[Peripheral artery disease: clinical and cost comparison between duplex ultrasonography and contrast-enhanced magnetic resonance angiography--a multicenter randomized trial]

OBJECTIVE

To determine the clinical and economic consequences of replacing duplex ultrasonography (DUS) by contrast-enhanced magnetic resonance angiography (CE-MRA) for the initial diagnostic work-up of patients with peripheral artery disease (PAD).

DESIGN

Randomised multicentre study.

METHOD

In the period from January 2002 to August 2003, consecutive patients with PAD were randomly assigned to CE-MRA or DUS. The primary outcome measure was the costs. Secondary outcome measures included the confidence with which the specialist could take a therapeutic decision on the basis of the imaging study, the change in disease severity, and the change in quality of life (QOL) assessed during 6 months of follow-up. In addition, all costs of imaging, therapeutic interventions and outpatient visits were calculated.

RESULTS

After 6 months of follow-up the data on 352 patients were analysed. Use of CE-MRA reduced the number of additional vascular-imaging procedures by 42% ((69-40)/69) and the specialists felt more confident about their therapeutic decisions. The diagnostic costs of all imaging studies taken together were Euro 167,- higher, on average, in the CE-MRA group (p < 0.001). However, after 6 months of follow-up, no statistically significant differences were found between the two groups with regard to the change in disease severity, the QOL, or the total costs (p > 0.05).

CONCLUSION

Based on these findings, a specialist that replaces DUS by CE-MRA will feel more confident about taking a therapeutic decision and will feel less need for additional imaging. However, the diagnostic costs were higher with CE-MRA.

Morbidity after inguinal sentinel lymph node biopsy and completion lymph node dissection in patients with cutaneous melanoma

BACKGROUND

Aim of the study was to assess the short-term and long-term morbidity after inguinal sentinel lymph node biopsy (SLNB) with or without completion groin dissection (GD) in patients with cutaneous melanoma.

METHODS

Between 1995 and 2003, 127 inguinal SLNBs were performed for cutaneous melanoma. Sixty-six patients, median age 50 (18-77) years, met the inclusion criteria and were studied. Short-term complications were analysed retrospectively, while long-term complications were evaluated using volume measurement and range of motion measurement of the lower extremities.

RESULTS

Fifty-two patients underwent SLNB alone (SLNB group) and 14 patients underwent completion groin dissection after tumour-positive SLNB (SLNB/GD group). Morbidity after SLNB alone: wound infections (n=1), seroma (n=1), postoperative bleeding (n=1), erysipelas (n=1), and slight lymphedema 6% (n=3). Morbidity after SLNB/GD: wound infections (n=4), seroma (n=1), wound necrosis (n=1), postoperative bleeding (n=1), and slight lymphedema 64% (n=9). There were differences between the two groups in the total number of short-term complications (p<0.001), volume difference (p<0.001), flexion (p=0.009), and abduction (p=0.011) limitation of the hip joint.

CONCLUSION

Inguinal SLNB is accompanied with a low complication rate. However, SLNB followed by groin dissection is associated with an increased risk of wound infection and slight lymphedema.

Morbidity after axillary sentinel lymph node biopsy in patients with cutaneous melanoma

AIM

In this study, the short-term and long-term morbidity was assesed after axillary sentinel lymph node biopsy (SLNB) with or without completion axillary lymph node dissection (SLNB/ALND) in patients with cutaneous melanoma.

METHODS

Between 1995 and 2003, 119 axillary SLNBs were performed for cutaneous melanoma. Fifty-eight patients met the inclusion criteria and entered the study.

RESULTS

Forty-four patients underwent SLNB alone and 14 patients underwent axillary lymph node dissection after positive SLNB. Complications after SLNB alone: post-operative bleeding (n=2), seroma (n=1) and slight lymphedema 11%. Complications after SLNB/ALND: wound infections (n=2), seroma (n=5) and slight lymphedema 7%. There were differences between the two groups in short-term complications (p<.001) and functional limitations of the shoulder (p=.011).

CONCLUSION

Axillary SLNB alone had a low complication rate. However, SLNB followed by completion ALND was associated with an increased risk of short- and long-term complications.

[Sentinel lymph node biopsy for melanoma: prognostic value and disadvantages in 300 patients]

OBJECTIVE

The aim of this study was to evaluate the advantages and disadvantages of sentinel lymph node biopsy (SLNB) in patients with cutaneous melanoma.

DESIGN

Descriptive follow-up study.

METHOD

In the period 1995-2004, 300 patients with cutaneous melanoma (Breslow thickness: > or = 1.0 mm) underwent SLNB and, in case of a tumour-positive result, regional lymph node dissection. Results of the SLNB procedure, postoperative complications, follow-up, recurrences, disease-free survival and disease-specific survival were evaluated.

