[What are the barriers for doctors to stop medication?] / Waarom vinden artsen het zo moeilijk om te stoppen met medicatie?

There are several dilemma's for the doctor in stopping or deminuishing medication and in diagnosing and exploring the origin of a diseaese. There can be doubt about having enough actual information about the patient, possessing knowledge about tapering and its consequences. The doctor can be vulnerable about her capacities in communication and shared decision making, in dealing with resistance or agression from the patient and with her own disappointment and feeling of failure. Also organizational barriers (such as a lack of time or continuity in care) can be involved. Team collaboration with discussion about aims and behaviour, and reflection on personal strategies and limits are necessary to guarantee quality of care.

Feasibility of measuring renal blood flow by phase-contrast magnetic resonance imaging in patients with autosomal dominant polycystic kidney disease.

OBJECTIVES: Renal blood flow (RBF) has been shown to predict disease progression in autosomal dominant polycystic kidney disease (ADPKD). We investigated the feasibility and accuracy of phase-contrast RBF by MRI (RBFMRI) in ADPKD patients with a wide range of estimated glomerular filtration rate (eGFR) values. METHODS: First, we validated RBFMRI measurement using phantoms simulating renal artery hemodynamics. Thereafter, we investigated in a test-set of 21 patients intra- and inter-observer coefficient of variation of RBFMRI. After validation, we measured RBFMRI in a cohort of 91 patients and compared the variability explained by characteristics indicative for disease severity for RBFMRI and RBF measured by continuous hippuran infusion. RESULTS: The correlation in flow measurement using phantoms by phase-contrast MRI was high and fluid collection was high (CCC=0.969). Technical problems that precluded RBFMRI measurement occurred predominantly in patients with a lower eGFR (34% vs. 16%). In subjects with higher eGFRs, variability in RBF explained by disease characteristics was similar for RBFMRI compared to RBFHip, whereas in subjects with lower eGFRs, this was significantly less for RBFMRI. CONCLUSIONS: Our study shows that RBF can be measured accurately in ADPKD patients by phase-contrast, but this technique may be less feasible in subjects with a lower eGFR. KEY POINTS: Renal blood flow (RBF) can be accurately measured by phase-contrast MRI in ADPKD patients. RBF measured by phase-contrast is associated with ADPKD disease severity. RBF measurement by phase-contrast MRI may be less feasible in patients with an impaired eGFR.

Early hepatic regeneration index and completeness of regeneration at 6 months after partial hepatectomy.

BACKGROUND: The liver is known to regenerate following partial hepatectomy (PH), but little is known about the timing and completeness of regeneration relative to the resected volume. This study examined whether liver volume regeneration following PH and its completeness 6 months after surgery is related to the resected volume. METHODS: A consecutive series of patients undergoing PH were included. All patients underwent preoperative computed tomography (CT) before and 7 days after surgery. Additional scans were performed 6 months after operation. Preoperative total liver volume (TLV), resected volume, future liver remnant (FLR) and liver remnant (LR) volumes were measured on CT images by freehand drawing of regions of interest in the portal venous phase on 2-mm thick slices. Regeneration indices were calculated at 7 days (RI(early)) and 6 months (RI(total)) using the formula 100 × (LR volume-FLR volume)/FLR volume. Patients were classified into five groups based on resected volume as a percentage of TLV: 0-19, 20-39, 40-59, 60-69 and at least 70 per cent in groups 1-5 respectively. RESULTS: Ninety-one patients were enrolled. RI(early) varied from 11 to 66 per cent in groups 1-5 (P < 0·001). RI(early) did not increase linearly with increasing resection volume and a plateau was seen from group 3 and above. In contrast, RI(total) was related linearly to resected volume; values ranged from 21 to 233 per cent in groups 1-5 (P < 0·001). At 7 days, LR volume represented 97, 87, 70, 58 and 41 per cent of TLV in groups 1-5. At 6 months, respective values were 102, 99, 87, 82 and 91 per cent. CONCLUSION: Early postoperative liver volume regeneration was not related linearly to resected volume. At 6 months after surgery, RI was related linearly to resected volume, but LRs had not yet regenerated to preoperative TLV.

Endoscopic ultrasonography in suspected pancreatic malignancy and indecisive CT.

