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.

[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.

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.

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.

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.

Incidence and characteristics of distal radial fractures in an urban population in The Netherlands.

The increasing incidence of distal radius fracture is thought to be due to the aging population. Surprisingly, some authors have reported a decrease in the incidence of distal radius fracture. Moreover, the type-specific incidence of distal radial fracture classified according to fracture severity is not well documented. The aim of this population-based study was to estimate the overall and type-specific incidences of distal radius fracture in a urban population in The Netherlands. During 2009, all persons aged ≥18 years old with an acute distal radius fracture in two hospitals in The Netherlands were prospectively registered. In 2009, the mid-year study population consisted of 245,559 inhabitants ≥18 years old. Fractures were categorized according to the AO classification. 494 patients with acute distal radius fractures were registered in the two participating hospitals during the 1-year study period. The overall incidence of distal radius fracture was 20 per 10,000 person-years. Among women, the incidence rate increased from the age of 50 and reached a peak of 124 per 10,000 person-years in women 80 years and older. Among men, the incidence rate was low until the age of 80 years and older, and reached a peak of 24 per 10,000 person-years. The incidence rate among women between 50 and 79 years was 54/10,000 person-years. Extra-articular AO type A fractures were most common among all age groups, comprising 50 % of all fractures (40 % in men and 53 % in women). The overall incidence rate of distal radius fracture was 20 per 10,000 person-years. This incidence increases with age for both women and men. A lower incidence rate among women 50-79 years of age was found than previously reported, which may indicate a declining incidence in this age group. Extra-articular AO type A fractures were the most common fracture types.

Primary subclavian vein thrombosis and its long-term effect on quality of life.

We aimed to compare the long-term results of three different strategies for treatment of patients with primary (spontaneous or effort related) subclavian vein thrombosis (PSVT). We followed 45 consecutive patients who had been treated for PSVT receiving either oral anticoagulant therapy only (n = 14, group 1); thrombolysis followed by anticoagulant therapy (n = 14, group 2); or thrombolysis, transaxillary first rib resection and anticoagulant therapy (n = 17, group 3). Endpoints were persisting symptoms and quality of life (QoL). The latter was assessed with the EuroQol (EQ-5D) questionnaire at the end of follow-up. The design is a case-control study with three different groups. Predictors for residual symptoms and QoL were analyzed with logistic and linear regression analysis. Patients in groups 2 and 3 had significantly less pain, swelling and fatigue in the afflicted limb at six weeks. There was no difference in pain (P = 0.90), swelling (P = 0.58), fatigue (P = 0.61), functional impairment (P = 0.61), recurrence (P = 0.10) or QoL (P = 0.25) between groups at the end of follow-up (mean follow-up 57 months [range 2-176, SD ± 46]). Treatment strategy was not predictive of QoL (P = 0.91, analysis of variance). No differences in long-term symptoms or QoL between patients with successful and unsuccessful thrombolysis were present. In conclusion, thrombolysis with or without first rib resection does not appear to contribute to lasting symptom reduction and improvement of QoL in this study. The effect of thrombolysis may be limited to short-term symptom relief. Transaxillary first rib resection was not associated with improved late outcome (symptoms, QoL) and did not reduce recurrence rate.

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.

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.

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.

Practice of the statutory disciplinary system for health care psychologists in the Netherlands.

A statutory disciplinary system for health care psychologists in the Netherlands was introduced in 1998. To provide an indication of the contribution of this system to monitoring the quality of health care psychology all complaints dealt with in the period 1999-2002 were studied. Questionnaires were sent to all 388 members of the disciplinary boards (response 89%) and 43 practicing lawyers (response 65%). The regional disciplinary boards dealt with 68 complaints about health care psychologists. A sanction was imposed 16 times (25%), mainly for sexual intimacies or a sexual relationship, violation of professional secrecy or incorrect statement or reporting. The statutory disciplinary system appears to be an important corrective instrument for serious forms of professional misconduct for health care psychologists.

[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.

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.

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: 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.

[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.