J.A. Rauwerda

Motives for (not) participating in a lifestyle intervention trial

BackgroundNon-participants can have a considerable influence on the external validity of a study. Therefore, we assessed the socio-demographic, health-related, and lifestyle behavioral differences between participants and non-participants in a comprehensive CVD lifestyle intervention trial, and explored the motives and barriers underlying the decision to participate or not.MethodsWe collected data on participants (n = 50) and non-participants (n = 50) who were eligible for inclusion in a comprehensive CVD lifestyle interventional trial. Questionnaires and a hospital patient records database were used to assess socio-demographic, health-related and lifestyle behavioral variables. Univariate and multivariate logistic regression was used to describe the relationship between explanatory variables and study participation. Furthermore, motives and barriers that underlie study participation were investigated by means of questionnaires.ResultsParticipants were younger, single, had a higher level of education and were employed. No statistically significant differences were found in health measures and behavioral variables. The motives for participation that were most frequently reported were: the perception of being unhealthy and willingness to change their lifestyle. The main barriers reported by non-participants were financial arguments and time investment.ConclusionThe differences between participants and non-participants in a lifestyle intervention trial are in mainly demographic factors. The participants consent in order to alter their lifestyle, and/or because they want to improve their health. To minimize non-participation, it is recommended that access to a lifestyle intervention program should be easy and cause no financial restraints.Trial registrationISRCTN69776211.

Low arginine plasma levels in patients after thoracoabdominal aortic surgery

Objective: Thoracoabdominal aortic surgery is a high-risk procedure and associated with a significant morbidity and mortality. Ischemia reperfusion of visceral organs and lower extremities is one of the most important determinants of this morbidity. Arginine is the precursor of nitric oxide and arginine plasma levels are important in maintaining organ blood flow. Furthermore, arginine is important in wound healing and the immune system. Because of increased utilization of arginine, low arginine plasma levels could be expected after thoracoabdominal aortic surgery. We therefore measured arginine plasma levels in these patients.Design: Six patients with thoracoabdominal aortic aneurysm were included in this study.Setting: University Hospital Vrije Universiteit, Department of Surgery, Amsterdam, The Netherlands.Subjects: Six patients undergoing thoracoabdominal aortic surgery.Intervention: Plasma levels of arginine were measured by high-performance liquid chromatography.Results: Very low arginine plasma levels were seen on the first postoperative day. From day 1 arginine slowly increased, but did not reach normal plasma levels on day 6.Conclusions: A significant decrease of arginine plasma levels was found and because of the fact that arginine has multiple functions, it may be important to keep these arginine plasma levels at normal or even higher levels in patients undergoing major vascular surgery.European Journal of Clinical Nutrition (2000) 54, 615–617.

Novel applications of therapeutic hypothermia: report of three cases

Therapeutic hypothermia can provide neuroprotection in various situations where global or focal neurological injury has occurred. Hypothermia has been shown to be effective in a large number of animal experiments. In clinical trials, hypothermia has been used in patients with postanoxic injury following cardiopulmonary resuscitation, in traumatic brain injury with high intracranial pressure, in the perioperative setting during various surgical procedures and for various other indications. There is thus evidence that hypothermia can be effective in various situations of neurological injury, although a number of questions remain unanswered. We describe three patients with unusual causes of neurological injury, whose clinical situation was in fundamental aspects analogous to conditions where hypothermia has been shown to be effective.

The effect of a comprehensive lifestyle intervention on cardiovascular risk factors in pharmacologically treated patients with stable cardiovascular disease compared to usual care: a randomised controlled trial