BACKGROUND: In the assessment of patients with a clinical suspicion of malignant pancreatic disease, computed tomography (CT) findings are sometimes negative or inconclusive. AIMS: To determine whether endoscopic ultrasonography (EUS) with or without fine needle aspiration (EUS÷FNA) was conclusive in patients with a clinical suspicion of pancreatic malignancy, in whom CT scan was negative or inconclusive. METHODS: Retrospective case series in a tertiary referral centre. From February 2006 to December 2007, EUS÷FNA was performed in all patients suspected of having malignant pancreatic disease with negative or inconclusive CT findings. Main outcome measurement was the diagnostic yield of EUS in these patients. RESULTS: 34 patients had a negative (n=11) or inconclusive (n=23) CT scan. EUS÷FNA established a correct diagnosis in 30÷34 cases (88%). Malignancy was diagnosed in 19÷34 patients and nonmalignant disease in 8÷34 cases. In 3÷34 patients no lesions were found and no malignant disease developed during follow-up (mean=728 days). EUS÷FNA was inconclusive in 4÷34 patients. CONCLUSION: In patients with a clinical suspicion of pancreatic malignancy with negative or inconclusive CT findings, EUS÷FNA was able to establish a diagnosis in 88% of cases. EUS should therefore be considered a diagnostic modality in this complex group of patients.

Impact of 18-fluorodeoxyglucose positron emission tomography on computed tomography defined target volumes in radiation treatment planning of esophageal cancer: reduction in geographic misses with equal inter-observer variability: PET/CT improves esophageal target definition.

Target volume definition in modern radiotherapy is based on planning computed tomography (CT). So far, 18-fluorodeoxyglucose positron emission tomography (FDG-PET) has not been included in planning modality in volume definition of esophageal cancer. This study evaluates fusion of FDG-PET and CT in patients with esophageal cancer in terms of geographic misses and inter-observer variability in volume definition. In 28 esophageal cancer patients, gross, clinical and planning tumor volumes (GTV; CTV; PTV) were defined on planning CT by three radiation oncologists. After software-based emission tomography and computed tomography (PET/CT) fusion, tumor delineations were redefined by the same radiation-oncologists. Concordance indexes (CCI's) for CT and PET/CT based GTV, CTV and PTV were calculated for each pair of observers. Incorporation of PET/CT modified tumor delineation in 17/28 subjects (61%) in cranial and/or caudal direction. Mean concordance indexes for CT-based CTV and PTV were 72 (55-86)% and 77 (61-88)%, respectively, vs. 72 (47-99)% and 76 (54-87)% for PET/CT-based CTV and PTV. Paired analyses showed no significant difference in CCI between CT and PET/CT. Combining FDG-PET and CT may improve target volume definition with less geographic misses, but without significant effects on inter-observer variability in esophageal cancer.

Detection of lymph node metastases with ultrasmall superparamagnetic iron oxide (USPIO)-enhanced magnetic resonance imaging in oesophageal cancer: a feasibility study.

AIM: In this feasibility study we investigated whether magnetic resonance imaging (MRI) with ultrasmall superparamagnetic iron oxide (USPIO) can be used to identify regional and distant lymph nodes, including mediastinal and celiac lymph node metastases in patients with oesophageal cancer. PATIENTS AND METHODS: Ten patients with a potentially curative resectable cancer of the oesophagus were eligible for this study. All patients included in the study had positive lymph nodes on conventional staging (including endoscopic ultrasound, computed tomography and fluorodeoxyglucose-positron emission tomography). Nine patients underwent MRI + USPIO before surgery. Results were restricted to those patients who had both MRI + USPIO and histological examination. Results were compared with conventional staging and histopathologic findings. RESULTS: One patient was excluded due to expired study time. Five out of 9 patients underwent an exploration; in 1 patient prior to surgery MRI + USPIO diagnosed liver metastases and in 3 patients an oesophageal resection was performed. USPIO uptake in mediastinal lymph nodes was seen in 6 out of 9 patients; in 3 patients non-malignant nodes were not visible. In total, 9 lymph node stations (of 6 patients) were separately analysed; 7 lymph node stations were assessed as positive (N1) on MRI+USPIO compared with 9 by conventional staging. According to histology findings, there was one false-positive and one false-negative result in MRI + USPIO. Also, conventional staging modalities had one false-positive and one false-negative result. MRI + USPIO had surplus value in one patient. Not all lymph node stations could be compared due to unforeseen explorations. No adverse effects occurred after USPIO infusion. CONCLUSION: MRI+USPIO identified the majority of mediastinal and celiac (suspect) lymph nodes in 9 patients with oesophageal cancer. MRI+USPIO could have an additional value in loco-regional staging; however, more supplementary research is needed.

