Quality of Life and Persistent Symptoms After Uncomplicated Acute Diverticulitis.

BACKGROUND: Although acute diverticulitis and its recurrence are well studied, little is known about the period after these attacks have passed. Many patients appear to be affected by persistent symptoms that impair quality of life. The few published studies on this topic are mostly limited by the lack of CT confirmation of the acute diverticulitis diagnosis, low numbers of patients, or cross-sectional design. OBJECTIVE: This study longitudinally evaluated quality of life and symptoms after antibiotic or observational treatment of uncomplicated acute diverticulitis. DESIGN: This was an observational study of randomized clinical trial data. SETTINGS: This study was conducted at a single tertiary care center. PATIENTS: Patients with CT-proven, primary, left-sided, uncomplicated acute diverticulitis were randomly assigned to observational or antibiotic treatment. MAIN OUTCOME MEASURES: Quality of life was assessed using questionnaires (EuroQol 5D, Short Form-36, and Gastrointestinal Quality of Life Index) at baseline and 3, 6, 12, and 24 months after random assignment. Patients were considered to have persistent symptoms when specific quality-of-life scores at the 12- and 24-month follow-ups were among the lowest 16% of scores measured in a healthy reference group. RESULTS: A total of 528 patients were included. No difference was detected between the observational and antibiotic groups in any quality-of-life score during follow-up. Overall, 32.2% to 38.2% of patients had persistent symptoms after 1 or 2 years, depending on which questionnaire (sub)score was assessed. Risk factors for persistent symptoms based on to the Gastrointestinal Quality of Life index GI symptoms score included a mean pain score ≥3.75 (OR = 2.77 (95% CI, 1.60-4.80)) during the first 10 days of disease and prolonged (≥28 d) time to recovery (OR = 2.25 (95% CI, 1.31-3.88)). Flatulence, rumblings, bloating, fullness, and many stools were the top 5 complaints at the 12- and 24-month follow-ups. LIMITATIONS: The study was limited by possible selection bias of patients included in a randomized controlled trial. CONCLUSIONS: More than one third of patients experience persistent symptoms after an episode of acute uncomplicated diverticulitis. Long-term quality of life is comparable after initial antibiotic or observational treatment. See Video Abstract at http://links.lww.com/DCR/A916.

The efficacy of continuous-flow cryo and cyclic compression therapy after hip fracture surgery on postoperative pain: design of a prospective, open-label, parallel, multicenter, randomized controlled, clinical trial.

BACKGROUND: The number of hip fractures and resulting post-surgical outcome are a major public health concern and the incidence is expected to increase significantly. The acute recovery phase after hip fracture surgery in elder patients is often complicated by severe pain, high morphine consumption, perioperative blood loss with subsequent transfusion and delirium. Postoperative continuous-flow cryocompression therapy is suggested to minimize these complications and to attenuate the inflammatory reaction that the traumatic fracture and subsequent surgical trauma encompass. Based on a pilot study in patients undergoing total hip arthroplasty for osteoarthritis, it is anticipated that patients treated with continuous-flow cryocompression therapy will have less pain, less morphine consumption and lower decrease of postoperative hemoglobin levels. These factors are associated with a shorter hospital stay and better long-term (functional) outcome. METHODS/DESIGN: One hundred and sixty patients with an intra or extracapsular hip fracture scheduled for internal fixation (intramedullary hip nail, dynamic hip screw or cannulated screws) or prosthesis surgery (total hip or hemiarthroplasty) will be included in this prospective, open-label, parallel, multicenter, randomized controlled, clinical superiority trial. Patients will be allocated to two treatment arms: group 'A' will be treated with continuous-flow cryocompression therapy and compared to group 'B' that will receive standard care. Routine use of drains and/or compressive bandages is allowed in both groups. The primary objective of this study is to compare acute pain the first 72 h postoperative, measured with numeric rating scale for pain. Secondary objectives are: (non-) morphine analgesic use; adjusted postoperative hemoglobin level; transfusion incidence; incidence, duration and severity of delirium and use of psychotropic medication; length of stay; location and duration of rehabilitation; functional outcome; short-term patient-reported health outcome; general and cryotherapy related complications and feasibility. DISCUSSION: This is the first randomized controlled trial that will assess the analgesic efficiacy of continuous-flow cryocompression therapy in the acute recovery phase after hip fracture surgery. TRIAL REGISTRATION: www.trialregister.nl, NTR4152 (23(rd) of August 2013).

