A silicone-based slippery polymer coating with humidity–dependent nanoscale topography

HYPOTHESIS

Slippery Omniphobic Covalently Attached Liquids (SOCAL) have been proposed for making omnirepellent thin films of self-assembled dimethylsiloxane polymer brushes grafted from silica surfaces. Smooth and flat at very small scale, these fluid surfaces could exhibit a more complex multiscale structure though showing very weak contact angle hysteresis (less than 5°).

EXPERIMENT

In this work, coatings were deposited on glass surfaces from an acidic dimethoxydimethylsilane solution under carefully controlled relative humidity. Ellipsometry mapping was used to analyze the surface structuration with nanometric thickness sensitivity. The sliding properties were determined using a drop shape analyzer with a tilting device, and chemical analyses of the coatings were performed using on-surface techniques (XPS, ATR-FTIR spectroscopy).

FINDINGS

Coated materials possessed an unexpected surface structure with multiscale semispherical-like features, which surprisingly, did not increase the contact angle hysteresis. A careful study of some parameters of the coating process and the related evolution of the surface properties allowed us to propose a new model of the chemical organization of the polymer to support this remarkable liquid-like behavior. These structures are made of end-grafted strongly adsorbed Guiselin brushes with humidity-dependent thickness: the higher the humidity, the thinner and the more slippery the coating.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

P-156 cellular uptake of polystyrene nanoplastics by oocytes and their impact on subsequent embryo development: a preliminary insight using a bovine in vitro model

Study question

Can polystyrene nanoplastics enter cumulus-enclosed oocytes (CEOs) and consequently alter oocyte quality and embryo development? Is this effect particle size-dependent?

Summary answer

After 24h in vitro exposure, polystyrene-nanoplastics entered the extracellular matrix and cytoplasm of peripheral cumulus cells, but not oocytes. Preimplantation embryo development was not altered.

What is known already

The ubiquitous use of plastic resulted in extreme global environmental plastic pollution. Chemical and physical processes contribute to the fragmentation of these macroplastic pollutants into heterogenous nanoplastics (NPs). Plastic intake is inevitable for humans by inhalation and ingestion of contaminated air, food (e.g. plastic ingested fish) and drinks (e.g. leakage of plastic bottles). Once imbibed, particles smaller than 150 µm can spread across the entire human body and reach the blood and lymphatic tissue. Due to the neovascularisation associated with an increased vascular permeability during follicular development, nanoparticles might reach the ovarian follicles, potentially affecting oocyte quality and embryo development.

Study design, size, duration

In a bottom-up approach, using a bovine in vitro oocyte maturation model, CEOs were exposed for 24h to 100µg/mL plain Nile Red-labelled polystyrene-nanoplastics (PS-NP) with average diameter of 50nm (PS-NP-50) or plain Flash Red-labelled PS-NP with average diameter of 200nm (PS-NP-200) (4 replicates using 714 CEOs). CEOs in NP-free control media (CONT) and in-vehicle control (SOLV) were included. Oocytes were in vitro fertilized (for 20h) and presumptive zygotes were cultured until 8 days post-insemination (p.i.).

Participants/materials, setting, methods

CEOs were fixed after IVM and examined for cumulus cell (CCs) expansion. The presence of NPs was assessed with laser-scanning Leica SP8 confocal microscope. Cleavage (48h p.i.) and blastocyst rates (8 days p.i.) were recorded together with differential staining of trophectoderm (TE, CDX2) and inner cell mass (ICM, Hoechst). The apoptotic-cell-index of the CCs and blastocysts was examined with Caspase-3 immunostaining. Images were quantified using ImageJ. Data were analysed using binary logistic regression and ANOVA.

Main results and the role of chance

At 24h of IVM, both PS-NP-50 and PS-NP-200 could be detected in the extracellular matrix surrounding the CCs and even within the cytoplasm of a few CCs in the outer layers of the CEOs. No NPs could be detected within the oocytes.

Irrespective of the size of the NP’s, no significant differences in cumulus expansion rate or embryo cleavage rate were observed and no difference in apoptotic-cell-index of the CCs could be demonstrated due to a plastic effect (P > 0.1). However, the blastocyst/cleaved rate of PS-NP-50 (56%) was significantly higher than SOLV (36%, p < 0.05). On top, PS-NP-50 showed a lower apoptotic-cell-index (4.11±0.90) of the TE compared to CONT (7.08±0.99, p < 0.1), SOLV (9.09±1.49, p < 0.05) and PS-NP-200 (7.65±1.09, p < 0.05).

There is a complete lack of univocal and sound scientific evidence of the actual amount of human plastic intake, making it difficult to determine a physiologically relevant concentration for testing possible effects. However, despite the high plastic concentration used in our model, no deteriorating effects on oocyte quality and embryo development were proven.

Limitations, reasons for caution

Exposure for only 24h during IVM resulted in a limited timeframe for uptake, consequently exerting its effects. However, long-term in vitro follicle culture models are not as straightforward. Limited reports give insight into the final destination of NPs inside the body, addressing the necessity for in vivo trials as confirmation.

