Validation of the Dutch functional, communicative and critical health literacy scales

OBJECTIVE

While most existing health literacy (HL) measures focus primarily on reading comprehension, the functional, communicative and critical HL scales from Ishikawa et al. [19] aim to measure a broader HL spectrum. The objective of this study was to evaluate the validity of the Dutch translation of this instrument.

METHODS

Two survey studies (n = 79 and n = 209) and one cognitive interview study (n = 18) were performed among samples of breast cancer patients and patients with rheumatic diseases.

RESULTS

Analyses showed the scales measured three distinct factors and convergent validity was satisfactory for communicative and critical HL. Nevertheless, the comprehension of the items and the suitability of the response options raised some problems.

CONCLUSION

The HL scales seem promising to measure a broad definition of HL. By revising some of the items and response options as proposed in this article, the scale will become more understandable for people with low HL skills, which might increase the content validity and the distributional properties of the scale.

PRACTICE IMPLICATIONS

The scale should be revised and revalidated. An improved version should be used in practice to gain insight into HL levels of patients. This will help to develop suitable education programs for people with low HL skills.

Future Prospects in Breast Cancer Research - Cancer Stem Cells

Breast cancer is one of the leading causes of cancer deaths among women. Although significant advances in the prevention, diagnosis and management are made, still every year half a million women die of breast cancer. Personalised treatment has the potential to increase treatment efficacy, and hence decrease mortality rates. Moreover, understanding cancer biology and translating this knowledge to the clinic, will improve the breast cancer therapy regime tremendously. Recently, it has been proposed that cancer stem cells (CSC) play an important role in tumour biology. CSC have the ability for self-renewal and are pivotal in setting the heterogeneous character of a tumour. Additionally, CSC possess several characteristics that make them resistant and more aggressive to the conventional chemo- and radiotherapy. Nowadays, breast cancer therapy is focused on killing the differentiated tumour cells, leaving the CSC unharmed, potentially causing recurrence of the disease and metastasis. Specific targeting of the CSC will improve the disease-free survival of breast cancer patients. In this article, two methods are described, aiming at specifically attacking the differentiated tumour cells ('Apoptosis chip') and the cancer stem cell. For this, microfluidics is used.

Visualizing breast cancer using the Twente photoacoustic mammoscope: what do we learn from twelve new patient measurements?

We acquired images of breast malignancies using the Twente photoacoustic mammoscope (PAM), to obtain more information about the clinical feasibility and limitations of photoacoustic mammography. Results were compared with conventional imaging and histopathology. Ten technically acceptable measurements on patients with malignancies and two measurements on patients with cysts were performed. In the reconstructed volumes of all ten malignant lesions, a confined region with high contrast with respect to the background could be seen. In all malignant cases, the PA contrast of the abnormality was higher than the contrast on x-ray mammography. The PA contrast appeared to be independent of the mammographically estimated breast density and was absent in the case of cysts. Technological improvements to the instrument and further studies on less suspicious lesions are planned to further investigate the potential of PAM.

Giant Diverticulum of the Duodenum

A 50-year old female presented herself with abdominal bloating and pain in the Emergengy Department. The symptoms persisted and a clinical evaluation was made. A lesion suspect for a giant duodenal diverticulum was seen on the CT-scan, which was confirmed by enteroclysis. Surgical resection was performed. The diagnosis was histological confirmed after surgery. Small bowel diverticula are relatively common, with an estimated 5 - 22% incidence in the healthy population. They are usually asymptomatic, but can present with abdominal pain and weight loss. Complications such as bleeding and perforation can occur. Surgical resection is the treatment of choice in symptomatic patients.

Viable tumor tissue adherent to needle applicators after local ablation: a risk factor for local tumor progression

Background

Local tumor progression (LTP) is a serious complication after local ablation of malignant liver tumors, negatively influencing patient survival. LTP may be the result of incomplete ablation of the treated tumor. In this study, we determined whether viable tumor cells attached to the needle applicator after ablation was associated with LTP and disease-free survival.