BackgroundThe additional benefit of lifestyle interventions in patients receiving cardioprotective drug treatment to improve cardiovascular risk profile is not fully established.The objective was to evaluate the effectiveness of a target-driven multidisciplinary structured lifestyle intervention programme of 6 months duration aimed at maximum reduction of cardiovascular risk factors in patients with cardiovascular disease (CVD) compared with usual care.MethodsA single centre, two arm, parallel group randomised controlled trial was performed. Patients with stable established CVD and at least one lifestyle-related risk factor were recruited from the vascular and cardiology outpatient departments of the university hospital. Blocked randomisation was used to allocate patients to the intervention (n = 71) or control group (n = 75) using an on-site computer system combined with allocations in computer-generated tables of random numbers kept in a locked computer file. The intervention group received the comprehensive lifestyle intervention offered in a specialised outpatient clinic in addition to usual care. The control group continued to receive usual care. Outcome measures were the lifestyle-related cardiovascular risk factors: smoking, physical activity, physical fitness, diet, blood pressure, plasma total/HDL/LDL cholesterol concentrations, BMI, waist circumference, and changes in medication.ResultsThe intervention led to increased physical activity/fitness levels and an improved cardiovascular risk factor profile (reduced BMI and waist circumference). In this setting, cardiovascular risk management for blood pressure and lipid levels by prophylactic treatment for CVD in usual care was already close to optimal as reflected in baseline levels. There was no significant improvement in any other risk factor.ConclusionsEven in CVD patients receiving good clinical care and using cardioprotective drug treatment, a comprehensive lifestyle intervention had a beneficial effect on some cardiovascular risk factors. In the present era of cardiovascular therapy and with the increasing numbers of overweight and physically inactive patients, this study confirms the importance of risk factor control through lifestyle modification as a supplement to more intensified drug treatment in patients with CVD.Trial registrationISRCTN69776211 at http://www.controlled-trials.com

Fenestrated and Branched Endografts: Assessment of Proximal Aortic Neck Fixation

Purpose: To investigate proximal fixation characteristics of different aortic endograft designs: a suprarenally placed fenestrated endograft, a modular branched endograft, an infrarenal endograft with suprarenal bare stent fixation, and the gold standard, a conventional hand-sewn anastomosis. Methods: Ten human cadaveric aortas were obtained at autopsy and transected 20 mm below the renal arteries to mimic an infrarenal aneurysm neck. In random order, the infrarenal, fenestrated, and branched endografts were deployed into the aorta. Using a hydraulic material testing machine, longitudinal load was applied to the distal end of each endograft until migration occurred, thus defining the displacement force (DF). Subsequently, a hand-sewn infrarenal anastomosis was tested in a similar manner. Results: The median DF was 4.67 N (3.82–6.37) for the infrarenal endograft, 9.17 N (8.03–10.81) for the fenestrated endograft, and 16.95 N (14.78–19.67) for the branched endograft. The differences in DF between the infrarenal and fenestrated endografts and between the fenestrated and branched designs were statistically significant (both p=0.005). The median force to dislodge the graft from the conventional anastomosis was 89.16 N (71.24–105.23). Conclusions: Suprarenally placed endografts, especially with additional branch grafts, provide improved proximal fixation compared to an infrarenal endograft with suprarenal bare stent fixation. However, none of the tested endografts approached the optimal, time-proven fixation, the hand-sewn anastomosis.

Plasma ADMA concentrations at birth and mechanical ventilation in preterm infants: A prospective pilot study

Nitric oxide (NO) produced in the lung is an important mediator of normal lung development, vascular smooth muscle relaxation, and ventilation perfusion matching. NO is synthesized from arginine by the action of NO‐synthase (NOS). Asymmetric dimethylarginine (ADMA), an endogenous derivate of arginine, inhibits NOS and is thereby a determinant of NO synthesis. We compared ADMA and arginine levels in preterm infants requiring mechanical ventilation with preterm infants who did not require mechanical ventilation and determined the relation between ADMA and the length of mechanical ventilation in these infants.

Robotic Selective Postganglionic Thoracic Sympathectomy for the Treatment of Hyperhidrosis

BACKGROUND The surgical management of hyperhidrosis is controversial. Robotic surgical systems with their high-definition magnified 3-dimensional view and increased maneuverability in a confined space may facilitate the technique of selective sympathectomy (ramicotomy). We present a case series of patients undergoing selective postganglionic thoracic sympathectomy using robotic technology. METHODS This study is a case series analysis of patients who underwent selective postganglionic thoracic sympathectomy from July 2006 to November 2011. The operation was performed on a video-assisted thoracoscopic surgery (VATS) platform. The robot was used for pleural dissection and division of the postganglionic sympathetic fibers and the communicating rami. The success of sympathectomy was assessed by intraoperative temperature measurement of the ipsilateral upper extremity, patient interviews, and scoring of the symptomatic nature of hyperhidrosis based on the Hyperhidrosis Disease Severity Scale. RESULTS There were 110 sympathectomies performed in 55 patients (25 men, 30 women). Simultaneous bilateral sympathectomy was performed in all patients. Median age was 28 years (range, 16 to 65 years). There was no conversion to thoracotomy. Complications were minor and were seen in 5 of 55 patients (9%). There were no deaths. Median hospital stay was 1 day (range, 1 to 4 days). Of the 55 patients, 53 (96%) had sustained relief of their hyperhidrosis at a median follow-up of 24 months (range, 3 to 36 months), and compensatory sweating was seen in 4 patients (7.2%). CONCLUSIONS Robotic thoracoscopic selective sympathectomy is an effective, feasible, and safe procedure with excellent relief of hyperhidrosis and low rates of compensatory sweating and complications.