Wider implications of the findings

While this study indicate that PS-NPs are not toxic for oocyte developmental competence upon direct exposure, this does not rule out the potential impact on e.g. embryo gene expression patterns and epigenetic programming. Future studies should also focus on indirect effects on the oocyte as PS-NP may alter follicular physiology.

Trial registration number

not applicable

Video assisted thoracoscopy or laparoscopy for enucleation of esophageal leiomyoma: A seven-year single center experience of 75 cases

OBJECTIVE

Leiomyoma is the most common benign tumor of the esophagus. Extra mucosal enucleation is the standard treatment. Herein we evaluated the feasibility and the outcomes of Minimally Invasive Surgery (MIS) using video-assisted thoracoscopic (VATS) or laparoscopic surgery (VALS) for esophageal leiomyoma enucleation.

SUBJECTS AND METHODS

Retrospective study of patients who were treated via VATS or VALS for esophageal leiomyoma enucleation in "Hanoi Viet Duc Hospital" from 2010 to 2017 by the same operator. The operative approach, tumor size, complications and outcomes after surgery were recorded.

RESULTS

Seventy-five patients were included. Mean age was 41.9 (range 20-68) years. The male/female sex ratio was 2.1:1. Fifty-five patients had clinical symptoms (73.3%). Tumors were identified in the upper third (12%), middle third (51%), and lower third (37%) of the esophagus. Mean tumor size was 3.7 (range 2-11) cm. VALS enucleation was performed in 23 patients who had leiomyoma located near the cardia (gastroesophageal junction or abdominal esophagus). The remaining 52 patients underwent right (n=42) or left VATS (n=10). Five patients (6.7%) sustained esophageal mucosa injury during dissection, repaired by MIS without late morbidity. A mini-incision (2 mini-laparotomies and 1 thoracotomy) was required in three patients (4%) due to large tumor size or mucosal injury. The mean operative time was 105min in VATS and 174min in VALS. No major perioperative surgical or medical complications were reported. The mean duration of hospital stay was 7.2 (range 5-12) days.

CONCLUSIONS

MIS enucleation of esophageal leiomyoma is technically safe and associated with a high therapeutic success rate with low medico-surgical morbidity. VATS could be applied for almost all esophageal leiomyoma tumors; however, the VALS approach was preferred for tumors located near the gastroesophageal junction in order to create an anti-reflux valve after enucleation.

Invasive rhino-orbital-cerebral aspergillosis in an immunocompetent patient

INTRODUCTION

Rhino-orbital-aspergillosis (ROA) is a rare but serious disease in immunocompetent patients. Diagnosis is often delayed due to the absence of specific clinical symptoms. We describe the case of a patient who presented initially with ROA which spread progressively to the right ethmoid-sphenoid sinuses and then to the brain.

OBSERVATION

A 61-year-old patient with a history of well-controlled diabetes presented with a sudden severe decrease in right visual acuity. Cerebral MRI showed the presence of an infiltrate in the right orbital apex extending to the homolateral cavernous sinus without any cerebral involvement. A diagnosis of right orbital myositis was made and corticosteroid therapy was started. His symptoms worsened progressively leading to quasi-blindness. A new MRI showed the development of right sphenoid-ethmoid osteolytic lesions. A fungal aetiology was suspected and tests for fungal biomarkers found a β-(1-3)-D-glucan level of 99pg/ml but negative galactomannan. An ethmoid biopsy was performed for histological and mycological investigations, including the detection of Aspergillus DNA by qPCR. qPCR was positive and culture resulted in the isolation of multi-sensitive Aspergillus fumigatus. Treatment was initiated with voriconazole. Due to persistence of blindness and the appearance of a lesion extending to the right frontal lobe, surgical excision was performed followed by antifungal treatment for a total duration of 1year. The patient is currently stable, but has persistence of blindness in the right eye.

CONCLUSION

Invasive ROA is a rare but serious disease in immunocompetent patients which should be evoked in the differential diagnosis of a tumour or vasculitis. Early diagnosis is essential for optimal management.

3 Dietary caloric normalization or restriction as preconception care strategies: Impact on metabolic health and fertility in high fat-induced obese outbred mice