The complicated Allen-Masters syndrome: small bowel herniation through a broad ligament defect.

Small bowel obstruction through a broad ligament defect is a very rare condition. We present 2 cases, one without any associated abdominal trauma. Rapid diagnosis and treatment of this rare condition is of paramount importance.

Anterior cutaneous nerve entrapment syndrome (ACNES): the forgotten diagnosis.

UNLABELLED: The abdominal wall is an often overlooked source of pain in children with chronic abdominal pain. For example, abdominal wall pain can be caused by the abdominal cutaneous nerve entrapment syndrome (ACNES). ACNES occurs in children as well as adults. In pediatrics, this diagnosis is largely unknown. ACNES is characterized by a sharp stabbing pain which characteristically increases with the use of abdominal muscles (Carnett's sign). The pain is usually located in the lower right quadrant. Very often patient go through a long clinical track, sometimes leading to frequent hospitalizations and unnecessary examinations. In some cases, children even end up in the psychiatric circuit because of misunderstood pain symptoms. We describe three illustrative cases of abdominal pain in which eventually ACNES was diagnosed and successfully treated with infiltration of an anesthetic agent, and we also performed a literature search. CONCLUSION: ACNES is a relatively unknown cause of abdominal pain in children. Diagnosis and treatment of ACNES are simply by local injection of anesthetics into the abdominal wall.

Study protocol: non-displaced distal radial fractures in adult patients: three weeks vs. five weeks of cast immobilization: a randomized trial.

BACKGROUND: Up to 30% of patients suffer from long-term functional restrictions following conservative treatment of distal radius fractures. Whether duration of cast immobilisation influences functional outcome remains unclear. METHODS/DESIGN: The aim of the study is to evaluate whether the duration of immobilization of non or minimally displaced distal radial fractures can be safely reduced. We will compare three weeks of plaster cast immobilization with five weeks of plaster cast immobilization in adult patient with non or minimally displaced distal radial fractures. STUDY DESIGN: a prospective randomized clinical trial. STUDY POPULATION: adult (>18 years) (independent in activities of daily living) patients with a non/minimal displaced distal radius fracture (dorsal angulation <15°, volar tilt <20°, radial inclination >15°, ulnar positive variance <5 mm and an articular step off <2 mm). INTERVENTION: three weeks of plaster cast immobilization versus five weeks of plaster cast immobilization.Main study parameters: primary outcome parameters: Patient related wrist evaluation (PRWE) Quick Disability of Arm, Shoulder and Hand (QUICKDASH) score after a one year follow-up, and secondary parameters: range of motion, pain level (VAS) and complications. DISCUSSION: The expectation of this study is that shorter duration of plaster cast immobilisation is beneficial for the patient with a distal radius fracture. This risk of specific complications is low and generally similar in both treatment options. Moreover, the burden of the study is not much higher compared to standard treatment. Follow-up is standardized according to current trauma guidelines. Literature indicates that both treatment options from the study are accepted for displaced distal radius fractures. No clear advantage for one treatment options is found at present in the literature, although there is no level I evidence present. This trial will provide level-1 evidence for the comparison of consolidation and functional outcome between two treatment options for non-displaced distal radial fractures. The gathered data may support the development of a clinical guideline for conservative treatment of distal radial fractures. TRIAL REGISTRATION: Netherlands National Trial Register NTR3552.

Randomized controlled multicentre study comparing biological mesh closure of the pelvic floor with primary perineal wound closure after extralevator abdominoperineal resection for rectal cancer (BIOPEX-study).