RESULTS

The SLNB detection rate was 99%. 85 patients had a tumour-positive SLNB (28%) and underwent completion regional lymph node dissection; 215 patients underwent SLNB alone. The rate of postoperative complications after SLNB was 7%. With a median follow up of 51 months, the false-negative rate was 11%. The recurrence rate was 23% (SLNB negative: 19%; SLNB positive 34%; p = 0.005). In-transit metastases were found in 4% of the SLNB-negative group and in 20% of the SLNB-positive group (p < 0.001). The 5-year disease-free survival and disease-specific survival rates were 79% and 86%, respectively, in SLNB-negative patients and 57% and 71%, respectively, in SLNB-positive patients. Multivariate analysis showed that the independent prognostic factors for disease-free survival were presence of ulceration (p < 0.001) and SLNB positivity (p < 0.01). Prognostic factors for overall survival were presence of ulceration (p < 0.001) and male sex (p < 0.05), but not the SLNB results. Multivariate analysis also showed that SLNB positivity (p < 0.001) and presence of ulceration (p < 0.01) were independent prognostic factors for developing in-transit metastases.

CONCLUSION

SLNB in patients with cutaneous melanoma is still only of prognostic value since survival benefit is not proven. Disadvantages of SLNB were the false-negative rate, the possibility of an increased risk of in-transit metastases in SLNB-positive patients, and postoperative complications. These must be kept in mind when offering patients SLNB.

Inherited Congenital Extrahepatic Portosystemic Shunts in Cairn Terriers

The pathogenesis of congenital portosystemic shunt (CPSS) in dogs still is incompletely understood. In Irish Wolfhounds and Yorkshire Terriers, CPSS is reported to be hereditary. The aim of this study was to investigate a possible genetic basis and the mode of inheritance of CPSS in Cairn Terriers. Between July 1990 and July 2001, 6-week-old pups of the Dutch Cairn Terrier population were screened by measuring venous ammonia concentrations and in the presence of hyperammonemia by ultrasonography, autopsy, portal vein angiography, or exploratory celiotomy. The same successfully operated female was used 3 times in test matings with an unrelated affected male, her unaffected sire, and an affected offspring. The prevalence of CPSS in the general Cairn Terrier population, the direct progeny of frequently used males, and the offspring of the test matings were tested for significant differences. In total, 6,367 Cairn Terriers were screened; 32 males and 26 females had CPSS. In 3 large family groups, significantly higher prevalences were found compared with the general population (P < .0001, P < .0001, and P < .044). The prevalence of CPSS in the offspring of the test matings was significantly higher (P < .002) than in the general population. No sex predisposition occurred among the affected dogs. The higher prevalence of CPSS in the test matings and the 3 family groups compared with the general population indicates that CPSS in Cairn Terriers is a genetic disease. The inheritance is autosomal and most likely polygenic or monogenic with variable expression.

The intake of total protein, natural protein and protein substitute and growth of height and head circumference in Dutch infants with phenylketonuria

In a previous study, Dutch children with phenylketonuria (PKU) were found to be slightly shorter than their healthy counterparts. In the literature, it has been hypothesized that a higher protein intake is necessary to optimize growth in PKU patients. The study aimed to investigate whether protein intake (total, natural and protein substitute) in this group might be an explanatory factor for the observed growth. Growth of height and head circumference and dietary data on protein intake (total, natural and protein substitute) from 174 Dutch PKU patients born between 1974 and 1996 were analysed retrospectively for the patients' first 3 years of life. Analyses were corrected for energy intake during the first year of life and for the clinical severity of the deficiency of phenylalanine hydroxylase by means of plasma phenylalanine concentration at birth. Neither protein nor energy intake correlated with height growth. A positive, statistically significant relation between head circumference growth and natural protein and total protein intake was found, but not with the intake of the protein substitute or energy. Therefore, this study suggests that improvement of the protein substitute rather than an increase of total protein intake may be important in optimizing head circumference growth in PKU patients.

A pharmacokinetic comparison of the modified release capsule and a plain tablet formulation of mebeverine

This study was conducted to compare the pharmacokinetic properties of the modified release 200 mg capsule of mebeverine and the plain 135 mg tablet of mebeverine after single and multiple doses in 12 healthy subjects in a randomised, crossover design. Single doses were given on days 1 and 7 and multiple doses (200 mg b.i.d. for the capsule and 135 mg t.i.d. for the tablet) on days 2-6 of the study. The 200 mg modified release capsule of mebeverine has extended release properties, as indicated by a lower Cmax, a later tmax and a longer elimination half-life than the plain tablet, while the bioavailability is optimal. No significant accumulation occurs after multiple doses of either formulation. The twice-daily dosage regimen of the 200 mg modified release capsule is a good alternative to the three times daily dosage regimen of the 135 mg plain tablet, because the reduced daily intake is likely to benefit patient compliance.

