European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness.

BACKGROUND AND PURPOSE: Patients with acquired brain injury and acute or prolonged disorders of consciousness (DoC) are challenging. Evidence to support diagnostic decisions on coma and other DoC is limited but accumulating. This guideline provides the state-of-the-art evidence regarding the diagnosis of DoC, summarizing data from bedside examination techniques, functional neuroimaging and electroencephalography (EEG). METHODS: Sixteen members of the European Academy of Neurology (EAN) Scientific Panel on Coma and Chronic Disorders of Consciousness, representing 10 European countries, reviewed the scientific evidence for the evaluation of coma and other DoC using standard bibliographic measures. Recommendations followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The guideline was endorsed by the EAN. RESULTS: Besides a comprehensive neurological examination, the following suggestions are made: probe for voluntary eye movements using a mirror; repeat clinical assessments in the subacute and chronic setting, using the Coma Recovery Scale - Revised; use the Full Outline of Unresponsiveness score instead of the Glasgow Coma Scale in the acute setting; obtain clinical standard EEG; search for sleep patterns on EEG, particularly rapid eye movement sleep and slow-wave sleep; and, whenever feasible, consider positron emission tomography, resting state functional magnetic resonance imaging (fMRI), active fMRI or EEG paradigms and quantitative analysis of high-density EEG to complement behavioral assessment in patients without command following at the bedside. CONCLUSIONS: Standardized clinical evaluation, EEG-based techniques and functional neuroimaging should be integrated for multimodal evaluation of patients with DoC. The state of consciousness should be classified according to the highest level revealed by any of these three approaches.

The vegetative state/unresponsive wakefulness syndrome: a systematic review of prevalence studies.

One of the worst outcomes of acquired brain injury is the vegetative state, recently renamed 'unresponsive wakefulness syndrome' (VS/UWS). A patient in VS/UWS shows reflexive behaviour such as spontaneous eye opening and breathing, but no signs of awareness of the self or the environment. We performed a systematic review of VS/UWS prevalence studies and assessed their reliability. Medline, Embase, the Cochrane Library, CINAHL and PsycINFO were searched in April 2013 for cross-sectional point or period prevalence studies explicitly stating the prevalence of VS/UWS due to acute causes within the general population. We additionally checked bibliographies and consulted experts in the field to obtain 'grey data' like government reports. Relevant publications underwent quality assessment and data-extraction. We retrieved 1032 papers out of which 14 met the inclusion criteria. Prevalence figures varied from 0.2 to 6.1 VS/UWS patients per 100 000 members of the population. However, the publications' methodological quality differed substantially, in particular with regards to inclusion criteria and diagnosis verification. The reliability of VS/UWS prevalence figures is poor. Methodological flaws in available prevalence studies, the fact that 5/14 of the studies predate the identification of the minimally conscious state (MCS) as a distinct entity in 2002, and insufficient verification of included cases may lead to both overestimation and underestimation of the actual number of patients in VS/UWS.

Clinimetric properties of the Nociception Coma Scale (-Revised): A systematic review.

The Nociception Coma Scale is a nociception behaviour observation tool, developed specifically for patients with disorders of consciousness (DOC) due to (acquired) brain injury. Over the years, the clinimetric properties of the NCS and its revised version (NCS-R) have been assessed, but no formal summary of these properties has been made. Therefore, we performed a systematic review on the clinimetric properties (i.e. reliability, validity, responsiveness and interpretability) of the NCS(-R). We systematically searched CENTRAL, CINAHL, Embase, PsycInfo and Web of Science until August 2015. Two reviewers independently selected the clinimetric studies and extracted data with a structured form. Included studies were appraised on quality with the COSMIN checklist. Eight studies were found eligible and were appraised with the COSMIN checklist. Although nearly all studies lacked sample size calculation, and were executed by the same group of authors, the methodological quality ranged from fair to excellent. Important aspects of reliability, construct validity and responsiveness have been studied in depth and with sufficient methodological quality. The overview of clinimetric properties in this study shows that the NCS and NCS-R are both valid and useful instruments to assess nociceptive behaviour in DOC patients. The studies provide guidance for the choice in NCS-R cut-off value for possible pain treatment and cautions awareness of interprofessional differences in NCS-R measurements. SIGNIFICANCE: This systematic review provides a structured overview of the clinimetric properties of the Nociception Coma Scale (-Revised) and provides insights for a solid evidence-based nociception behaviour assessment and treatment plan.

