Burden of disease of type 2 diabetes mellitus: cost of illness and quality of life estimated using the Maastricht Study.

AIMS: To estimate the societal costs and quality of life of people with type 2 diabetes and to compare these results with those of people with normal glucose tolerance or prediabetes. METHODS: Data from 2915 individuals from the population-based Maastricht Study were included. Costs were assessed through a resource-use questionnaire completed by the participants; cost prices were based on Dutch costing guidelines. Quality of life was expressed in utilities using the Dutch EuroQol 5D-3L questionnaire and the SF-36 health survey. Based on normal fasting glucose and 2-h plasma glucose values, participants were classified into three groups: normal glucose tolerance (n = 1701); prediabetes (n = 446); or type 2 diabetes (n = 768). RESULTS: Participants with type 2 diabetes had on average 2.2 times higher societal costs than those with normal glucose tolerance (€3,006 and €1,377 per 6 months, respectively) and had lower utilities (0.77 and 0.81, respectively). No significant differences were found between participants with normal glucose tolerance and those with prediabetes. Subgroup analyses showed that higher age, being female and having two or more diabetes-related complications resulted in higher costs (P < 0.05) and lower utilities. CONCLUSIONS: This study showed that people with type 2 diabetes have substantially higher societal costs and lower quality of life than people with normal glucose tolerance. The results provide important input for future model-based economic evaluations and for policy decision-making.

Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands.

OBJECTIVE: The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR). METHODS: This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests. RESULTS: The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively). CONCLUSION: In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

The use of thoracic stent grafts for endovascular repair of abdominal aortic aneurysms.

Objectives Stent grafts for endovascular repair of infrarenal aneurysms are commercially available for aortic necks up to 32 mm in diameter. The aim of this study was to evaluate the feasibility of endovascular repair with large thoracic stent grafts in the infrarenal position to obtain adequate proximal seal in wider necks. Methods All patients who underwent endovascular aneurysm repair using thoracic stent grafts with diameters greater than 36 mm between 2012 and 2016 were included. Follow-up consisted of CT angiography after six weeks and annual duplex thereafter. Results Eleven patients with wide infrarenal aortic necks received endovascular repair with thoracic stent grafts. The median diameter of the aneurysms was 60 mm (range 52-78 mm) and the median aortic neck diameter was 37 mm (range 28-43 mm). Thoracic stent grafts were oversized by a median of 14% (range 2-43%). On completion angiography, one type I and two type II endoleaks were observed but did not require reintervention. One patient experienced graft migration with aneurysm sac expansion and needed conversion to open repair. Median follow-up time was 14 months (range 2-53 months), during which three patients died, including one aneurysm-related death. Conclusions Endovascular repair using thoracic stent grafts for patients with wide aortic necks is feasible. In these patients, the technique may be a reasonable alternative to complex endovascular repair with fenestrated, branched, or chimney grafts. However, more experience and longer follow-up are required to determine its position within the endovascular armamentarium.

The utility of contrast enhanced MR angiography as a first stage diagnostic modality for treatment planning in lower extremity arterial occlusive disease.

INTRODUCTION: The aim of this study was to evaluate the applicability of contrast enhanced magnetic resonance angiography (ce-MRA) as a first stage imaging tool for individual treatment planning in patients with lower extremity arterial occlusive disease. PATIENTS AND METHODS: Between August, 2003 and June, 2004, in 128 consecutive patients (182 extremities) with clinical manifestations of lower limb ischemia eligible for invasive therapy, treatment was planned based on clinical assessment, ankle/brachial pressure index measurements combined with ce-MRA. Additional duplex ultrasonography (DUS) or digital subtraction angiography (DSA) was done when necessary. Ce-MRA findings were compared with findings during open surgical, endovascular or combined procedures. RESULTS: In 28 extremities (15%) ce-MRA was found inconclusive and additional imaging was performed. In the remaining patients (85% of the extremities (n = 154), treatment was initiated as planned. However, in 19 (11%) of these patients, the treatment plan was altered. In 7 of them, procedural findings did not correspond with those at the time of ce-MRA, including 6 patients (3%) with a falsely diagnosed stenosis or occlusion. In total, 62 patients received non-operative treatment (34%), 65 an endovascular procedure (36%), 49 open surgical reconstruction (27%) and 6 a combined treatment. CONCLUSIONS: We conclude that in the majority of patients treatment can be planned based on ce-MRA images, although sometimes additional DUS or DSA may be required.