Sleep problems and daytime problem behaviours in children with intellectual disability

BACKGROUND

Sleep problems are common among children with intellectual disability (ID).

METHOD

The present study assessed the prevalence of severe sleep problems in a sample of children (n=286) with mild to profound ID who lived at home with their parents(s) in the Netherlands. It also explored relationships between severe sleep problems, and family and child variables. Demographic information, data on children's sleep behaviours and parent variables were collected using questionnaires.

RESULTS

Severe settling problems, night waking and early waking were present in 4.2%, 10.8% and 4.2% of cases, respectively; 16.1% of children had at least one type of sleep problem. Children with a severe sleep problem had more severe levels of ID, used medication more often, had a greater frequency of epilepsy, were younger, had a greater frequency of cerebral palsy, and showed more daytime drowsiness and daytime napping than children without a severe sleep problem. Furthermore, children with a severe sleep problem showed more severe levels of daytime problem behaviours; for example, aggression, non-compliance and hyperactivity.

CONCLUSION

The results of the present study are discussed with regard to the assessment and treatment of sleep problems in children with ID.

Physical activity and exercise performance in symptomatic Cambodia veterans

BACKGROUND

Dutch (ex-)servicemen who encounter health problems since return from the 1992-3 peace operation UNTAC, commonly complain of reduced activity levels, decreases in physical fitness and aggravation of symptoms after strenuous exercise.

AIM

To evaluate these symptoms.

DESIGN

A prospective study of 26 symptomatic Cambodia veterans and 26 matched controls (healthy Cambodia veterans).

METHODS

Using an actometer and diaries, both groups were followed for a 12-day baseline period prior to an incremental maximal exercise test on a bicycle ergometer, followed by 7 days of post-ergometer data.

RESULTS

During baseline, symptomatic Cambodia veterans reported more symptoms, had lower levels of physical activity and took longer periods of rest after high activity periods. Symptomatic veterans did not perceive the exercise test needing more exertion than healthy veterans did, although their physical fitness was decreased. Post-ergometer, daily observed symptoms did not aggravate in symptomatic veterans. Four days post-ergometer, actometer and daily observed activity scores were lowered in both groups. As compared to baseline, one day post-ergometer, levels of physical activity were changed in healthy veterans, but not in controls.

DISCUSSION

Complaints about reduced activity levels and decreases in physical fitness in symptomatic Cambodia veterans were confirmed. Post-exertion malaise was not found. The observed post-exertion effects were traced back to weekday patterns.

Effects of 2-week ingestion of (-)-hydroxycitrate and (-)-hydroxycitrate combined with medium-chain triglycerides on satiety and food intake

The aim of this study was to assess the effects of 2 weeks of supplementation with (-)-hydroxycitrate (HCA) and HCA combined with medium-chain triglycerides (MCT) on satiety and energy intake. The experimental design consisted of three intervention periods of 2 weeks separated by washout periods of 2 or 6 weeks in a double-blind, placebo-controlled, randomized, and crossover design. Seven male and 14 female normal to moderately obese subjects (mean+/-S.D.; age, 43+/-10 years; body mass index, 27.6+/-2.0 kg/m(2)) participated in this study. Subjects consumed three self-selected meals and four isoenergetic snacks daily with either no supplementation (PLA), with 500 mg HCA (HCA), or 500 mg HCA and 3 g MCT (HCA+MCT). Each intervention period ended with a test day, consisting of a standardized breakfast and ad libitum a lunch and a dinner. There was a significant body weight (BW) loss during the 2 weeks of intervention (PLA, -0.5+/-0.3 kg, P<.05; HCA, -0.4+/-0.2 kg, P<.05; HCA+MCT, -0.7+/-0.2 kg, P<.01), but this reduction was not different between treatments. Twenty-four-hour energy intake (PLA, 8.1+/-0.3 MJ; HCA, 8.3+/-0.3 MJ; HCA+MCT, 8.4+/-0.3 MJ) and the area under the curve of the appetite-related parameters during the test day were similar for all treatments. Two weeks of supplementation with HCA and HCA combined with MCT did not result in increased satiety or decreased energy intake compared to placebo in subjects losing BW.