[The unresponsive wakefulness syndrome: Dutch perspectives]. / Als het bewustzijn niet meer terugkeert.

The unresponsive wakefulness syndrome (UWS), formerly known as the vegetative state, is one of the most dramatic outcomes of acquired brain injury. Patients with UWS open their eyes spontaneously but demonstrate only reflexive behavior; there are no signs of consciousness. Research shows that, for years now, the Netherlands has the world's lowest documented prevalence of UWS. Unfortunately, this small group of vulnerable patients does not receive the care it needs. Access to specialized rehabilitation is limited, misdiagnosis rates are high and a substantial number of UWS patients receive life-prolonging treatment beyond chances of recovery, despite a framework allowing for discontinuation of such treatment once recovery of consciousness has become unlikely. By comparing data from 2012 with that of 2003, this paper illustrates the current situation and outlook for UWS patients in the Netherlands and makes recommendations for the optimization of treatment and care, as well as for future research.

Fear for the intraabdominal abscess after laparoscopic appendectomy: not realistic.

BACKGROUND: The risk for intraabdominal abscess (IAA) after laparoscopic appendectomy (LA) is still a matter of debate. The aim of the present study was to evaluate postoperative complications after open (OA) and laparoscopic appendectomy, in particular in perforated appendicitis (PA). METHODS: In the period 1999-2002, 331 appendectomies were performed for histological proven appendicitis, 144 by the open and 187 by the laparoscopic technique. Parameters were conversion rate, perforation, wound infection, and IAA. RESULTS: Conversion to OA was done in 20 cases (10.7%). Perforated appendicitis led more frequently to conversion than simple appendicitis (23.5 vs 7.8%; p = 0.007). Perforated appendicitis was equally seen in the open and laparoscopic technique (15 vs 18%). Wound infections after OA, converted and LA for acute appendicitis were 3 of 144 (2.1%), 1 of 20 (5.0%) and 1 of 167 (0.6%), respectively (NS). IAA formation did not differ among the three procedures (3.5 vs 0 vs 3.6%). In PA the rate of IAA formation was increased. However, the risk was not influenced by the technique: Two patients after the OA, none after a converted procedure, and two patients after LA formed an abscess (9.5 vs 0 vs 7.7% [NS]). CONCLUSION: LA does not lead to more intraabdominal abscesses than the open technique; even for perforated appendicitis the laparoscopic technique can be used safely.

A chromosomal abnormality in hyaline vascular Castleman's disease: evidence for clonal proliferation of dysplastic stromal cells.

The pathogenesis of the hyaline vascular variant of Castleman's disease is currently unknown; however, vascular and dendritic cell proliferations are common in this disorder. We report a clonal karyotypic abnormality (46,XX,t(1;16) (p11;p11), del(7)(q21q22),del(8)(q12q22)) in 15 of 20 cells obtained after short-term stromal cultures of a typical case of hyaline vascular Castleman's disease (HVCD). There was no histologic, immunohistochemical, or genotypic evidence of a clonal lymphoid or plasma cell proliferation supporting origin of this aberration from the stromal component, possibly dendritic cells. We re-examined 15 previous cases of HVCD and identified a spectrum of dysplastic changes in the follicular dendritic cells (FDC) of atrophic lymphoid follicles, with some cases showing expansions of FDC networks by CD21 immunostaining. We propose that localized clonal proliferations of stromal elements, particularly follicular dendritic cells, occur in typical HVCD and likely explain the increased incidence of FDC sarcomas in these patients.

Laparoscopic spinal fusion of L4-L5 and L5-S1.