Maternal metabolic disorders such as obesity and metabolic syndrome are linked to decreased oocyte and embryo quality and thus reproductive failure. Overweight and obese patients are advised to lose weight before conception to increase the chance of a healthy pregnancy. Human studies show conflicting results and are often underpowered, leading to a lack of scientifically substantiated advice. Furthermore, the effects of significant weight loss, due to caloric restriction, on oocyte quality are not known. Therefore, we aimed to feed a normal control or low-calorie diet as a preconception care strategy in high-fat-fed obese Swiss mice to improve their metabolic health and oocyte quality. Five-week-old female outbred Swiss mice (as a model for human physiology) were fed a control (CTRL; 10% fat) or a high-fat (HF; 60% fat) diet for seven weeks. Afterward, HF mice were switched to different preconception care interventions (PCCI) for six weeks, resulting in four treatment groups: (1) control diet for 13 weeks (CTRL_CTRL), (2) high fat diet for 13 weeks (HF_HF), (3) switch from a HF to an ad libitum CTRL diet (HF_CTRL), and (4) switch to a 30% caloric restriction diet (HF_CR). Change in bodyweight (twice a week, n=156 mice), metabolic health (glucose and insulin tolerance tests; n=32 mice), oocyte quality and pregnancy rates (n=32 mice) were studied. To assess oocyte quality, mature oocytes were collected after hormonal stimulation (10IU equine chorionic gonadotrophin followed by 10IU human chorionic gonadotrophin 48h later, IP injected) to evaluate oocyte lipid content (Bodipy staining; 11-12 oocytes/group) and to examine mitochondrial ultrastructure by transmission electron microscopy (4-5 oocytes/group). All data were analysed using analysis of variance and Bonferroni corrected. In comparison with the CTRL group, HF diet increased bodyweight after seven weeks (40.01±0.54g vs. 32.01±0.47 g; P<0.05). After 2 weeks of PCCI, both HF_CTRL and HF_CR mice had lost weight, reaching similar weights as control mice. Overall, the deteriorated glucose tolerance and insulin sensitivity in the HF_HF group were normalized to levels similar to the CTRL_CTRL group in both PCCI. Transmission electron microscopy of HF_HF oocytes showed higher proportions of mitochondrial ultrastructural abnormalities, e.g. low electron density and rose petal appearance (Boudoures et al. 2016 Reproduction 151(3):261-270) compared with CTRL_CTRL (54.70% vs. 30.52%; P<0.05). After six weeks of PCCI, the proportions of mitochondrial abnormalities were partially reduced in both HF_CTRL (39.64%) and HF_CR (44.47%) groups. The HF_HF diet increased the intracellular lipid content in oocytes with 84.41% compared with the CTRL_CTRL group (P<0.05). However, both PCCI strategies failed to alleviate this effect. The HF_HF-fed mice displayed lower pregnancy rates compared with those on the CTRL_CTRL diet (12.5% vs. 100%; P<0.05). Pregnancy rates were completely restored in the HF_CTRL and HF_CR group. In conclusion, both PCCI improved metabolic health (reduced weight, restored glucose tolerance and insulin sensitivity), partially improved oocyte quality, and restored pregnancy rates in HF-induced obese mice.

70 Trolox during invitro maturation of bovine oocytes protects developing embryos from palmitic acid-induced lipotoxicity

Maternal metabolic disorders are associated with elevated concentrations of palmitic acid (PA), which is known to jeopardize bovine oocyte and embryo development and quality. Analyses of PA-exposed bovine oocytes and embryos point toward oxidative stress (OS)-related pathways. Previous research has shown that the detrimental effects of PA exposure during oocyte IVM cannot be alleviated by antioxidant supplementation, e.g. Trolox (TR, water-soluble vitamin E), during IVM or invitro culture (IVC). In contrast, supplementing TR during IVM could protect developing zygotes from PA-induced lipotoxicity by increasing their development into 4-cell embryos and Day 8 blastocysts. In the present study, we examined the effects of TR during IVM or IVC on PA-exposed oocytes and embryos by evaluating OS and mitochondrial membrane potential (MMP) of the produced ≥2-cell Day 2 embryos (Table 1). Bovine cumulus-oocyte complexes (COCs) were matured, fertilised, and cultured in 2 experiments. In Experiment 1, COCs were exposed to pathophysiological follicular PA concentrations (150 µM), and subsequent embryos were cultured under solvent control (ethanol) conditions (PA-SC). The TR treatment was applied during IVM or IVC (100 µM; PATR-SC, PA-TR). In Experiment 2, COCs were matured under SC conditions, and subsequent embryos were exposed to pathophysiological oviductal PA concentrations (230 µM; SC-PA). The TR treatment was applied during IVM or IVC (100 µM; TR-PA, SC-PATR). In each experiment, a SC was included (SC-SC). A total of 126 and 137 Day 2 embryos were stained with JC-1 and CellRox Deep Red in Experiment 1 and Experiment 2 (3 repeats), respectively. The MMP was evaluated as active/total mitochondria and OS as OS/total mitochondria and analysed by one-way ANOVA. Exposure of oocytes and embryos to PA significantly increased OS and MMP in Day 2 embryos compared with controls. Regardless of the moment of PA exposure, TR treatment during IVM increased MMP even more. The increased MMP levels in PA-exposed oocytes and embryos were not influenced by TR treatment during IVC. Regardless of the antioxidant effect of TR, increased embryonic OS levels observed in PA-exposed oocytes and embryos could not be reversed to control levels by TR treatment during IVM or IVC. However, when OS levels were expressed on active mitochondria, we found that TR treatment before the PA insult (TR-PA) generated Day 2 embryos that displayed significantly lower OS/active mitochondria rates compared with SC-PA-treated embryos. Taken together, we conclude that the combination of relatively low OS levels with highly active mitochondria may be a mechanism implicated in the protective effect of TR before the PA insult on embryo developmental competence. Table 1.Effects of TR during IVM or IVC on PA-exposed oocytes and embryos in Experiments 1 and 2 Controls PA exposure TR during IVM TR during IVC SC-SC PA-SC PATR-SC PA-TR Exp. 1 MMP 0.39±0.02a 0.53±0.02b 0.65±0.02c 0.50±0.02b OS 0.55±0.04a 0.68±0.04b 0.78±0.03b 0.59±0.03ab SC-SC SC-PA TR-PA SC-PATR Exp. 2 MMP 0.39±0.02a 0.50±0.02b 0.65±0.02c 0.58±0.02b OS 0.55±0.04a 0.69±0.04b 0.70±0.03b 0.71±0.02b abcDifferent letters in the same row indicate significant differences (P<0.05).