Limited additional value of positron emission tomography in staging oesophageal cancer.

BACKGROUND: The detection of distant metastases in patients with oesophageal cancer may be improved with [(18)F]fluorodeoxyglucose positron emission tomography (FDG-PET), preventing unnecessary surgical explorations. The aim of this study was to assess the additional value of FDG-PET after a state-of-the-art preoperative staging protocol. METHODS: All patients in this prospective cohort study were staged with multidetector computed tomography, endoscopic ultrasonography and external ultrasonography of the neck, both combined with selective fine-needle aspiration cytology. Patients considered eligible for curative surgery after these investigations underwent FDG-PET. RESULTS: FDG-PET revealed suspicious hot spots in 30 (15.1 per cent) of 199 patients. Metastases were confirmed in eight (4.0 per cent). In six of these, distant metastases were confirmed before surgery, but exploratory surgery was necessary for histological confirmation in the other two. All eight upstaged patients had clinical stage III-IV disease before FDG-PET (6.6 per cent of 122 with stage III-IV disease). In seven patients (3.5 per cent) hot spots appeared to be synchronous neoplasms, mainly colonic polyps. However, those in the remaining 15 (7.5 per cent) were false positive, leading to unnecessary additional investigations. CONCLUSION: FDG-PET improves the selection of patients with oesophageal cancer for potentially curative surgery, especially in stages III-IV. However, the diagnostic benefit is limited after state-of-the-art staging, and so broad implementation in daily clinical practice is questionable.

Neglectable benefit of searching for incidental findings in the Dutch-Belgian lung cancer screening trial (NELSON) using low-dose multidetector CT.

The purpose of this study was to prospectively determine the frequency and spectrum of incidental findings (IFs) and their clinical implications in a high risk population for lung cancer undergoing low-dose multidetector computed tomography (MDCT) screening for lung cancer. Scans of 1,929 participants were evaluated for lung lesions and IFs by two radiologists. IFs were categorised as not clinically relevant or possibly clinically relevant. Findings were considered possibly clinically relevant if they could require further evaluation or could have substantial clinical implications. All possibly clinically relevant IFs were reviewed by a third radiologist, who determined its clinical relevance. Of all 1,929 participants, 1,410 (73%) had not clinically relevant IFs and 163 (8%) had possibly clinically relevant IFs of which 129 (79%) were indeed considered clinically relevant. Additional imaging was performed mainly by ultrasound (112 of 118, 96%). All but one lesion were concluded to be benign, mostly cysts (n = 115, 80%). Only 21 (1%) participants had findings with clinical implications. In one participant a malignancy was found, yet without any clinical benefit since no curative treatment was possible. Based on our results, we advise against systematically searching for and reporting of IFs in lung cancer screening studies using low-dose MDCT.

Routine radiography does not have a role in the diagnostic evaluation of ambulatory adult febrile neutropenic cancer patients.

Cancer patients treated with chemotherapy are susceptible to bacterial infections. When an adult patient presents with febrile neutropenia, standard diagnostic care includes physical examination, laboratory diagnostics, chest X-ray (CXR) and sinus radiography. However, the yield of routine radiography in the diagnostic evaluation of ambulatory adult febrile neutropenic patients with normal findings at their physical examination is questionable. Two CXRs and one sinus X-ray were obtained in 109 and 106 febrile neutropenic episodes after chemotherapy in ambulatory adult patients who had no clinical signs suggesting pulmonary infection or sinusitis. We found that in only two of 109 (1.8%; 95% Confidence Interval (CI): 0.3-5.8%) febrile neutropenic episodes without clinical signs of new pulmonary disease, the CXR showed a consolidation suggesting pneumonia. In addition, in five of 88 (5.7%; 95% CI: 2.2-12.0%) febrile episodes in asymptomatic patients, sinus X-ray suggested sinusitis. In none of these seven episodes was a change of antibiotic therapy necessary. In the absence of clinical signs indicating pneumonia or sinusitis, the yield of CXR and sinus radiography in ambulatory adult cancer patients presenting with febrile neutropenia is minimal; CXR and sinus radiography should no longer be performed on a routine basis.