Halo pin positioning in the temporal bone; parameters for safe halo gravity traction.

INTRODUCTION: Halo gravity traction (HGT) is increasingly used pre-operatively in the treatment of children with complex spinal deformities. However, the design of the current halo crowns is not optimal for that purpose. To prevent pin loosening and to avoid visual scars, fixation to the temporal area would be preferable. This study aims to determine whether this area could be safe for positioning HGT pins. METHODS: A custom made traction setup plus three human cadaver skulls were used to determine the most optimal pin location, the resistance to migration and the load to failure on the temporal bone. A custom-made spring-loaded pin with an adjustable axial force was used. For the migration experiment, this pin was positioned at 10 predefined anatomical areas in the temporal region of adult cadaver skulls, with different predefined axial forces. Subsequently traction force was applied and increased until migration occurred. For the load-to-failure experiment, the pin was positioned on the most applicable temporal location on both sides of the skull. RESULTS: The most optimal position was identified as just antero-cranial to the auricle. The resistance to migration was clearly related to the axial tightening force. With an axial force of only 100 N, which corresponds to a torque of 0.06 Nm (0.5 in-lb), a vertical traction force of at least 200 N was needed for pin migration. A tightening force of 200 N (torque 0.2 Nm or 2 in-lb) was sufficient to resist migration at the maximal applied force of 360 N for all but one of the pins. The load-to-failure experiment showed a failure range of 780-1270 N axial force, which was not obviously related to skull thickness. CONCLUSION: The temporal bone area of adult skulls allows axial tightening forces that are well above those needed for HGT in children. The generally applied torque of 0.5 Nm (4 in-lb) which corresponds to about 350 N axial force, appeared well below the failure load of these skulls and much higher than needed for firm fixation.

The influence of choice of therapy on quality of life in patients with neurogenic thoracic outlet syndrome.

OBJECTIVES: We aimed to compare quality of life (QoL) after surgical decompression of the thoracic outlet versus non-operative therapy in patients with neurogenic thoracic outlet syndrome (N-TOS). DESIGN AND METHODS: We retrospectively identified 46 patients, diagnosed with N-TOS between 1999 and 2008. Twenty-four operated and 22 conservatively treated patients were sent questionnaires on their current symptoms and QoL. A matched control group (n = 24) of healthy individuals was selected for QoL comparison. Statistics were performed with linear and logistic regression analysis. RESULTS: ANOVA revealed a significant QoL difference between the three groups (p = 0.001). Separate analysis between groups demonstrated that all patients with N-TOS-like symptoms have a lower QoL than healthy controls (p = 0.001 resp. p < or = 0.000). No difference was found between conservatively and surgically treated patients (p = 0.26). EQ-5D response rate was 83%. Of the 24 surgically treated patients, 15 would choose surgery again in a similar situation, although 4 did not benefit in terms of symptom reduction. Symptom relief and VAS pain scores in the conservatively and surgically treated patients did not show significant differences (p = 0.95 resp. p = 0.40). CONCLUSIONS: All patients with N-TOS have a significantly decreased QoL compared with healthy individuals, regardless of the type of therapy they received. In this small study, surgical decompression fails to improve QoL in patients with N-TOS to the level measured in the healthy control group, despite symptom reduction consistent with previous reports. Variables significantly associated with outcome were duration of symptoms and localisation (variables included in the prediction model: age, sex, duration of symptoms, presence of paraesthesias, localisation, Adson's, Wright's and Roos' test, history of trauma, cervical arthrosis). In the perspective of QoL, the benefit of decompressive surgery is questionable. Improving patient selection seems imperative in order to achieve better results in our surgically treated patients.

[Lymphogranuloma venereum, an STI that is sometimes recognized late in secondary care]. / Lymphogranuloma venereum.