1178Unsuspected role of the cardiac PKA type I in excitation-contraction coupling and in heart failure development

The cAMP-dependent protein kinase (PKA) consists of two regulatory (R) and two catalytic (C) subunits and comprises two subtypes, PKAI and PKAII, defined by the nature of their regulatory subunits, RIα and RIIα respectively. Whereas PKAII is thought to play a key role in β-adrenergic (β-AR) regulation of cardiac contractility, the function of PKAI is unclear. To address this question, we generated mice with cardiomyocyte-specific and conditional invalidation of the RIα subunit of PKA. Tamoxifen injection in 8 weeks-old mice resulted in a >70% decrease in RIα protein without modification of other PKA subunits, which was associated with ∼2-fold increased basal PKA activity in RIα-KO mice (p<0.05, N=6/group). This translated into enhanced cardiac contraction and relaxation, as observed in vivo by increased fractional shortening and E-wave velocity (p<0.05, N=10/group) and ex vivo by increased LV pressure and maximal rate of contraction and relaxation (p<0.05, N=9/group). L-type Ca2+ current density was increased in ventricular myocytes from RIα-KO, and β-AR stimulation was decreased by ∼50% (p<0.05, n=38 cells for WT, and, n=40 for RIα-KO). Consistently, Ca2+ transients amplitude and relaxation kinetics were increased, along with increased occurrence of Ca2+ sparks and waves (p<0.05, n=44 cells for WT, and, n=50 for RIα KO). Phosphorylation of Ca2+ channels (CaV1.2), PLB, RyR2 and cMyBP-C at PKA sites was increased >2-fold (p<0.05, N=6/group) in RIα KO without modification of total protein expression. With age, these mice developed a congestive heart failure (HF) phenotype with massive hypertrophy and fibrosis which eventually led to death in 50% of RIα-KO mice at 50 weeks (versus 0% in WT, p<0.01). These results reveal a previously unsuspected role of PKA type I in cardiac excitation-contraction coupling and HF.

Prospective Trial on Probe-Based Confocal Laser Endomicroscopy for the Identification of the Distal Limit in Rectal Adenocarcinoma

Background. Intraoperative decision of the level of distal resection in rectal cancer is often imprecise, based exclusively on digital examination and pretherapeutic imaging. Design. Prospective, single institution, nonrandomized trial ( ClinicalTrial.gov identification no. NCT01887509) to evaluate the contribution of probe-based confocal laser endomicroscopy (pCLE) to establish the optimal resection margin of rectal adenocarcinoma. The primary outcome was the concordance in the identification of lower tumor margins between pCLE and histopathology. For each patient, pCLE examination was performed on nonneoplastic and neoplastic aspects of the distal tumor margin, before and after neoadjuvant chemoradiation, or preceding surgery, if chemoradiation was not required. Biopsies were taken at the same locations. The intraclass correlation coefficient was determined. Results. Twenty-one patients were enrolled. Thirteen patients completed the full study. Six patients completed imaging only before chemoradiation. Two patients retracted their consent after inclusion. A total of 134 videos and corresponding histopathology samplings were analyzed. The sensitivity and specificity of in vivo pCLE interpretation were 0.915 (95% confidence interval [CI] = 0.840-0.970) and 0.736 (95% CI = 0.657-0.821), respectively. The sensitivity and specificity of the blinded pCLE reinterpretation were 0.930 (95% CI = 0.858-0.980) and 0.688 (95% CI = 0.600-0.770), respectively. No deep layer tumor infiltration was encountered in the samplings with superficial healthy layers. The intraclass correlation coefficient for in vivo pCLE interpretation and blinded pCLE reinterpretation were 0.747 (95% CI = 0.257-0.993) and 0.766 (95% CI = 0.280-0.995), respectively. Conclusions. This supports the concordance between pCLE and histopathology in identifying the “tumor-free” limit of a rectal tumor preceding resection.

A step towards stereotactic navigation during pelvic surgery: 3D nerve topography

Background

Long-term morbidity after multimodal treatment for rectal cancer is suggested to be mainly made up by nerve-injury-related dysfunctions. Stereotactic navigation for rectal surgery was shown to be feasible and will be facilitated by highlighting structures at risk of iatrogenic damage. The aim of this study was to investigate the ability to make a 3D map of the pelvic nerves with magnetic resonance imaging (MRI).

Methods

A systematic review was performed to identify a main positional reference for each pelvic nerve and plexus. The nerves were manually delineated in 20 volunteers who were scanned with a 3-T MRI. The nerve identifiability rate and the likelihood of nerve identification correctness were determined.