BACKGROUND: Primary perineal wound closure after conventional abdominoperineal resection (cAPR) for rectal cancer has been the standard of care for many years. Since the introduction of neo-adjuvant radiotherapy and the extralevator APR (eAPR), oncological outcome has been improved, but at the cost of increased rates of perineal wound healing problems and perineal hernia. This has progressively increased the use of biological meshes, although not supported by sufficient evidence. The aim of this study is to determine the effectiveness of pelvic floor reconstruction using a biological mesh after standardized eAPR with neo-adjuvant (chemo)radiotherapy compared to primary perineal wound closure. METHODS/DESIGN: In this multicentre randomized controlled trial, patients with a clinical diagnosis of primary rectal cancer who are scheduled for eAPR after neo-adjuvant (chemo)radiotherapy will be considered eligible. Exclusion criteria are prior radiotherapy, sacral resection above S4/S5, allergy to pig products or polysorbate, collagen disorders, and severe systemic diseases affecting wound healing, except for diabetes. After informed consent, 104 patients will be randomized between standard care using primary wound closure of the perineum and the experimental arm consisting of suturing a biological mesh derived from porcine dermis in the pelvic floor defect, followed by perineal closure similar to the control arm. Patients will be followed for one year after the intervention and outcome assessors and patients will be blinded for the study treatment. The primary endpoint is the percentage of uncomplicated perineal wound healing, defined as a Southampton wound score of less than II on day 30. Secondary endpoints are hospital stay, incidence of perineal hernia, quality of life, and costs. DISCUSSION: The BIOPEX-study is the first randomized controlled multicentre study to determine the additive value of using a biological mesh for perineal wound closure after eAPR with neo-adjuvant radiotherapy compared to primary perineal wound closure with regard to perineal wound healing and the occurrence of perineal hernia. TRAIL REGISTRATION NUMBER: NCT01927497 (Clinicaltrial.gov).

Review of current classifications for diverticular disease and a translation into clinical practice.

INTRODUCTION: Diverticular disease of the sigmoid colon prevails in Western society. Its presentation may vary greatly per individual patient, from symptomatic diverticulosis to perforated diverticulitis. Since publication of the original Hinchey classification, several modifications and new grading systems have been developed. Yet, new insights in the natural history of the disease, the emergence of the computed tomography scan, and new treatment modalities plead for evolving classifications. METHODS: This article reviews all current classifications for diverticular disease. RESULT: A three-stage model is advanced for a renewed and comprehensive classification system for diverticular disease, incorporating up-to-date imaging and treatment modalities.

Microbiota composition and mucosal immunity in patients with asymptomatic diverticulosis and controls.

INTRODUCTION: The etiology of diverticulosis is still poorly understood. However, in patients with diverticulitis, markers of mucosal inflammation and microbiota alterations have been found. The aim of this study was to evaluate potential differences of the gut microbiota composition and mucosal immunity between patients with asymptomatic diverticulosis and controls. METHODS: We performed a prospective study on patients who underwent routine colonoscopy for causes not related to diverticular disease or inflammatory bowel disease. Participants were grouped based on the presence or absence of diverticula. Mucosal biopsies were obtained from the sigmoid and transverse colon. Microbiota composition was analyzed with IS-pro, a 16S-23S based bacterial profiling technique. To predict if patients belonged to the asymptomatic diverticulosis or control group a partial least squares discriminant analysis (PLS-DA) regression model was used. Inflammation was assessed by neutrophil and lymphocyte counts within the taken biopsies. RESULTS: Forty-three patients were enrolled. Intestinal microbiota profiles were highly similar within individuals for all phyla. Between individuals, microbiota profiles differed substantially but regardless of the presence (n = 19) of absence (n = 24) of diverticula. Microbiota diversity in both sigmoid and transverse colon was similar in all participants. We were not able to differentiate between diverticulosis patients and controls with a PLS-DA model. Mucosal lymphocyte counts were comparable among both groups; no neutrophils were detected in any of the studied biopsies. CONCLUSIONS: Microbiota composition and inflammatory markers were comparable among asymptomatic diverticulosis patients and controls. This suggests that the gut microbiota and mucosal inflammation do not play a major role in the pathogenesis of diverticula formation.

A multicenter randomized clinical trial investigating the cost-effectiveness of treatment strategies with or without antibiotics for uncomplicated acute diverticulitis (DIABOLO trial).