Endoscopic thoracic sympathectomy: long-term results for treatment of upper limb hyperhidrosis and facial blushing.

Abstract Background : Endoscopic thoracic sympthectomy (ETS) is frequently used in the management of patients with hyperhidrosis and excessive blushing. Long term-follow up is scarce. We retrospectively reviewed long-term morbidity, success and overall patient satisfaction rates in patients operated in our department. Method : Data of all patients undergoing ETS for either upper limb hyperhidrosis or facial blushing and sweating between January 1994 and December 2006 were reviewed. A standard questionnaire inquiring on relief of symptoms, satisfaction with the operation and occurrence of compensatory sweating (CS) was sent out in January 2008. Results : We performed bilateral thoracoscopic sympathectomies in 73 patients. There were no operative mortalities, minor complications occurred in 22%. Initial success rate was 88%. Median follow up was 93 (24–168) months, response rate to the questionnaire was 85%. Sixty-nine per cent of patients continued to have relief of initial symptoms, whereas patient satisfaction rate was 56%. CS was present in 42 patients (68%). Long-term satisfaction rates per initial indication group were 42% for facial blushing and 65% for hyperhidrosis (n.s.), and CS was present in 79% vs 61%, respectively. Conclusion : ETS appears a safe treatment for upper limb hyperhydrosis with acceptable long-term results. For excessive blushing, however, long term satifaction rates of ETS are severely hampered by a high incidence of disturbing compensatory sweating. ETS should only be indicated in patients with unbearable symptoms refractory to non-surgical treatment. The patient information must include the long-term substantial risk for sever CS and regret of the procedure.

Intraoperative continuous hemofiltration for metabolic management in acute aortoiliac occlusion

Acute aortoiliac occlusion, or Leriches syndrome, carries a risk of the development of severe ischemia-reperfusion injury, characterized by electrolyte and acid-base balance disturbances. These injuries are often fatal, because of the rapid deterioration of multiple organ systems. We present a case in which we intraoperatively and postoperatively treated hyperkalemia and metabolic acidosis by high-volume, continuous, veno-venous hemofiltration, which is a recently developed form of continuous renal replacement therapy.

Homocysteine Induces Phosphatidylserine Exposure in Cardiomyocytes through Inhibition of Rho Kinase and Flippase Activity.

Aims: Increased levels of homocysteine (Hcy) form an independent risk factor for cardiovascular disease. In a previous study we have shown that Hcy induced phosphatidylserine (PS) exposure to the outer leaflet of the plasma membrane in cardiomyocytes, inducing a pro-inflammatory phenotype. In the present study the mechanism(s) involved in Hcy-induced PS exposure were analyzed. Methods: H9c2 rat cardiomyoblasts were subjected to 2.5 mM D,L-Hcy and analyzed for RhoA translocation and activity, Rho Kinase (ROCK) activity and expression and flippase activity. In addition, the effect of ROCK inhibition with Y27632 on Hcy-induced PS exposure and flippase activity was analyzed. Furthermore, GTP and ATP levels were determined. Results: Incubation of H9c2 cells with 2.5 mM D,L-Hcy did not inhibit RhoA translocation to the plasma membrane. Neither did it inhibit activation of RhoA, even though GTP levels were significantly decreased. Hcy did significantly inhibit ROCK activation, but not its expression, and did inhibit flippase activity, in advance of a significant decrease in ATP levels. ROCK inhibition via Y27632 did not have significant added effects on this. Conclusion: Hcy induced PS exposure in the outer leaflet of the plasma membrane in cardiomyocytes via inhibition of ROCK and flippase activity. As such Hcy may induce cardiomyocytes vulnerable to inflammation in vivo in hyperhomocysteinaemia patients.