Jaap F. Hamming

Improving Diagnosis of Acute Appendicitis: Results of a Diagnostic Pathway with Standard Use of Ultrasonography Followed by Selective Use of CT

BACKGROUND Preoperative imaging has been demonstrated to improve diagnostic accuracy in appendicitis. This prospective study assessed the accuracy of a diagnostic pathway in acute appendicitis using ultrasonography (US) and complementary contrast-enhanced multidetector CT in a general community teaching hospital. STUDY DESIGN One hundred fifty-one patients with clinically suspected appendicitis followed the designed protocol: patients underwent operations after a primary performed positive US (graded compression technique) or after complementary CT (contrast-enhanced multidetector CT) when US was negative or inconclusive. Patients with positive CT findings underwent operations. When CT was negative for appendicitis, they were admitted for observation. Results of US and CT were correlated with surgical findings, histopathology, and followup. RESULTS Positive US was confirmed at operation in 71 of 79 patients and positive CT was confirmed in all 21 patients. All 39 patients with negative CT findings recovered without operations. The negative appendicitis rate was 8% and perforation rate was 9%. The sensitivity and specificity of US was 77% and 86%, respectively. The sensitivity and specificity of CT was both 100%. The sensitivity and specificity of the whole diagnostic pathway was 100% and 86%, respectively. CONCLUSIONS A diagnostic pathway using primary graded compression US and complementary multidetector CT in a general community teaching hospital yields a high diagnostic accuracy for acute appendicitis without adverse events from delay in treatment. Although US is less accurate than CT, it can be used as a primary imaging modality, avoiding the disadvantages of CT. For those patients with negative US and CT findings, observation is safe.

Doxycycline for Stabilization of Abdominal Aortic Aneurysms: A Randomized Trial

BACKGROUND Doxycycline inhibits formation and progression of abdominal aortic aneurysms (AAAs) in preclinical models of the disease, but it is unclear whether and how this observation translates to humans. OBJECTIVE To test whether doxycycline inhibits AAA progression in humans. DESIGN Randomized, placebo-controlled, double-blind trial. (Dutch Trial Registry: NTR 1345) SETTING: 14 Dutch hospitals. PATIENTS 286 patients with small AAAs between October 2008 and June 2011. INTERVENTION Daily dose of 100 mg of doxycycline (n = 144) or placebo (n = 142) for 18 months. MEASUREMENTS The primary outcome measure was aneurysm growth at 18 months, as estimated by repeated single-observer ultrasonography. Secondary outcomes included growth at 6 and 12 months and the need for elective surgery. RESULTS Mean aneurysm diameter (approximately 43 mm) and other baseline characteristics were similar in both groups. Doxycycline treatment was associated with increased aneurysm growth (4.1 mm in the doxycycline group vs. 3.3 mm in the placebo group at 18 months; difference, 0.8 mm [95% CI, 0.1 to 1.4 mm]; P = 0.016 mm). Twenty-one patients receiving doxycycline and 22 patients receiving placebo had elective surgical repair (Kaplan–Meier estimates were 16.1% for those receiving doxycycline and 16.5% for those receiving placebo; difference, -0.4% [CI, -9.3% to 8.5%]; P = 0.83). Time to repair was similar in the groups (P = 0.92). LIMITATIONS This study focuses on patients with small AAAs. As such, whether the data can be extrapolated to larger AAAs (>55 mm) is unclear. The high number of elective repairs (n = 43) was unanticipated. Moreover, the study did not follow patients who withdrew because of an adverse effect. CONCLUSION This trial found that 18 months of doxycycline therapy did not reduce aneurysm growth and did not influence the need for AAA repair or time to repair. PRIMARY FUNDING SOURCE The Netherlands Organisation for Health Research and Development, and the NutsOhra Fund.

Variations in Surgical Procedures for Hind Limb Ischaemia Mouse Models Result in differences in Collateral Formation

OBJECTIVE To identify the optimal mouse model for hind limb ischaemia, which offers a therapeutic window that is large enough to detect improvements of blood flow recovery, for example, using cell therapies. MATERIALS AND METHODS Different surgical approaches were performed: single coagulation of femoral and iliac artery, total excision of femoral artery and double coagulation of femoral and iliac artery. Blood flow restoration was analysed with laser Doppler perfusion imaging (LDPI). Immuno-histochemical stainings, angiography and micro-computed tomography (CT) scans were performed for visualisation of collaterals in the mouse. RESULTS Significant differences in flow restoration were observed depending on the surgical procedure. After single coagulation, blood flow already restored 100% in 7 days, in contrast to a significant delayed flow restoration after double coagulation (54% after 28 days, P<0.001). After total excision, blood flow was 100% recovered within 28 days. Compared with total excision, double coagulation displayed more pronounced corkscrew phenotype of the vessels typical for collateral arteries on angiographs. CONCLUSION The extent of the arterial injury is associated with different patterns of perfusion restoration. The double coagulation mouse model is, in our hands, the best model for studying new therapeutic approaches as it offers a therapeutic window in which improvements can be monitored efficiently.