BACKGROUND: Conservative treatment of uncomplicated or mild diverticulitis usually includes antibiotic therapy. It is, however, uncertain whether patients with acute diverticulitis indeed benefit from antibiotics. In most guidelines issued by professional organizations antibiotics are considered mandatory in the treatment of mild diverticulitis. This advice lacks evidence and is merely based on experts' opinion. Adverse effects of the use of antibiotics are well known, including allergic reactions, development of bacterial resistance to antibiotics and other side-effects. METHODS: A randomized multicenter pragmatic clinical trial comparing two treatment strategies for uncomplicated acute diverticulitis. I) A conservative strategy with antibiotics: hospital admission, supportive measures and at least 48 hours of intravenous antibiotics which subsequently are switched to oral, if tolerated (for a total duration of antibiotic treatment of 10 days). II) A liberal strategy without antibiotics: admission only if needed on clinical grounds, supportive measures only. Patients are eligible for inclusion if they have a diagnosis of acute uncomplicated diverticulitis as demonstrated by radiological imaging. Only patients with stages 1a and 1b according to Hinchey's classification or "mild" diverticulitis according to the Ambrosetti criteria are included. The primary endpoint is time-to-full recovery within a 6-month follow-up period. Full recovery is defined as being discharged from the hospital, with a return to pre-illness activities, and VAS score below 4 without the use of daily pain medication. Secondary endpoints are proportion of patients who develop complicated diverticulitis requiring surgery or non-surgical intervention, morbidity, costs, health-related quality of life, readmission rate and acute diverticulitis recurrence rate. In a non-inferiority design 264 patients are needed in each study arm to detect a difference in time-to-full recovery of 5 days or more with a power of 85% and a confidence level of 95%. With an estimated one percent of patients lost to follow up, a total of 533 patients will be included. CONCLUSION: A clinically relevant difference of more than 5 days in time-to-full recovery between the two treatment strategies is not expected. The liberal strategy without antibiotics and without the strict requirement for hospital admission is anticipated to be more a more cost-effective approach. TRIAL REGISTRATION NUMBER: NCT01111253.

Postoperative continuous-flow cryocompression therapy in the acute recovery phase of hip fracture surgery-A randomized controlled clinical trial.

BACKGROUND: The acute recovery phase after hip fracture surgery is often complicated by severe pain, postoperative blood loss with subsequent transfusion, and delirium. Prevalent comorbidity in hip fracture patients limit the use of opioid-based analgesic therapies, yielding a high risk for inferior pain treatment. Postoperative cryotherapy is suggested to provide an analgesic effect, and to reduce postoperative blood loss. In this prospective, open-label, parallel, multicentre, randomized controlled, clinical trial, we aimed to determine the efficacy of continuous-flow cryocompression therapy (CFCT) in the acute recovery phase after hip fracture surgery. METHODS: Patients with an intra or extracapsular hip fracture scheduled for surgery were included. Subjects were allocated to receive postoperative CFCT or usual care. The primary endpoint was numeric rating scale (NRS) pain the first 72 postoperative hours. Secondly, analgesic use; postoperative haemoglobin change and transfusion incidence; functional outcome; length of stay; delirium incidence; location of rehabilitation; patient-reported health outcome; complications and feasibility were assessed. RESULTS: Sixty-one subjects in the control group, and 64 subjects in the CFCT group were analysed. Within the CFCT group, post treatment NRS pain declined 0.31 (p=0.07) at 24h, 0.28 (p=0.07) at 48h, and 0.47 (p=0.002) at 72h relative to pre treatment NRS pain. Sensitivity analysis at 72h showed that NRS pain was 0.92 lower in the CFCT group when compared to the control group (1.50 vs. 2.42; p=0.03). Postoperative analgesic use was comparable between groups. Between postoperative day one and three haemoglobin declined 0.29mmol/l in the CFCT group and 0.51mmol/l in controls (p=0.06), and transfusion incidence was comparable. The timed up and go test and length of stay were also comparable between both groups. Complications, amongst delirium and cryotherapy-related adverse events were not statistically significantly different. Discharge locations did not differ between groups. At outpatient follow-up subjects did not differ in patient-reported health outcome scores. Subjects rated CFCT satisfaction with an average of 7.1 out of 10 points. CONCLUSIONS: No evidence was recorded to suggest that CFCT has an added value in the acute recovery phase after hip fracture surgery. If patients complete the CFCT treatment schedule, a mild analgesic effect is observed at 72h.