Methods

In this prospective study, tissue was collected of 96 consecutive patients who underwent local liver ablations for 130 liver malignancies. Cells and tissue attached to the needle applicators were analyzed for viability using glucose-6-phosphate-dehydrogenase staining and autofluorescence intensity levels of H&E stained sections. Patients were followed-up until disease progression.

Results

Viable tumor cells were found on the needle applicators after local ablation in 26.7% of patients. The type of needle applicator used, an open approach, and the omission of track ablation were significantly correlated with viable tumor tissue adherent to the needle applicator. The presence of viable cells was an independent predictor of LTP. The attachment of viable cells to the needle applicators was associated with a shorter time to LTP.

Conclusions

Viable tumor cells adherent to the needle applicators were found after ablation of 26.7% of patients. An independent risk factor for viable cells adherent to the needle applicators is the omission of track ablation. We recommend using only RFA devices that have track ablation functionality. Adherence of viable tumor cells to the needle applicator after local ablation was an independent risk factor for LTP.

[A man with thoracic pain]

A 46-year-old man had pain between the shoulders and at the sternum. Two and a half months earlier he had fallen when cycling. It appeared the pain was caused by fractures of thoracic vertebrae V and VI and a dislocation of the manubrium and body of the sternum.

Duodenal Lipoma as a Rare Cause of Upper Gastrointestinal Bleeding

A 52-year-old female was referred because of melaena. After initital work-up, including gastroduodenoscopy, endosonography and CT scan, a duodenotomy was performed. Definite diagnosis was a duodenal lipoma based on histological findings. Lipomas of the gastrointestinal tract are rare. Only 4% occur in the duodenum. The peak incidence is around the 5th and 7th decade of life, with a slight female preponderance. Gastrointestinal lipomas are usually asymptomatic, but can present with mild to severe gastrointestinal bleeding, intussusceptions, abdominal pain, constipation and diarrhea. Clinical, endoscopical, surgical, and radiological features are described in this case of duodenal lipoma.

Gastric Schwannoma Presenting as an Incidentaloma on CT-Scan and MRI

A 67 year old female was referred because of an incidentaloma on CT-scan and MRI which showed a 5.0 cm large mass in the wall of the distal stomach. After an initial work-up which suggested a gastrointestinal stromal tumor (GIST), a partial gastrectomy with a Billroth II gastrojejunostomy was performed. The histological diagnosis was a schwannoma. Gastric schwannomas are rare tumors which comprise 0.2% of all gastric tumors and 4% of all benign gastric neoplasms with a peak of incidence in the 4th and 5th decade of life. Gastric schwannomas are usually asymptomatic, but can present with ulceration and/or gastrointestinal bleeding. Clinical, endoscopical, surgical, radiological and histological features of this case are described and the relevant literature is reviewed.

DIRECT trial. Diverticulitis recurrences or continuing symptoms: Operative versus conservative treatment. A multicenter randomised clinical trial

Background

Persisting abdominal complaints are common after an episode of diverticulitis treated conservatively. Furthermore, some patients develop frequent recurrences. These two groups of patients suffer greatly from their disease, as shown by impaired health related quality of life and increased costs due to multiple specialist consultations, pain medication and productivity losses.

Both conservative and operative management of patients with persisting abdominal complaints after an episode of diverticulitis and/or frequently recurring diverticulitis are applied. However, direct comparison by a randomised controlled trial is necessary to determine which is superior in relieving symptoms, optimising health related quality of life, minimising costs and preventing diverticulitis recurrences against acceptable morbidity and mortality associated with surgery or the occurrence of a complicated recurrence after conservative management.

We, therefore, constructed a randomised clinical trial comparing these two treatment strategies.

Methods/design

The DIRECT trial is a multicenter randomised clinical trial. Patients (18-75 years) presenting themselves with persisting abdominal complaints after an episode of diverticulitis and/or three or more recurrences within 2 years will be included and randomised. Patients randomised for conservative treatment are treated according to the current daily practice (antibiotics, analgetics and/or expectant management). Patients randomised for elective resection will undergo an elective resection of the affected colon segment. Preferably, a laparoscopic approach is used.