Matrix-assisted laser desorption/ionization quadrupole time-of-flight mass spectrometry: an elegant tool for peptidomics

A Matrix-assisted laser desorption/ionization hybrid quadrupole orthogonal acceleration time-of-flight mass spectrometer was employed to acquire neuropeptide mass spectra, directly from neuropeptide secreting tissue deposited on the sample target, in the presence of dihydroxybenzoic acid as matrix. The cockroach corpus cardiacum served as model neuroendocrine tissue. Twelve neuropeptide ion peaks, with mass-to-charge ratio values ranging between 800 and 3,000 Da were selected for tandem mass spectrometry. All peptides below 1,600 Da could be fully sequenced; tandem mass spectrometry analysis of the remaining (three) largest peptides resulted in (limited) sequence tags, which, also due to unavailability of an appropriate neuropeptide structure database, did not allow complete structure elucidation.

Measurement of prolonged fatigue in the working population: determination of a cutoff point for the checklist individual strength

In the Netherlands, a large-scale prospective cohort study was started on prolonged fatigue in the working population. The 1st issue that had to be addressed was the determination of a cutoff point for fatigue for use in the working population. Fatigue is measured with the Checklist Individual Strength (CIS), a 20-item self-report questionnaire. This article demonstrates the process of decision making in the determination of the cutoff point. Total CIS scores were calculated, sensitivity and specificity were compared for potential cutoff points, and a receiver operating characteristics analysis was conducted. A CIS total cutoff point for fatigue of >76 was determined, with a specificity of 90% and a sensitivity of 73%. Limitations regarding the use of cutoff points are discussed. It is concluded that the defined cutoff point seems to be appropriate for use in the working population.

Somatic hypotheses of war syndromes

Since the end of the American Civil War, unexplained symptoms in military personnel arising after a war or peace mission have frequently been described. The pattern of symptoms is highly similar for all of the various war syndromes although the conditions of each war or peace mission are widely different. Many somatic hypotheses have been formulated to explain these syndromes; a considerable proportion of them are already outdated. In the last few years much attention has been given to Gulf War Syndrome and to unexplained symptoms of military personnel who were sent to Cambodia, Rwanda, Burundi, Zaire, or the former Yugoslavia. In this review the symptoms of war syndromes will be considered in more detail and the suggested somatic explanations will be discussed. During the last decade the following somatic causes have been suggested as possible explanations for these symptoms: (persistent) infection, abnormal immune response, administration of multiple vaccinations within a short period of time, use of malaria chemoprophylaxis, neurological abnormalities, exposure to toxicological substances and environmental factors. The various investigations performed to study these hypotheses are discussed. The fact that bias regularly occurs in the course of these investigations is pointed out. For the future, a reliable investigation of a war syndrome should be a prospective multidisciplinary study and should distinguish between causative and sustaining factors.

Fatigue in Cambodia veterans

In 1992 and 1993, Dutch military personnel were deployed in the peace operation UNTAC in Cambodia. Since returning, Cambodia veterans have reported health complaints which they perceive to be related to their service. Their symptoms strikingly resemble health problems reported by Gulf War veterans. Four years post-return, a cross-sectional survey on health symptoms in Cambodia veterans was initiated. Questionnaires were sent to all Cambodia veterans and four comparison groups. Forgetfulness, difficulty concentrating and fatigue were the symptoms most commonly endorsed. An operational case definition was constructed using a validated fatigue severity questionnaire. Cases were not uniquely found in Cambodia veterans (17%). In Rwanda and Bosnia veterans, respectively, 28% and 11% also met our case definition. Fatigue severity level was predicted by pre-mission, during-mission and post-mission variables, of which retrospective recollection of side-effects of vaccines and causal attributions also have been shown to be relevant in studies on Gulf-related illness.

[Somatic and psychological symptoms in soldiers after military clashes and peace-keeping missions]

Dutch soldiers who have participated in the peace keeping operation United Nations Transitional Authority in Cambodia (UNTAC) have reported various somatic and psychological symptoms since their return. Their symptoms show similarities to the Gulf War Syndrome. The question arises whether Gulf War Syndrome, symptoms in UNTAC soldiers and other symptoms after acts of war and peace operations are unique syndromes or comparable complaints? From an historical overview it is not plausible that new and unique syndromes will occur with each war or peace operation. On the other hand it also seems unlikely that war syndromes can be reduced to one diagnostic category. The post-Cambodia complaints may be described in four hypothetical models: the somatic start model, the psychotrauma start model, the premorbidity model and the complaints-not-related-to-Cambodia model. These models are expected to be applicable, after further validation, to other symptoms after acts of war and peace operations. Also they will provide points of application for prevention and treatment of symptoms after future wars and peace operations.