Lymphogranuloma venereum (LGV) is an invasive sexually transmitted infection caused by Chlamydia trachomatis genotypes L1, L2 and L3. Until recently, LGV was rarely seen in developed countries. However, an outbreak of LGV infections in Europe amongst men who have sex with men (MSM) has been reported in the past decades. Diagnosing LGV can be challenging since there is no pathognomic clinical presentation. Most patients are diagnosed with LGV by Community Healthcare Services and general practitioners. Recent data show that a significant diagnostic delay can occur when patients present in a hospital with symptoms due to LGV infection. This can result in unnecessary additional diagnostic procedures and a subsequent diagnostic delay. In order to create more awareness, we describe 3 cases in our hospital with an initially unrecognized LGV infection. We also discuss the epidemiology, clinical manifestations, diagnostic process and treatment of LGV infection.

Transanal resection for villous adenomas using the Fansler proctoscope.

Benign rectal tumours represent a frequently occurring condition that often requires surgical treatment. In the literature, Transanal Endoscopic Microsurgery (TEM) has claimed a position as the gold standard for this kind of transanal surgery. In this study, we evaluate the results in a series of 34 patients who underwent a transanal resection after an extensive pre-operative work-up, using the Fansler proctoscope. Although the level of evidence in retrospective studies may have its limitations, our results seem to meet those of TEM in the literature. Also, the Fansler proctoscope provides us with a much more economical and easier to learn method. We conclude that the Fansler proctoscope approach can be a valuable alternative to TEM in the treatment of benign rectal tumours.

A rare case of thromboembolism in a 21-year old female with elevated factor VIII.

In this article we present the history of a previously healthy female adolescent, who was seen at our hospital with abdominal pain. This was the result of a large floating thrombus in the aorta. Widespread embolism occurred, which lead to the loss of a limb and a left hemicolectomy. Although our patient is a smoker, used oral contraceptives and was found to have a heterozygote mutation at the factor V Leiden gene, the most important factor contributing to her thrombophilia is thought to be her significantly elevated factor VIII. We stress an aggressive diagnostic and therapeutic approach in young patients with unknown embolism in order to avoid the grave consequences of delay.

The disciplinary code for nurses and its contribution to the quality of nursing care in the Netherlands.

AIM: To obtain insight into the contribution of the disciplinary code for nurses to monitoring the quality of nursing care in the Netherlands. METHODS: Complaints dealt with in the period 1998-2001 were studied. Questionnaires were sent to 3200 nurses (71%), all 388 members of the disciplinary boards (89%) and 43 lawyers (65%). RESULTS: There was an increase in the number of nurses who were accused (20 in 1998, 12 in 1999, 54 in 2000, and 56 in 2001) and also in the annual percentages of sanctions imposed (0% in 1998, 8% in 1999, 13% in 2000 and 16% in 2001). The disciplinary code appears to be an important corrective instrument for serious professional misconduct.

Risky procedures by nurses in hospitals: problems and (contemplated) refusals of orders by physicians, and views of physicians and nurses.

Occurrence of problems with, refusals of orders and contemplated refusals of orders for risky procedures by nurses in Dutch hospitals and views on the safety of performance was studied using postal questionnaires (600 physicians and 3200 nurses, response 60-71%). Of the respondents, 11-30% experienced problems with and (contemplated) refusals of orders for risky procedures in the previous 12 months. Gynaecologists and internists most frequently mentioned problems concerning the practical performance of the procedure (44% and 30%, respectively). The reason for a problem or a contemplated refusal most frequently given by nurses was that they disagreed with the medication policy (34% and 35%, respectively). The reason for a refusal most frequently given by the gynaecologists, internists and nurses was that the nurses themselves were of the opinion that they did not have the necessary authorisation (95%, 67%, and 62%, respectively). With regard to certain procedures, the views of professionals are more strict than the current legal regulations.

Risky procedures by nurses in hospitals: problems and (contemplated) refusals of orders by physicians, and views of physicians and nurses: a questionnaire survey.

Occurrence of problems with, refusals of orders and contemplated refusals of orders for risky procedures by nurses in Dutch hospitals and views on the safety of performance was studied using postal questionnaires (600 physicians and 3200 nurses, response 60--71%). Of the respondents, 11--30% experienced problems with and (contemplated) refusals of orders for risky procedures in the previous 12 months. Gynaecologists and internists most frequently mentioned problems concerning the practical performance of the procedure (44% and 30%, respectively). The reason for a problem or a contemplated refusal most frequently given by nurses was that they disagreed with the medication policy (34% and 35%, respectively). The reason for a refusal most frequently given by the gynaecologists, internists, and nurses was that the nurses themselves were of the opinion that they did not have the necessary authorisation (95%, 67%, and 62%, respectively). With regard to certain procedures, the views of professionals are more strict than the current legal regulations.

