in the 10(5) cfu E. coli group. The groups receiving 10(4)-10(6) cfu E. coli showed similar plasma IL-6 concentrations after 6 h which were lowered significantly after 24 h. No circulating TNF-alpha was found. Considerable concentrations of TNF-alpha, IL-6, IL-1beta, and IL-10, were found in the peritoneal fluid after 24 h but no differences were observed between the contro groups and those receiving 10(4)-10(6) cfu E. coli. At 72 h cytokine levels were reduced significantly and remained the highest in the animals dosed with 10(6) cfu E. coli. The present model is suitable to study the mechanisms involved in, and prevention of, intra-abdominal abscess formation after surgical treatment of generalized peritonitis.

Carbonyl sulfide (COS) is formed photochemically from chromophoric dissolved organic matter (CDOM) in surface sea water. Its inertness against photo-oxidation allows COS to be transported into the stratosphere, where it is photodissociated and oxidised to sustain the background concentration of the stratospheric sulfate aerosol. This sulfuric acid aerosol is believed to affect the earth’s radiation balance as well as heterogeneous reactions linked to ozone depletion.