Results

The analysis included 61 studies on pelvic nerve anatomy. A main positional reference was defined for each nerve. On MRI, the sacral nerves, the lumbosacral plexus, and the obturator nerve could be identified bilaterally in all volunteers. The sympathetic trunk could be identified in 19 of 20 volunteers bilaterally (95%). The superior hypogastric plexus, the hypogastric nerve, and the inferior hypogastric plexus could be identified bilaterally in 14 (70%), 16 (80%), and 14 (70%) of the 20 volunteers, respectively. The pudendal nerve could be identified in 17 (85%) volunteers on the right side and in 13 (65%) volunteers on the left side. The levator ani nerve could be identified in only a few volunteers. Except for the levator ani nerve, the radiologist and the anatomist agreed that the delineated nerve depicted the correct nerve in 100% of the cases.

Conclusion

Pelvic nerves at risk of injury are usually visible on high-resolution MRI with dedicated scanning protocols. A specific knowledge of their course and its application in stereotactic navigation is suggested to improve quality of life by decreasing the likelihood of nerve injury.

Electronic supplementary material

The online version of this article (10.1007/s00464-018-6086-3) contains supplementary material, which is available to authorized users.

Inkjet Printing NiO-Based p-Type Dye-Sensitized Solar Cells

Fabrication at low cost of transparent p-type semiconductors with suitable electronic properties is essential toward the scalability of many electronic devices, especially for photovoltaic and photocatalytic applications. In this context, the synthesis of mesoporous NiO films through inkjet printing of a sol-gel ink was investigated for the first time. Nickel chloride and Pluronic F-127, used as nickel oxide precursor and pore-forming agent, respectively, were formulated in a water/ethanol mixture to prepare a jettable ink for Dimatix printer. Multilayer NiO films were formed, and different morphologies could be obtained by playing on the interlayer thermal treatment. At low temperature (30 °C), a porous nanoparticulate-nanofiber dual-pore structure was observed. On the other hand, with a high temperature treatment (450 °C), nanoparticulate denser films without any dual structure were obtained. The mechanism for NiO formation during the final sintering step, investigated by means of X-ray photolectron spectroscopy, shows that a Ni(OH)₂ species is an intermediate between NiCl₂ and NiO. The different morphologies and thicknesses of the NiO films were correlated to their performance in a p-DSSC configuration, using a new push-pull dye (so-called "RBG-174") and an iodine-based electrolyte. Moreover, the positive impact of a nanometric NiO_x layer deposited by spin-coating and introduced between FTO and the NiO mesoporous network is highlighted in the present work. The best results were obtained with NiO_x/four layer-NiO mesoporous photocathodes of 860 nm, with a current density at the short circuit of 3.42 mA cm^-2 (irradiance of 100 mW cm^-2 spectroscopically distributed following AM 1.5).

Appropriateness of aminoglycoside prescriptions in a French university hospital

INTRODUCTION

Aminoglycosides are a major class of antibiotics. Their use is particularly interesting in the treatment of severe infections but their toxicity is well known. They are mostly prescribed combined with other agents and as first-line treatments. We aimed to assess the appropriateness of aminoglycoside prescriptions in a French university hospital on the basis of the latest French recommendations published in 2011.

METHOD

We conducted a prospective study between January 17th and February 4th, 2014 to assess prescription modalities of aminoglycosides on the basis of the following criteria: indication, duration of treatment, dosing schedule, administration modalities, and drug level monitoring. Prescriptions were then compared to the 2011 national guidelines.

RESULTS

A total of 68 consecutive prescriptions were analyzed and only 47.8% complied with guidelines. Most physicians complied with recommendations, particularly with the indication for severe infections (95.6%), the administration of a single daily dose (92.6%), and the slow intravenous infusion (30minutes) administration (84%). However, physicians tended to prescribe lower doses than recommended (40.3%), especially to patients presenting with renal insufficiency, and drug level monitoring was not optimal.

CONCLUSION

Although new and accurate national recommendations were recently published, aminoglycoside prescription is still not optimal, in particular for dosing and plasma concentration monitoring.

Surgical antibiotic prophylaxis compliance in a university hospital

OBJECTIVE

To assess surgical antibiotic prophylaxis (SAP) practices in a university hospital in order to identify risk factors associated with non-compliance.

STUDY DESIGN

Retrospective monocentric study conducted over a 4-month period.

PATIENTS AND METHODS

Data were collected from the software used in the operating theatre. Practice non-compliance was evaluated in comparison with the 2010 version of the French national recommendations. We only took in account the interventions identified as priority surveillance interventions according to the surgical site infections national surveillance. The risk factors associated with SAP non-compliance were identified with a multivariate statistical analysis.

RESULTS

We evaluated 1312 SAPs. Among the 1298 indicated SAPs, 44.4% were not compliant. The most frequent inappropriate criterion was the timing of injection (34.8% non-compliance), which was, in the majority of cases, too close to the time of incision. Other inappropriate criteria were identified: antibiotic choice for patients allergic to β-lactams (inappropriate among 45% of allergic patients), and antibiotic dosing for obese patients (96% of non-compliance). Obesity (OR=84.32), allergy to β-lactams (OR=17.11) and certain types of surgery (digestive, OR=4.56; gynaecological and obstetrical, OR=7.10; urological, OR=3.95) were independently associated with the non-compliance of SAP practices.

CONCLUSION

Improvement measures that target the timing of injection, obese or allergic patients are necessary.