[Diagnostic imaging in acute pancreatitis]. / Beeldvormende diagnostiek bij acute pancreatitis.

Acute pancreatitis is a potentially severe disease with a high morbidity and mortality rate. The natural history of acute pancreatitis is characterised by a variable clinical picture ranging from a mild and self-limiting disease to a necrotising form with various severe and potentially lethal complications. The use of early and reliable diagnostics in the detection of (infected) pancreatic necrotic tissue in the treatment of acute pancreatitis allows adequate supportive treatment to be initiated before the onset of complications, such as infection of the pancreatic necrotic tissue or multiple organ failure. Contrast-enhanced CT is currently the gold standard in the detection of necrosis. Because of some diagnostic shortcomings and disadvantages associated with this technique, such as the use of ionising radiation and the potential nephrotoxicity of the contrast agents, reliable alternative (imaging) techniques are being sought. In particular, contrast-enhanced MRI may play an increasingly important role in the future diagnostics of acute pancreatitis.

[Tuberculosis of the pancreas in a HIV-seropositive patient]. / Tuberculose van het pancreas bij een HIV-seropositieve patiënt.

A 34-year-old man from Nigeria who had resided permanently in the Netherlands for five years had experienced fever, upper abdominal pain and weight loss for several months. He did not give the impression of being ill. A CT scan gave cause to suspect pancreatitis. An HIV test gave a positive result. Puncture of the accumulated fluid around the pancreas led to the diagnosis 'tuberculosis' (infection by Mycobacterium tuberculosis). Once the patient had made a good recovery with antituberculosis therapy, antiretroviral therapy was initiated, whereupon the number of CD4+ cells in the blood increased. Extrapulmonal tuberculosis is not unusual in HIV seropositive patients from countries with a high prevalence of tuberculosis. However, in such patients isolated tuberculosis of the pancreas is unusual and has not previously been described in the Netherlands. The diagnosis can be established following a CT guided puncture; tuberculosis is instantly suspected if the Ziehl-Neelsen stains are positive and the diagnosis can then be confirmed by a polymerase chain reaction (PCR) analysis and by culturing. Anti-retroviral therapy is withheld until response to anti-tuberculosis treatment is satisfactory.

Role of abdominal sonography in excluding abdominal malignancy in the initial workup of patients with abdominal complaints.

OBJECTIVE: The objective of this study was to evaluate the diagnostic performance and role of abdominal sonography in excluding abdominal malignancy in the initial workup of patients with abdominal complaints. MATERIALS AND METHODS: The sonographic report and follow-up data of 494 patients who had undergone a primary sonographic examination were retrospectively reviewed. Sensitivity and specificity of sonography for the diagnosis of an abdominal malignancy-that is, a primary tumor or metastasis-were determined. Multivariate logistic regression analysis was performed to determine the incremental value of sonography, and a prediction rule was derived. RESULTS: An abnormality on sonography--that is, a mass, ascites, pleural effusion, hydronephrosis, or focal intraparenchymal heterogeneity suggestive of a mass--had a sensitivity for abdominal malignancy of 86% and a specificity of 94%. In the multivariate analysis, the sonographic findings were found to have significant incremental value (odds ratio = 74) after adjustment for the clinical determinants. In patients younger than 38 years with no previous malignancy, no palpable mass, normal liver function test results, and negative findings on sonographic examination, the risk of an abdominal malignancy was less than 1 in 500. CONCLUSION: Our results suggest that sonography may be useful in excluding an abdominal malignancy when used in a primary care setting in patients with abdominal complaints who are at low risk for a malignancy.

[Neostigmine treatment of acute pseudo-obstruction of colon (Ogilvie syndrome)]. / Neostigmine voor de behandeling van acute pseudo-obstructie van het colon (Ogilvie-syndroom).

In a 77-year-old male patient with Parkinson's disease and with acute pseudo-obstruction of the colon (Ogilvie's syndrome) conservative therapy was ineffective. Neostigmine was recently shown to be effective and safe for the treatment of Ogilvie's syndrome. Intravenous neostigmine treatment caused a prompt clinical and radiological response in the patient. Early recognition of the condition and prompt neostigmine treatment if conservative measures fail is important to reduce the risk of bowel perforation.

Arteriography and portal venography on routine follow-up after orthotopic liver transplantation.