[Patient safety in hospitals]. / Veiligheid van patiënten in ziekenhuizen.

In various studies outside the Netherlands, it has been shown that a substantial number of patients suffer some kind of damage during their treatment in a hospital. The incidence of these so-called adverse events varies between 2.9% and 16.6%; of these, estimates between more than a quarter and up to half are considered to have been avoidable. Preventable adverse events can offer a starting point for interventions to increase patient safety. Therefore, a study has been initiated in Dutch hospitals investigating the nature and extent of adverse events and their causes. Important goals of the study are to reach a consensus on basic concepts and to improve the research methodology.

[Publication practice and policy for disciplinary proceedings regarding health care in the Netherlands]. / Publicatiepraktijk en -beleid van de tuchtrechtspraak voor de gezondheidszorg.

OBJECTIVE: To provide insight into practice and policy regarding the publication of disciplinary verdicts in Dutch health care. DESIGN: Descriptive. METHOD: The study covered all of the verdicts issued by disciplinary boards and courts of justice that were published in the Dutch the Staats-courant (Government Gazette) during the period 1995-2002. The following attributes were recorded for each verdict: year of publication and verdict, the disciplinary board concerned, the accused professional, the type of complainant, the nature of the complaint and verdict, and the journals that were offered the decision. The published verdicts were related to the total number of verdicts and cases during the study period. Questionnaires were used to investigate the publication policy of the disciplinary boards. RESULTS: A total of 4% of all verdicts were published in the Dutch Government Gazette (323/8902). The central disciplinary board decided to publish more often than the regional disciplinary boards (8% and 2%, respectively). There were considerable differences between the various regional disciplinary boards (range: 1-5%). Per professional group the percentage of verdicts in cases that were published ranged from 2% to 23%. The decisions were offered to over 20 journals, but mainly to the Tijdschrift voor Gezondheidsrecht [Dutch Journal of Health Law] (TvGR; 92%) and Medisch Contact [Medical Contact] (MC; 88%). The TvGR published almost two-thirds of the verdicts offered (63%), and the MC published almost three-quarters (74%). In the decision to publish, the disciplinary boards differed in their interpretation of the concept of 'general importance'. CONCLUSION: If disciplinary proceedings are to achieve the desired quality-promoting effect on professional practice, then more attention will need to be paid to the publication policy, and the disciplinary boards will have to develop a joint code of practice. More verdicts could be published, also in professional journals.

Primary intradural classic chondrosarcoma: case report and literature review.

OBJECTIVE AND IMPORTANCE: The exact origin of rare intradural chondrosarcomas remains obscure. We present a case report of an intradural classic chondrosarcoma (a very rare subtype of chondrosarcoma in this location), with a review of the literature, in an attempt to clarify the histogenesis of these tumors. CLINICAL PRESENTATION: A 48-year-old man presented with a 12-month history of progressive right hemiparesis. Computed tomography and magnetic resonance imaging demonstrated a left parietal space-occupying lesion. INTERVENTION: The patient underwent an image-guided, left parietal parasagittal craniotomy. An extrinsic tumor, which seemed to arise from the dura, was macroscopically removed. There was no bone involvement. The histological examination revealed a Grade II classic chondrosarcoma with tumor infiltration into the dura. Adjuvant radiotherapy was administered. CONCLUSION: Intradural chondrosarcomas are rare tumors, the majority of which are mesenchymal. Classic chondrosarcomas in this location are much rarer. Their histogenesis is uncertain. In this case, the origin seems to be from the dura. Because of the malignant potential of these tumors, radical extirpation whenever possible, followed by radiotherapy, is indicated.

En bloc removal of the lower lumbar vertebral body for chordoma. Report of two cases.