Is ileostomy always necessary following rectal resection for deep infiltrating endometriosis?

OBJECTIVE

To verify the hypothesis that in most patients bowel segmental resection to treat endometriosis can be safely performed without creation of a stoma and to discuss the limitations of this statement.

DESIGN

Retrospective study (Canadian Task Force classification III).

SETTING

Tertiary referral center.

PATIENTS

Forty-one women with sigmoid and rectal endometriotic lesions who underwent segmental resection.

INTERVENTION

Segmental resection procedures performed between 2004 and 2011. Patient demographic, operative, and postoperative data were compared.

MEASUREMENTS AND MAIN RESULTS

Sigmoid resection was performed in 6 patients (15%), and rectal anterior resection in 35 patients (high in 21 patients [51%], and low, i.e., <10 cm from the anal verge, in 14 [34%]). In 4 patients a temporary ileostomy was created. There was 1 anastomotic leak (2.4%), in a patient with an unprotected anastomosis, which was treated via laparoscopic surgery and creation of a temporary ileostomy. Other postoperative complications included hemoperitoneum, pelvic abscess, pelvic collection, and a ureteral vaginal fistula, in 1 patient each (all 2.4%).

CONCLUSION

A protective stoma may be averted in low anastomosis if it is >5 cm from the anal verge and there are no adverse intraoperative events.

Clinical Evaluation of an Internal Adjustable Retractor in Laparoscopic Cholecystectomy

Introduction. Reducing the number of abdominal incisions in laparoscopic cholecystectomy introduces ergonomic challenges while establishing the critical view during dissection of the triangle of Calot (TC). This study investigates the use of a novel internal retracting device in performing cholecystectomy with a reduced number of ports. Methods. A 3-port laparoscopic cholecystectomy was attempted by 4 surgeons unfamiliar with the novel device. Exposure of the TC was obtained using the internal retractor, which comprises 2 clips, linked by an adjustable thread. One clip is fixed on the gallbladder and the other is fixed to the peritoneum. The endpoint was to evaluate the efficacy and reliability of the device in establishing the critical view of safety. Results. Thirteen patients with a mean body mass index of 25.29 kg/m2(standard deviation = 6.24; range = 17.6-36.7 kg/m2) were included in the study. The critical view was obtained in 10 of 13 patients. Application of the device was completed in a median time of 2.25 minutes without injury of the gallbladder or bile leak. Failure occurred in 3 patients, related to wrong manipulation of the device (2 patients), and correct placement of the device but inadequate exposure (1 patient). A conventional 4-port technique was used in these patients. Operators rated their experience with the device as an “easy-to-operate” device with a good safety profile and without any interference with the operative process. Conclusions. Throughout the minimization process specific to minimal access surgery, internal retractors will certainly allow for a reduction in the number of trocars used in laparoscopic procedures.

Totally laparoscopic intracorporeal anastomosis with natural orifice specimen extraction (NOSE) techniques, particularly suitable for bowel endometriosis

The objective of this retrospective study was to evaluate the feasibility of natural orifice specimen extraction (NOSE) techniques in 41 patients undergoing bowel resection for treatment of deep infiltrating endometriosis. In all patients laparoscopic treatment of rectovaginal endometriosis with bowel resection had been performed. In 32 patients the classic approach was adopted (group 1), and in 9 a NOSE technique was performed (group 2). Demographic, operative, and postoperative data were compared. Statistical analyses were performed using SPSS software, version 16.0. When needed, qualitative variables were compared using the χ(2) test or the Fisher exact test. Quantitative variables using the t-test were used. The threshold of statistical significance was set at p = .05. No statistically significant difference was observed between the 2 groups. Eight complications (19.5%) were observed, 2 minor (4.8%) and 6 major (14.6%). Of major complications, 2 were observed in the NOSE group (n = 2; 22.2%). It was concluded that the NOSE technique is a feasible approach in patients undergoing bowel resection for treatment of deep infiltrating endometriosis.

Career decisions: factors that influence the Māori doctor

BACKGROUND

Māori have known health disparities that may be addressed through increasing the cultural competency of New Zealand's medical workforce. There is a paucity of Māori health professionals choosing paediatrics or adult medicine as a career and the factors influencing their career decision are yet to be explored.

AIMS

First, to differentiate factors influencing the medical career choice of non-Māori paediatricians and physicians, Māori paediatricians and physicians and other Māori doctors. Second, to identify ways in which Māori doctors may be encouraged to choose paediatricians or adult medicine.

METHODS

A questionnaire was distributed by email to New Zealand physicians and paediatricians and to Māori doctors. Questions included demographic information, a matrix rating table and open-ended questions.

RESULTS

Altogether 199 people accessed the questionnaire. Response rates were 9% (n = 118) for non-Māori paediatricians and physicians, 70% (n = 19) for Māori paediatricians and physicians, and 31% (n = 62) for other Māori doctors. Māori paediatricians and physicians highlighted mentoring as having significant impact on career choice. Non-Māori paediatricians and physicians regarded interest as having the most influence on career choice (P < 0.01). Lifestyle factors influenced other Māori doctors (P < 0.001). All three groups regarded poor lifestyle as having the largest negative influence. No group regarded potential income as important.