Depressive symptoms in peripheral arterial disease: A follow-up study on prevalence, stability, and risk factors

BACKGROUND Depressive symptoms are associated with poor prognosis in coronary artery disease, but there is a paucity of research on these symptoms in peripheral arterial disease (PAD). We examined the clinical correlates and 18-month course of depressive symptoms in PAD patients. METHODS 166 patients with symptomatic lower-extremity PAD (39% women; M age=64.9 +/- 10 years) completed the 10-item Center for Epidemiological Studies Depression scale. A score > or =4 indicates clinically relevant depressive symptoms. Depressive symptoms were re-assessed at 6, 12, and 18 months follow-up. Ankle-brachial index (ABI) and treadmill walking distance were used to assess PAD severity. RESULTS At baseline, depressive symptoms (CES-D > or =4) were present in 16% of the patients. Depressed patients performed worse regarding pain free (p=0.003) and maximum (p=0.005) walking distance. After adjusting for age, sex, education, ABI, psychotropic medication use, cardiovascular risk factors, and comorbidity, depressive symptoms remained stable in initially depressed patients. Using mixed modelling, three subgroups were identified in the total sample. The majority of PAD patients did not have depressive symptoms (58%), but there were two groups who persistently experienced either subclinical (27%) or clinically manifest (15%) depressive symptoms. LIMITATIONS Only baseline data of ABI and treadmill walking performance were available. CONCLUSIONS Depressive symptomatology was present in a substantial number of PAD patients, tended to be stable, and was associated with reduced walking distance. These apparently evident results are overlooked thus far in this patient group and deserve further attention in research and clinical care.

Colonic diverticulitis: a prospective analysis of diagnostic accuracy and clinical decision-making.

Objective  To evaluate the diagnostic accuracy of clinical evaluation and cross‐sectional imaging modalities such as ultrasound and computed tomography for patients with suspected colonic diverticulitis and to determine the value of these examinations in clinical decision‐making.

Early magnetic resonance imaging compared with bone scintigraphy in suspected scaphoid fractures

We evaluated 100 consecutive patients with a suspected scaphoid fracture but without evidence of a fracture on plain radiographs using MRI within 24 hours of injury, and bone scintigraphy three to five days after injury. The reference standard for a true radiologically-occult scaphoid fracture was either a diagnosis of fracture on both MRI and bone scintigraphy, or, in the case of discrepancy, clinical and/or radiological evidence of a fracture. MRI revealed 16 scaphoid and 24 other fractures. Bone scintigraphy showed 28 scaphoid and 40 other fractures. According to the reference standard there were 20 scaphoid fractures. MRI was falsely negative for scaphoid fracture in four patients and bone scintigraphy falsely positive in eight. MRI had a sensitivity of 80% and a specificity of 100%. Bone scintigraphy had a sensitivity of 100% and a specificity of 90%. This study did not confirm that early, short-sequence MRI was superior to bone scintigraphy for the diagnosis of a suspected scaphoid fracture. Bone scintigraphy remains a highly sensitive and reasonably specific investigation for the diagnosis of an occult scaphoid fracture.

A Systematic Review of Implementation of Established Recommended Secondary Prevention Measures in Patients with PAOD

OBJECTIVE Since patients with peripheral arterial occlusive disease (PAOD) are at high-risk for cardiovascular morbidity and mortality, preventive measures aimed to reduce cardiovascular adverse events are advocated in the current guidelines. We conducted a systematic review to assess the implementation of secondary prevention (SP) measures in PAOD patients. METHODS PubMed, Cochrane Library, EMBASE and Web of Science databases were searched to perform a systematic review of the literature from 1999 till June 2008 on SP for PAOD patients. Assessment of study quality was done following the Cochrane Library review system. The record outcomes were antiplatelet agents, heart rate lowering agents, blood pressure lowering agents, lipid lowering agents, glucose lowering agents, smoking cessation and walking exercise. RESULTS From a total of 2137 identified studies, 83 observational studies met the inclusion criteria, of which 24 were included in the systematic review comprising 34 157 patients. These patients suffered from coronary artery disease (n=3516, 41%), myocardial infraction (n=2647, 38%), angina pectoris (n=1790, 31%), congestive heart failure (n=2052, 14%), diabetes mellitus (n=10 690, 31%),hypertension (n=20 823, 73%) and hyperlipidaemia (n=15 067, 64%). Contrary to what the guidelines prescribe, antiplatelet agents, heart rate lowering agents, blood pressure lowering agents and lipid lowering agents were prescribed in 63%, 34%, 46% and 45% of the patients, respectively. Glucose lowering agents were prescribed in 81% and smoking cessation in 39% of the patients. CONCLUSION The majority of patients suffering from PAOD do not receive the entire approach of SP measures as suggested by the current guidelines. To our knowledge, the cause of this undertreatment is multifactorial: patient, physician or health-care-related.

Role of fine-needle aspiration biopsy and frozen section examination in determining the extent of thyroidectomy.