BACKGROUND: Patients with degenerative disc disease were treated by laparoscopic spondylodesis. Clinical outcome and quality of life were then analyzed in a retrospective study. METHODS: Thirty patients with a mean age of 43 years (range, 26-63) who suffered from instability of levels L4-L5 (n = 23), L5-S1 (n = 3), or both (n = 2) underwent surgery. Spondylodesis was achieved with two BAK cylinders. After 6 months, all patients completed a questionnaire designed to assess satisfaction with the operative outcome. RESULTS: After a median follow-up of 2.3 years (range, 0.9-3.5), 23 patients were free of pain or greatly improved. Complications included bleeding (n = 2), cage displacement (n = 1), retrograde ejaculation (n = 3), and postoperative ileus (n = 1). Good improvement was reported in daily activities and quality of life. CONCLUSION: Laparoscopic spondylodesis has a good clinical outcome with a low rate of morbidity. Notable improvements can be achieved in terms of daily activities and quality of life; however, these improvements are moderate in degree, and patient activity remains somewhat limited.

Complications and feasibility of laparoscopic adhesiolysis in patients with chronic abdominal pain. A retrospective study.

BACKGROUND: A retrospective study was done to determine whether laparoscopic adhesiolysis benefits patients with chronic abdominal pain. Factors that influence complications and feasibility of laparoscopic adhesiolysis were evaluated. METHODS: 174 consecutive operations in 157 patients were retrospectively analyzed for factors which might influence the complication rate and the feasibility of laparoscopic adhesiolysis. RESULTS: In 128 out of 174 procedures a complete adhesiolysis was performed. We had to accept an incomplete adhesiolysis in 39 other patients and in 7 patients a primary conversion was needed. We noticed 16 major complications. Two patients died. Relief of pain was recorded in 80% of patients after short follow-up. The number of previous abdominal operations and patient age significantly affected the outcome of surgery. CONCLUSION: Laparoscopic adhesiolysis in patients with chronic abdominal pain seems to be a feasible and effective operation with considerable risk.

[Laparoscopy useful in the diagnosis and surgery of acute appendicitis]. / Laparoscopie goed bruikbaar bij diagnostiek en chirurgie wegens appendicitis acuta.

The value of diagnostic laparoscopy was evaluated in 74 patients who had clinical signs of acute appendicitis. The average age was 27 years (5-67). The laparoscopically determined degree of inflammation was compared with the results of histologic examination, and the results of laparoscopic appendectomy were evaluated. In 6 patients laparoscopic appendectomy was not performed, because of infiltrative disease (twice), twisted ovary, ovulatory bleeding, enteritis and partially incarcerated inguinal hernia. In 2 patients suffering of acute appendicitis conversion to laparotomy was necessary because of obscured anatomy. On 57 out of 68 patients who underwent appendectomy, the laparoscopic findings were in accordance with histologic examination; i.e. 54 times acute appendicitis and 3 times appendix sana. In 7 patients the appendix was classified as inflamed during laparoscopy, histological examination revealing lymphoid hyperplasia or a subacute inflammation. In 4 patients with a laparoscopically normal appendix, inflammation was seen histologically. The average operation time was 29 minutes and the average postoperative hospital stay was 4 days. Three complications occurred: an inflammatory mass developed in 2 patients post-operatively and I patient had a hematoma in the trocar puncture site and a wound abscess developed. Laparoscopy is an aid in diagnosing appendicitis, and may prevent unnecessary appendectomy. If inflammation is established appendectomy can be performed safely and effectively.

[Initial experiences with laparoscopic cholecystectomy]. / De eerste ervaringen met laparoscopische cholecystectomie.

Laparoscopic cholecystectomy was performed in 45 patients for treatment of symptomatic gallbladder disease. The age distribution was 23 to 79 years. In four patients the procedure was not completed and a laparotomy was performed to remove the gallbladder: once because of a defective instrument, once because of bleeding of an omental adhesion and twice because of disturbed anatomy of the cystic duct region by inflammatory tissue. In four cases a laparoscopic cholecystectomy was performed because of an acute cholecystitis and in three cases a laparoscopic cholecystectomy à froid was performed. There were three postoperative complications: one case of bleeding and two cases of leakage of bile during five and ten days, respectively. In all these cases the treatment was conservative and laparotomy was not necessary. The postoperative hospital stay varied between 3 and 11 days with a mean of 4.2 days. The period of unfitness for work after leaving hospital ranged from one to three weeks. If for whatever reason the laparoscopic procedure cannot be completed, a laparotomy to remove the gallbladder should be performed in the same session. Laparoscopic cholecystectomy is a new, safe, less invasive method to remove the gallbladder with significant benefit to the patient. The morbidity is low and the hospital stay is short. A considerable reduction of costs is achieved with this treatment.