CONCLUSION

Mentoring provides an opportunity to attract Māori into paediatric and adult physician training. The use of existing mentoring programmes could facilitate in expanding Māori RACP workforce development. This extended Māori workforce would have benefits for the health of New Zealand as a whole.

Innovations in minimally invasive surgery: lessons learned from translational animal models

PURPOSE

Animal models are key elements of surgical research and promotion of new techniques. Inanimate models, anatomical specimens, and living animals are all necessary to solve the various problems encountered by the advent of a new surgical technique. The development of Natural Orifice Transluminal Endoscopic Surgery (NOTES) procedures is a representative model.

METHODS

Over 400 experimental procedures were performed in inanimate models, ex vivo tissues and animals to solve all problems faced by the development of NOTES surgery: peritoneal access, gastrotomy closure, exposure, retraction, dissection as well as education to start this new procedure.

RESULTS

The successive use of all models allows to identify the ideal solution for each problem and to precisely define the safest and most reliable option to apply the new technique in patients. It allowed to perform the first transvaginal and transgastric cholecystectomy in patients in a safe way.

CONCLUSION

Animal experimentation remains necessary as even sophisticated computer-based solutions are unable to model all interactions between molecules, cells, tissues, organisms, and their environment. Animal research is required in many areas to validate new technologies, develop training, let alone its major goal (namely to avoid using patients for experimentation) which is to be the first "model" for the surgeon.

MAGNAMOSIS IV: magnetic compression anastomosis for minimally invasive colorectal surgery

BACKGROUND AND STUDY AIMS

MAGNAMOSIS forms a compression anastomosis using self-assembling magnetic rings that can be delivered via flexible endoscopy. The system has proven to be effective in full-thickness porcine small-bowel anastomoses. The aim of this study was to show the feasibility of the MAGNAMOSIS system in hybrid endoscopic colorectal surgery and to compare magnetic and conventional stapled anastomoses.

METHODS

A total of 16 swine weighing 35 - 50 kg were used following animal ethical committee approval. The first animal was an acute model to establish the feasibility of the procedure. The subsequent 15 animals were survival models, 10 of which underwent side-to-side anastomoses (SSA) and 5 of which underwent end-to-side (ESA) procedures. Time to patency, surveillance endoscopy, burst pressure, compression force, and histology were assessed. Histology was compared with conventional stapled anastomoses. Magnetic compression forces were measured in various anastomosis configurations.

RESULTS

Colorectal anastomoses were performed in all cases using a hybrid NOTES technique. The mean operating time was 71 minutes. Mean time to completion of the anastomosis was similar between the SSA and ESA groups. Burst pressure at 10 days was greater than 95 mmHg in both groups. One complication occurred in the ESA group. Compression force among various configurations of the magnetic rings was significantly different (P < 0.05). Inflammation and fibrosis were similar between magnetic SSA and conventional stapled anastomoses.

CONCLUSION

MAGNAMOSIS was feasible in performing a hybrid NOTES colorectal anastomosis. It has the advantage over circular staplers of precise endoscopic delivery throughout the entire colon. SSA was reliable and effective. A minimum initial compression force of 4 N appears to be required for reliable magnetic anastomoses.

Antibiotic prescription in nursing homes for dependent elderly people: a cross-sectional study in Franche-Comté

OBJECTIVES

We had for objective to determine the rate of patients treated with antibiotics and the determinants of antibiotic stewardship in nursing homes for dependent elderly people (French acronym EHPAD), of a French region (Franche-Comté).

PATIENTS AND METHODS

A representative sample of EHPAD, in Franche-Comté, was included in a cross-sectional study made between April and June 2012. An external auditor and the EHPAD head physician collected data on the facility and on residents receiving antibiotics on the study day. An infectious diseases specialist and an infection control practitioner analyzed each prescription, a posteriori, to assess criteria of antimicrobial stewardship including re-assessment of the prescription between 48 and 72h after initiation of antibiotic treatment.

RESULTS

Sixty-one (2.76%) of the 2210 residents in 18 nursing homes were under antibiotic treatment. This rate ranged from 0% to 7.5% among nursing homes. Sixty-two percent of prescriptions complied with recommendations regarding the choice of the drug, and 41.5% could not be improved by choosing an agent with a weaker ecological impact. Globally, 17.8% of prescriptions met all stewardship criteria including re-assessment of the prescription between 48 and 72h after initiation of antibiotic treatment.

CONCLUSIONS

The study results differed. The rate of antibiotic prescription was low in Franche-Comté EHPAD compared to available European data, but antibiotic therapy could be greatly improved. This stresses the need to better train EHPAD physicians for antibiotic stewardship.

Laparoscopic sigmoidectomy for endometriosis with transanal specimen extraction

STUDY OBJECTIVE

To describe a more conservative and less invasive surgical approach to laparoscopic colorectal segmental resection for treatment of endometriosis.

DESIGN

Video of elective sigmoidectomy to treat colorectal endometriosis.

SETTING

Tertiary referral center for laparoscopic gynecologic surgery at the University Hospitals of Strasbourg, France.

PATIENT

A 29-year-old woman with dysmenorrhea, constipation, and cyclic diarrhea and two sigmoid endometriotic lesions evident at colonoscopy.