Abstract. Traditionally the extent of thyroidectomy in patients with nodular thyroid disease has been based on peroperative frozen section examination (FS). Fine-needle aspiration biopsy (FNAB) and FS were evaluated with regard to the reliability to determine whether an operation for cancer is necessary. Both methods were performed in 240 patients operated for nodular thyroid disease and compared with the final histology on paraffin sections. Altogether 72 (30%) patients were found to have a malignant lesion on final histology. Only a malignant FNAB diagnosis and a malignant FS diagnosis were considered positive results for determining the extent of thyroidectomy. The test characteristics were equal: the sensitivity of FNAB and FS was 67%, the specificity 99%, and the accuracy 89%. The positive predictive value was 96% for FNAB and 98% for FS; the negative predictive values were 88% and 87%, respectively. Further analysis of the results indicates that FS is not necessary for patients with a malignant FNAB result. These patients should undergo a therapeutic operation for malignancy. When the FNAB result is uncertain, patients should undergo diagnostic surgery, and definitive surgery should be based on the final histology. Routine use of FS can be omitted.

Resection of carotid body tumors: Results of an evolving surgical technique

Objective:To evaluate a modified technique for carotid body tumor (CBT) resection. Background:Resection of CBT can lead to substantial postoperative morbidity because of a rich vascularization and close connection to neurovascular structures. The impact of a modified surgical technique on postoperative outcome was evaluated and compared with a historical group and the literature. Methods:Medical records of patients who underwent CBT surgery at Leiden University Medical Center between 1963 and 2005 were retrospectively reviewed. Before 1992, a standard approach was conducted. After 1992, most tumors were resected using an alternative technique, working in a craniocaudal fashion from skull base to carotid bifurcation. Data were reported as details of the pre, intra-, and postoperative periods. Results:A total of 111 CBT resections (69 standard, 42 craniocaudal) were performed in 94 patients (44 male/50 female, mean age 41). The standard group consisted of 39 Shamblin I (56%), 22 II (32%), and 8 III (12%) tumors. The craniocaudally approached CBT included 12 Shamblin I (29%), 13 II (31%), and 17 III (40%) tumors. The mean blood loss was 901 mL (standard operations) versus 281 mL (craniocaudal approach, P < 0.0005). Persistent cranial nerve damage was encountered after 26 (23%) of 111 operations; 21 after the standard operations (30% within this group, including 3 preexistent nonresolved cranial nerve deficits); and 5 (12%, including 2 due to additional vagal body resections) after the craniocaudal operations (P = 0.025). Conclusions:The craniocaudal dissection technique of a CBT can be applied with little blood loss, thereby reducing the risk of postoperative morbidity.

The effect of implementation of an optimized care protocol on the outcome of arteriovenous hemodialysis access surgery

BACKGROUND The long-term patency of arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) suffers from a high incidence of primary failure due to early thrombosis, myointimal hyperplasia at the venous access site, or failure to mature. A multidisciplinary meeting in vascular access surgery was initiated to optimize the timing, indication, type of intervention, and the logistics of AVFs/AVGs during the preoperative and postoperative period. This study evaluated the influence of the new optimized care protocol on the incidence of revisions (surgical and endovascular) and patency rates. METHODS This protocol for vascular access surgery of AVFs/AVGs for hemodialysis was introduced in January 2004. It was initiated with the presence of the vascular surgeons, nephrologists, interventional radiologists, dialysis nurses, and the ultrasound technicians. Every patient who needed an AVF/AVG because of long-term treatment of chronic renal failure or awaiting kidney transplantation, or who needed a revision of an AVF/AVG, was discussed. Two groups were compared. Group I patients were treated with an AVF/AVG before the introduction of the new protocol (2001 and 2002). Group II patients were treated with an AVF/AVG after the introduction of the new optimized care protocol (2004 and 2005). Both groups were followed up after 12 months. RESULTS During the study period, 146 AVFs/AVGs were attempted, and 111 postoperative revisions were performed to restore primary and secondary patency: 63 in group I (60 surgical, 3 radiology) and 48 in group II (23 surgical, 25 radiology). Significantly more segmental access replacements (P < 0.027) occurred in group I than in group II. Significantly fewer surgical revisions (P < 0.019) and more endovascular balloon angioplasties (P < 0.001) occurred in group II. Significantly higher cumulative primary and secondary patency rates of all AVFs/AVGs (P < 0.001), radial-cephalic direct wrist AVFs (P < 0.001), and brachial-cephalic forearm looped transposition AVGs (P < 0.001) were achieved in group II after follow-up. CONCLUSION The new protocol outlined in a bimonthly multidisciplinary meeting for vascular access surgery of AVFs/AVGs for hemodialysis resulted in more effective logistics according to preoperative diagnostics and operation. More importantly, a significant increase in endovascular balloon angioplasties and a significant decrease in surgical revisions was observed, resulting in less patient morbidity. Also, higher primary and secondary patency was achieved after the introduction of the new optimized care protocol.