Diagnosing perforated appendicitis in pediatric patients: a new model.

OBJECTIVE: Studies have investigated sensitivity and specificity of symptoms and tests for diagnosing appendicitis in children. Less is known with regard to the predictive value of these symptoms and tests with respect to the severity of appendicitis. The aim of this study was to determine the predictive value of patient's characteristics and tests for discriminating between perforated and nonperforated appendicitis in children. PATIENTS AND METHODS: Pediatric patients who underwent an appendectomy at Spaarne Hospital Hoofddorp, the Netherlands, between January 1, 2009 and December 31, 2013, were included. Baseline patient's characteristics, history, physical examination, laboratory data and results of ultrasounds were collected. Univariate and multivariate logistic regressions were used to determine predictors of perforation. RESULTS: In total, 375 patients were included in this study of which 97 children (25.9%) had significant signs of perforation. Univariate analysis showed that age, duration of complaints, temperature, vomiting, CRP, WBC, different findings on ultrasound and the diameter of the appendix were good predictors of a perforated appendicitis. The final multivariate prediction model included temperature, CRP, clearly visible appendix and free fluids on ultrasound and diameter of the appendix and resulted in an area under the curve (AUC) of 0.91 showing sensitivity and specificity of respectively 85.2% and 81.2%. CONCLUSION: This prediction model can be used for identification of 'high-risk' children for a perforated appendicitis and might be helpful to prevent complications and longer hospitalization by bringing these children to theater earlier.

Hair thread tourniquet syndrome in a toe of an 18 mo old girl.

Hair thread tourniquet syndrome is rare and usually affects little children. If the tourniquet is not incised, the affected body part becomes ischemic or even necrotic. An 18 mo old girl was seen in the emergency ward with a painful, red and swollen third toe of the left foot. The toe appeared to be strangulated with a hair, and the diagnosis hair thread tourniquet syndrome was made. After incision of the hair tourniquet the symptoms soon subsided. The diagnosis is easily made if the clinical features are recognized. However, if the tourniquet is not cut through, the affected body part may become ischemic and even necrotic.

[A woman with an umbilical swelling]. / Een vrouw met een zwelling van de navel.

A 78-year-old woman presented with a 9-month history of an ulcerative umbilical swelling, which had recently started to produce feces. An abdominal CT-scan showed a tumour in the transverse colon, infiltrating the abdominal wall and skin, but without signs of distant metastases. Histopathological examination of a biopsy specimen revealed a slime-producing adenocarcinoma. Due to a myocardial infarction, the patient died two days prior to surgery. No permission to conduct an autopsy was granted.

[Treatment for diverticulitis not thoroughly researched]. / Geen goed onderzochte behandeling voor diverticulitis.

In the Netherlands approximately 14,000 patients are referred to hospital for diverticular disease each year. Overall controversy persists about four aspects of treatment of the different stages of diverticulitis, i.e. the role of antibiotics in the treatment of mild diverticulitis, the question of whether elective surgical resection is justified in recurrent diverticulitis or in persisting abdominal symptoms after an episode of diverticulitis, the question of whether patients with purulent peritonitis due to perforation may be treated with laparoscopic peritoneal lavage instead of Hartmann's procedure, and finally, whether resection with a primary anastomosis is a feasible and safe alternative to Hartmann's procedure in the surgical treatment of Hinchey III or IV diverticulitis. These questions will be addressed in four upcoming Dutch randomised trials.

Small bowel volvulus diagnosed by the CT "whirl sign".

A 24-year-old man presented to the emergency department with acute onset, colicky, abdominal pain. A CT scan showed the "whirl sign" diagnostic of small bowel volvulus. Diagnosis of a small bowel volvulus can be challenging, and CT scan is the imaging modality of choice.