[Unfounded doubt in laparoscopic cholecystectomy]. / Onterechte twijfel aan de laparoscopische cholecystectomie.

Laparoscopic cholecystectomy began to gain ground in the late eighties. The smaller incision led to less postoperative pain and faster recovery. By now, the method has become a matter of controversy: the laparoscopic operation took more time than the 'minilaparotomy'. This criticism can be refuted: laparoscopy gives faster recovery than the conventional large incision and a better view than the 'minilaparotomy'.

Laparoscopic surgery during pregnancy.

BACKGROUND: Laparoscopic surgery is known for its many advantages, but the use of this modality during pregnancy is still under discussion. METHODS: The subjects in this discussion are the unknown influence of the pneumoperitoneum and the fear of damaging the uterus while inserting the Veress needle and trocars. In a review of recent literature describing laparoscopic surgery during pregnancy, no complications were seen. We performed four laparoscopic appendectomies and three laparoscopic cholecystectomies between 12 and 33 weeks estimated gestational age (EGA). RESULTS: All pregnancies passed without complications and ended in at-term deliveries of healthy babies. CONCLUSIONS: The risks, precautions to avoid them, and the safety of laparoscopic surgery during pregnancy are discussed in the light of our experience and reports in recent literature.

Percutaneous transluminal dilatation of the iliac artery: long-term results.

One hundred fifty-four patients with stenosis of the iliac artery underwent percutaneous transluminal angioplasty (PTA). These patients were followed for 1-7 years. The long-term results of the PTAs were analyzed by computer, and life tables were generated for dilatations of the iliac arteries with unimpaired flow and for those with an obstruction in the outflow tract. The accumulative 7-year patency rate was 90%, which agrees with other reports. This study demonstrates that the long-term results of PTA of iliac arterial stenoses are competitive with reconstructive vascular surgery. PTA should be the treatment of choice in patients with iliac arterial stenoses.

Percutaneous transluminal angioplasty of the femoropopliteal artery: initial and long-term results.

Patients with dilated stenoses and recanalized occlusions were evaluated to assess the initial and long-term results of percutaneous transluminal angioplasty (PTA) in the femoropopliteal artery. The follow-up period was at least 1 year. The initial success rate was 84% (128/164). The initial results were influenced by the radiologist's experience, catheter selection, and type of lesion. The 5- and 7-year cumulative patency rates were 70% and 60%. There was no difference in long-term patency between initially successful stenoses and short (less than 3 cm) occlusions. Both the morphology and location of the stenotic lesion influenced the long-term results. Although many factors influence the initial and long-term success rate, results of this study justify PTA in the femoropopliteal artery. Patients with localized stenoses and short occlusions are best suited for this treatment.

Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial.

BACKGROUND: Laparoscopic adhesiolysis for chronic abdominal pain is controversial and is not evidence based. We aimed to test our hypothesis that laparoscopic adhesiolysis leads to substantial pain relief and improvement in quality of life in patients with adhesions and chronic abdominal pain. METHODS: Patients had diagnostic laparoscopy for chronic abdominal pain attributed to adhesions; other causes for their pain had been excluded. If adhesions were confirmed during diagnostic laparoscopy, patients were randomly assigned either to laparoscopic adhesiolysis or no treatment. Treatment allocation was concealed from patients, and assessors were unaware of patients' treatment and outcome. Pain was assessed for 1 year by visual analogue score (VAS) score (scale 0-100), pain change score, use of analgesics, and quality of life score. Analysis was by intention to treat. FINDINGS: Of 116 patients enrolled for diagnostic laparoscopy, 100 were randomly allocated either laparoscopic adhesiolysis (52) or no treatment (48). Both groups reported substantial pain relief and a significantly improved quality of life, but there was no difference between the groups (mean change from baseline of VAS score at 12 months: difference 3 points, p=0.53; 95% CI -7 to 13). INTERPRETATION: Although laparoscopic adhesiolysis relieves chronic abdominal pain, it is not more beneficial than diagnostic laparoscopy alone. Therefore, laparoscopic adhesiolysis cannot be recommended as a treatment for adhesions in patients with chronic abdominal pain.