RATIONALE AND OBJECTIVES: To describe the findings of routinely performed angiographic examinations in patients at discharge 2 months after orthotopic liver transplantation (OLT) and at follow-up 1 year later. METHODS: The findings of 315 angiographic examinations performed in 190 patients 2 months and 1 year after OLT were reviewed, and the changes at the anastomotic site of the hepatic artery and portal vein were analyzed. RESULTS: Routine angiography 2 months and 1 year after OLT demonstrated a normal anastomosis or low-grade stenosis in 82% and 84% of the patients (hepatic artery) and in 88% and 84% (portal vein), respectively. High-grade stenosis occurred in 9% and 5% of the patients (hepatic artery) and in 3% and 5% (portal vein). Hepatic artery occlusion and portal vein occlusion were observed in two and seven patients and in one and three patients, respectively. In 76% of patients, the anastomotic site of the hepatic artery did not change significantly. In eight patients, a normal anastomosis or a low- or medium-grade stenosis developed into high-grade stenosis or occlusion. Conversely, in nine patients, medium- or high-grade stenosis developed into a normal anastomosis or a low-grade stenosis. In all eight patients who initially had a high-grade stenosis, the hepatic artery proved to be patent at 1 year. In 98% of patients, the anastomotic site of the portal vein did not change significantly. In one patient who initially had a normal anastomosis, occlusion was found at I year. CONCLUSIONS: In most patients, routine angiography 2 months and 1 year after OLT demonstrated normal findings or a low-grade stenotic anastomosis of the hepatic artery and portal vein. Significant changes occurred mainly at the anastomotic site of the hepatic artery and could not be predicted by previous angiograms.

Can we see enough? A comparative study of film-screen vs digital radiographs in small lesions in rheumatoid arthritis.

The aim of this study was to evaluate the performance of digital radiography in the detection of early very small erosions and joint space narrowing in the hands and feet in rheumatoid arthritis. Fifty-three sets of film-screen and digital radiographs of the same hands and feet with very small and sometimes questionable lesions (possible erosions and cysts) were scored independently two times by four investigators. The percentage of lesions found in exactly the same position for each investigator was calculated. Intra-observer agreement between first and second reading in film-screen radiography was 64-76 % (mean 67 %), and in digital radiographs 60-71 % (mean 64 %). Agreement between film-screen and digital radiographs ranged from 54 to 64 % (mean 58 %) in the first reading and from 56 to 66 % (mean 62 %) in the second reading. Overall agreement between both techniques between first and second reading ranged between 62 and 73 % (mean 65 %). Digital radiography of the hands and feet can be used in patients suspected of rheumatoid arthritis and in follow-up of those patients, because small and early erosions can be seen equally well with the digital technique as compared with the conventional film-screen technique.

The value of Doppler ultrasound in cirrhosis and portal hypertension.

BACKGROUND: Cirrhosis and portal hypertension affect the flow profile of the liver vasculature. In these conditions Doppler ultrasound can provide important information on the hemodynamics of the portal venous system, the hepatic artery and the hepatic veins. METHODS: The value of Doppler ultrasound in the assessment of the patient with cirrhosis and portal hypertension was determined by reviewing the literature. RESULTS: Portal venous blood flow becomes reversed with advanced portal hypertension. Reversed flow is also demonstrated in patients with veno-occlusive disease and portosystemic shunts. Despite general agreement that portal flow velocity is decreased in cirrhotic patients, the absolute values of portal flow velocity in both healthy subjects and cirrhotic patients vary considerably. Errors in Doppler measurements, observer variability and collateral pathways contribute to these variations. Furthermore, portal blood flow is influenced by numerous factors such as changes in the body position, phase of respiration, timing of meals, exercise and cardiac output. Finally, portal flow may be unaltered due to a combination of high inflow from the splanchnic organs and increased resistance within the liver. High resistive index of the hepatic artery is seen in patients with end-stage liver disease, particularly in children with severe cirrhosis secondary to biliary atresia. However, hepatic artery flow remains normal in most patients. Abnormal hepatic vein flow profiles are seen in patients with cirrhosis, but dampening or flattening of the flow profile has a multifactorial origin (Budd-Chiari, metastases, ascites) and can be observed in healthy subjects. CONCLUSIONS: Although many factors may affect the accuracy of volume flow and velocity measurements and the flow profile of the liver vasculature may change in different situations, Doppler ultrasound is useful in the assessment of the patient with cirrhosis and portal hypertension.