A decision aid regarding treatment options for patients with an asymptomatic abdominal aortic aneurysm: a randomised clinical trial.

OBJECTIVE: Abdominal aortic aneurysm patients tend to be informed inconsistently and incompletely about their disorder and the treatment options open to them. The objective of this trial was to evaluate whether these patients are better informed and experience less decisional conflict regarding their treatment options after viewing a decision aid. DESIGN: A six-centre, randomised clinical trial comparing a decision aid plus regular information versus regular information from the surgeon. METHODS: Included patients had recently been diagnosed with an asymptomatic abdominal aortic aneurysm at least 4 cm in diameter. The decision aid consisted of a one-time viewing of an interactive CD-ROM elaborating on elective surgery versus watchful waiting. Generally, the decision aid advised patients with aneurysms less than 5.5 cm to agree to watchful waiting, for larger aneurysms the decision aid provided insight into the balance of benefit and harm of surgical and conservative approaches, taking into account age, co-morbidity and size of the aneurysm. The primary outcome was patient decisional conflict measured at 1 month follow-up (Decisional Conflict Scale). Secondary outcomes were patient knowledge, anxiety and satisfaction. RESULTS: In 178 aneurysm patients, decisional conflict scores did not differ significantly between the decision aid and the regular information groups (22 vs. 24 on the 0-100 Decisional Conflict Scale; p = .33). Patients in the decision aid group had significantly better knowledge (10.0 vs. 9.4 out of 13 points; p = .04), whereas anxiety levels (4.4 and 5.0 on a 0-21 scale; p = .73) and satisfaction scores (74 and 73 on a 0-100 scale; p = .81) were similar in both groups. CONCLUSION: In addition to regular patient-surgeon communication, a decision aid helps to share treatment decisions with abdominal aortic aneurysm patients by increasing their knowledge about the disorder and available treatment options without raising anxiety levels; however, it does not reduce decisional conflict, nor does it improve satisfaction.

[Cystic abnormalities of the pancreas: inflammatory pseudocyst or neoplasm]. / Cysteuze afwijkingen van het pancreas: inflammatoire pseudocyste of neoplasma.

A 79-year-old woman presented with complaints of upper abdominal pain, nausea and vomiting since a few days. Laboratory tests showed no abnormalities except for some indications of an inflammation. Based on the medical history, physical examination and findings from radiological examination, initially the diagnosis was 'chronic pancreatitis with formation ofa pseudocyst caused by alcohol abuse'. After one week the patient developed cholestatic liver function disorders with elevated serum pancreatic enzymes. A CT scan of the abdomen showed a dilated gallbladder and progression of the cystic lesion in the pancreatic head with compression of the distal common bile duct. An endoscopic retrograde cholangiopancreatography was performed and the findings fitted a diagnosis of an intraductal papillary mucinous neoplasm. Differentiation between an inflammatory or neoplastic origin of cystic lesions in the pancreas can be difficult. There is a risk ofmisdiagnosing a cystic neoplasm for a pseudocyst. This may lead to delays in making the correct diagnosis.

Ergotamine-induced constriction of cranial arteriovenous anastomoses in dogs pretreated with phentolamine and pizotifen.

Previous investigations from our laboratory have shown that ergotamine causes a selective vasoconstriction in the carotid vascular bed of the dog and that the drug constricts arteriovenous anastomoses (AVAs) in cats and pigs. Since ergotamine can act via alpha-adrenergic or D-serotonergic receptors in certain vascular and non-vascular tissues, we have attempted to ascertain here if these receptors mediate the constriction of AVAs. Using radioactive microspheres of 15 microns diameter we found in the dog that about 40% of the carotid arterial blood is shunted to the venous side via AVAs. Ergotamine (2-20 micrograms X kg-1, i.v.) reduced total carotid blood flow to a larger extent in the AVA part than in the extracerebral part (muscles, ears, skin and fat). The cerebral component of carotid blood did not change. These results, confirming that ergotamine decreases arteriovenous shunting, show that the drug has a more selective action on the AVAs than on the arterioles. Pretreatment with phentolamine (0.5 mg X kg-1), pizotifen (0.5 mg X kg-1) or their combination did not effectively modify the responses to ergotamine. It is concluded that the vasoconstriction of cranial AVAs (and arterioles) by ergotamine does not appear to be primarily mediated by either alpha-adrenergic or D-serotonergic receptors. However, the role of atypical serotonin receptors has yet to be determined.

Rupture of true aneurysms of the pancreaticoduodenal arcade: treatment with transcatheter arterial embolization.

We present 2 cases of ruptured true aneurysms of the pancreaticoduodenal arcade, underscoring the role of transcatheter arterial embolization (TAE) as the initial treatment of choice in pancreaticoduodenal arcade aneurysm. Ruptured true aneurysms of the pancreaticoduodenal artery (PDA) are uncommon and few cases have been reported, whereas false aneurysms are seen more often. The first patient we describe is a 63-year-old woman with an aneurysm of the PDA initially treated by TAE. The second case is a 67-year-old woman with an aneurysm of the inferior PDA post-operatively treated by TAE. In both patients TAE via a combined superior mesenteric artery and celiac axis approach was successful. Follow-up contrast-enhanced computed tomography showed prolonged occlusion of both aneurysms. A review of the literature concerning TAE supports our experience that TAE of ruptured aneurysms of the pancreaticoduodenal arcade, when feasible, is at least as effective as conventional surgery, but with lower morbidity and mortality. Therefore, TAE should be the initial treatment of choice in this group of patients.

Interobserver variation in interpretation of arteriography and management of severe lower leg arterial disease.

OBJECTIVE: arteriography is the reference standard for the assessment of the lower leg arteries in patients with severe lower limb ischaemia. Interobserver variation in arteriography interpretation may cause disparities with non-invasive imaging modalities. We determined interobserver variation in lower leg artery assessment with intra-arterial digital subtraction angiography (IaDSA) and subsequent patient management. MATERIALS: iaDSA studies of patients evaluated for severe claudication (n =5) or critical ischaemia ( n =43). METHODS: arteriograms were independently judged by four observers. The popliteal and tibial arteries were graded as fully patent, severely diseased, occluded or non-diagnostic. The dorsalis pedis, common and deep plantar artery were graded as directly, indirectly or not filling the pedal arch or non-diagnostic. Agreement on grading arteries was expressed as kappa-values. Treatment plans (conservative, PTA, surgery, amputation, non-diagnostic) proposed by each observer based on clinical information and iaDSA were compared. RESULTS: the rate of non-diagnostic judgements ranged from 1% in the popliteal to 22% in the pedal arteries. Overall agreement was good for grading the popliteal arteries (kappa=0.64), moderate for the tibial (kappa=0.47--0.54) and fair for the pedal arteries (kappa=0.39). Agreement was good to excellent for grading occluded or fully patent popliteal and tibial artery segments, and fair to moderate for grading severe disease. In 57% of cases at least 3 observers proposed identical treatment, which indicates fair overall agreement (kappa=0.33). CONCLUSION: interobserver agreement on iaDSA is good to determine occluded or fully patent popliteal or tibial arteries, but not for severe disease. This should be taken into account when other diagnostic modalities are compared with iaDSA. Evaluation of diagnostic modalities as concordance in treatment plans is flawed by interindividual variation.