INTERVENTION

The conservative surgical strategy, possible in cases of benign lesions such as endometriosis, consists of dividing the mesentery close to the digestive tract to preserve the vascular-lymphatic vessels and the surrounding sympathetic and parasympathetic nerves. The less invasive approach consists of natural orifice specimen extraction via the transanal route.

MEASUREMENTS AND MAIN RESULTS

The postoperative course was favorable. The conservative technique enables preservation of the superior rectal vessels, which contribute to 80% of the vascularization of the rectum, to maintain the best vascularization, essential for intestinal anastomosis. Transanal specimen extraction maximizes the benefits of laparoscopy by sparing the abdominal wall from incision and its associated complications.

CONCLUSION

A conservative surgical approach should be used in segmental bowel resection for treatment of endometriosis. Moreover, the segmental bowel resection can be safely performed with transanal specimen extraction, with great advantages for the patient.

Quantitative polymerase chain reaction detection of circulating DNA in serum for early diagnosis of mucormycosis in immunocompromised patients

BACKGROUND

The aim of our study was to assess the detection of circulating DNA from the most common species of Mucorales for early diagnosis of mucormycosis in at-risk patients.

METHODS

We retrospectively evaluated a combination of 3 quantitative polymerase chain reaction (qPCR) assays using hydrolysis probes targeting Mucor/Rhizopus, Lichtheimia (formerly Absidia), and Rhizomucor for circulating Mucorales detection. Serial serum samples from 10 patients diagnosed with proven mucormycosis (2-9 samples per patient) were analyzed.

RESULTS

No cross-reactivity was detected in the 3 qPCR assays using 19 reference strains of opportunistic fungi, and the limit of detection ranged from 3.7 to 15 femtograms/10 µL, depending on the species. DNA from Mucorales was detected in the serum of 9 of 10 patients between 68 and 3 days before mucormycosis diagnosis was confirmed by histopathological examination and/or positive culture. All the qPCR results were concordant with culture and/or PCR-based identification of the causing agents in tissue (Lichtheimia species, Rhizomucor species, and Mucor/Rhizopus species in 4, 3, and 2 patients, respectively). Quantitative PCR was negative in only 1 patient with proven disseminated mucormycosis caused by Lichtheimia species.

CONCLUSION

Our study suggests that using specific qPCR targeting several species of Mucorales according to local ecology to screen at-risk patients could be useful in a clinical setting. The cost and efficacy of this strategy should be evaluated. However, given the human and economic cost of mucormycosis and the need for rapid diagnosis to initiate prompt directed antifungal therapy, this strategy could be highly attractive.

Small bowel exploration and resection using single-port surgery: a safe and feasible approach

AIM

The aim of this study is to demonstrate the efficacy of wireless capsule endoscopy for preoperative identification of bleeding sources and/or small bowel tumours in surgical patients and to evaluate the feasibility of single-port surgery in the treatment of such pathologies.

METHOD

Five patients presenting with obscure gastrointestinal bleeding or/and mild small bowel obstruction were investigated to diagnose and localize the bleeding source or tumour using capsule endoscopy imaging, and, if necessary, with other investigative modalities. All patients were operated on using single-port surgery for small bowel exploration, lesion confirmation, small bowel resection and anastomosis.

RESULTS

Small bowel pathology was successfully detected by video capsule endoscopy in three of four patients, and was further substantiated by contrast CT, double-balloon endoscopy or enteroclysis. Complete small bowel exploration, intra-operative identification and oncological resection of the involved segment and anastomosis (intracorporeal and extracorporeal) was successfully performed in all five patients using single-port access without any complication, morbidity or mortality.

CONCLUSION

This study demonstrates the feasibility and safety of single-port small bowel resection performed after a high-quality preoperative localization of the tumour.

Appropriate use of carbapenems in the Besançon university hospital

INTRODUCTION

The excessive and inappropriate use of carbapenems is responsible for the development of resistance. The scientific community has been requiring caution and using these agents in specific cases only.

OBJECTIVES

The authors had for aim to evaluate the appropriate use of carbapenems in a French university hospital.

DESIGN

A retrospective survey was made over two months as a clinical audit to assess professional practices. The evaluation criteria for this audit were: the appropriateness of the indication, the possibility of alternative therapeutic strategies, the choice of an antibiotic combination, duration of treatment and dosage.

RESULTS

During the audit period, 103 carbapenem prescriptions were included. Ninety-nine cases were analyzed. Among the carbapenem prescriptions, 28.3% (28/99) did not meet the criterion "appropriateness of the indication". Carbapenems were mostly prescribed empirically (60/99 [60%]) and most often for lung infections or nosocomial urinary tract infections. Finally, 66.7% (66/99) of all prescriptions were considered inappropriate for at least one criterion. The rate of inappropriateness ranged around 30% for each criterion.

CONCLUSIONS

This study allowed us to assess professional practices for carbapenem prescriptions. The overall rate of inappropriateness was quite important. Carbapenems were not always used appropriately. These findings highlight the need of new regional guidelines and regular updating of local best practices recommendations. Finally, a stricter validation of carbapenem prescriptions will be implemented at the hospital pharmacy level.