En bloc removal of the lower lumbar vertebral bodies (VBs) is a major surgical challenge. The authors describe the surgical technique used in two patients who presented with chordoma confined to the L-5 and L-4 VB, respectively. These tumors were diagnosed using magnetic resonance (MR) imaging during investigation for back pain. Both patients underwent a combined (two-stage) anterior-posterior approach. In the first case the posterior stage of the procedure was followed by an anterior retroperitoneal approach, and in the second case a lateral retroperitoneal approach was used. Complete en bloc excision of the tumor was achieved in each case, even though in the second case the VB fractured when it was mobilized. The correlation between the MR imaging findings and surgical specimens was remarkable. The authors conclude that en bloc resection is feasible in these cases. Because mobilization of the VB is more difficult in the lateral approach, the authors favor the anterior retroperitoneal approach. The authors anticipate the need for such procedures to increase with the widespread use of MR imaging, which demonstrates the extent of these tumors with remarkable accuracy.

Reserved procedures in Dutch hospitals: knowledge, experiences and views of physicians and nurses.

The Individual Health Care Professions Act came into force in The Netherlands in 1997, introducing a mixed system for the regulation of the practice of medicine. One of its components, the reserved procedures regulations, was studied in hospitals to gain insight into the knowledge, experiences and views of physicians and nurses with regard to these regulations. Questionnaires were sent to representative samples of 250 gynaecologists, 350 internists, and 3200 nurses, response rates were 65, 60 and 71%, respectively. Almost all respondents were aware that physicians are authorised to perform reserved procedures on their own initiative (93-99%), and 48-63% knew that nurses are not authorised to do this. A substantial percentage of the nurses performed reserved procedures on their own initiative (17-53%). A majority of gynaecologists and internists presumed that the hospital had ensured the proficiency of the nurses to perform reserved procedures (58% resp. 65%), while 82% of the nurses determined their own proficiency for each procedure. Most respondents felt that the reserved procedures regulations offer adequate protection for patients (58-72%). Although recommendations are made for improvement, the functioning of the reserved procedures regulations in hospitals is considered to be moderately positive.

Paratuberculosis: a surgical method of diagnosis in practice.

This article examines the use of the surgical mesenteric lymph node biopsy in cattle under field conditions. The surgical method and the complications which occurred are described. It is better not to give a sedative to an animal in advanced pregnancy. The site of the incision depended on the stage of pregnancy. In animals in advanced pregnancy in incision should be caudo-ventral in the right-hand flank. To prevent complications, the grid incision should be used then.

The intravenous administration of johnin in the diagnosis of paratuberculosis in practice.

The diagnostic value of the intravenous injection of 1.6 or 3.2 ml of johnin was evaluated in a total of 116 cattle. The sensitivity was 84% with clinically suspect cattle. A general reaction occurred frequently as well as elevation of body temperature (average 1.47 degrees C). The observance of a general reaction was a good additional source of information when evaluating the test. There was no significant difference in elevation of temperature between the cattle injected with 1.6 ml and those injected with 3.2 ml. A combination of diagnostic techniques such as the complement fixation test, intravenous johnin test, microscopic examination of the faeces and a biopsy examination of the rectal mucosa were necessary, in order to confirm the diagnosis of Johne's disease. In this manner a diagnosis can be confirmed with clinically suspect cattle in 96% of the cases. The sensitivity of the intravenous johnin test was considerably lower in cases of non-clinical Johne's disease.

The role of the medical examiner in the euthanasia notification procedure in The Netherlands.

The objective of the study was to provide an insight into the role of the medical examiner in the euthanasia notification procedure in The Netherlands. At the beginning of 1996 a representative group of 116 medical examiners was interviewed. The study found that there was a considerable variation in the way in which the medical examiners fulfilled their tasks. In all cases, after the physician-assisted death had taken place, the medical examiner investigated whether the attending physician had met the requirements for prudent practice, and in approximately 75% of the cases he reported his findings to the Public Prosecutor. In 78% of cases the attending physician was well known to the medical examiners, who were general practitioners, and in a third of the cases this influenced their assessment. Seventy-six per cent of the medical examiners, 61% of the members of the public prosecution and 47% of the physicians thought that it is the task to the medical examiner to review whether the requirements for prudent practice have been met by the attending physician. In conclusion further specification of the task of the medical examiner would appear to be beneficial to increase uniformity in the procedure. In particular, it should be determined whether it is the medical examiner's responsibility to review whether the requirements for prudent practice have been met. It should also be taken into consideration whether the position of the general practitioner medical examiner is sufficiently independent to make an objective report.