The primary outcome is health related quality of life measured by the Gastro-intestinal Quality of Life Index, Short-Form 36, EQ-5D and a visual analogue scale for pain quantification. Secondary endpoints are morbidity, mortality and total costs. The total follow-up will be three years.

Discussion

Considering the high incidence and the multicenter design of this study, it may be assumed that the number of patients needed for this study (n = 214), may be gathered within one and a half year.

Depending on the expertise and available equipment, we prefer to perform a laparoscopic resection on patients randomised for elective surgery. Should this be impossible, an open technique may be used as this also reflects the current situation.

Trial Registration

(Trial register number: NTR1478)

Long-term results of the cut-closed-reconnected Roux loop for enterogastric reflux

BACKGROUND

The aim of this study was to present the long-term results of the cut-closed-reconnected (CCR)-Roux procedure for reflux gastritis.

METHODS

A retrospective analysis was performed on 14 patients with proven reflux gastritis and/or esophagitis who were treated at our institution with a CCR-Roux procedure between 1992 and 1997.

RESULTS

The closure of the afferent loop in the CCR-Roux procedure is effective and permanent. The CCR-Roux patients did not need a rest gastrectomy. No signs of Roux stasis syndrome were seen. There was a consistent weight gain at 2 and 5 years of follow-up. These results permit a comparison with those of the Roux-Y procedure and other alternative procedures as well.

CONCLUSION

In the long run, the CCR-Roux procedure is effective in the treatment of reflux gastritis.

Fissurectomy combined with botulinum toxin A injection for medically resistant chronic anal fissures

INTRODUCTION

Chemical sphincterotomy, the use of pharmacological agents to reduce anal sphincter resting pressure, has become more and more popular in the treatment of chronic anal fissures (CAFs). It offers the possibility to avoid a lateral internal sphincterotomy and its associated risk of incontinence. In our hospital, patient with a chronic anal fissure are consecutively treated with isosorbide dinitrate 1% ointment, applied 6 times a day for 8 weeks, followed by diltiazem 2% ointment, applied 2 times a day for 8 weeks and Botulin Toxin A injections (Dysport; Ipsen, Hoofddorp, the Netherlands) in the internal anal sphincter. In a previous study (1), we describe high healing rates with this regime. Objective The objective of this study is to evaluate the effect of the combination of fissurectomy and Botulin Toxin A in the treatment of CAFs.

METHODS

Twenty-one patients (10 male patients, median age 48 years) with persistent symptoms of chronic anal fissures after following the above mentioned treatment, were enrolled in this study. Fissurectomy was combined with Botulinum Toxin A (80 U of Dysport) under regional anaesthesia in day care. Results After 12 weeks 19/21 CAFs (90%) had healed. Median follow-up was 16 (9-30) months. No recurrences were seen.

CONCLUSION

Fissurectomy in combination with Botulinum Toxin A injection in the internal anal sphincter is an effective treatment for medically resistant CAFs.

Preoperative staging with chest CT in patients with colorectal carcinoma: not as a routine procedure

Background

Preoperative staging of patients with colorectal carcinoma (CRC) has the potential benefit of altering treatment options when metastases are present. The clinical value of chest computed tomography (CT) in staging remains unclear.

Materials and Methods

All patients who undergo colorectal surgery in our hospital are prospectively registered, including patient, treatment, and histopathological characteristics; outcome; and follow-up. Since January 2007, routine preoperative staging CT of chest and abdomen for patients with CRC has been performed as part of our regional guidelines. In this observational cohort study, an analysis on outcome was done after inclusion of 200 consecutive patients.

Results

Synchronous metastases were present in 60 patients (30%). Staging chest CT revealed pulmonary metastases in 6 patients, with 1 false positive finding. In 50 patients indeterminate lesions were seen on chest CT (25%). These were diagnosed during follow-up as true metastases (n = 8), bronchus carcinoma (n = 2), benign lesions (n = 25), and remaining unknown (n = 15). Ultimately, synchronous pulmonary metastases were diagnosed in 13 patients (7%), in 6 patients confined to the lung (3%). In none of the patients the treatment plan for the primary tumor was changed based on the staging chest CT.

Conclusion

The low incidence of pulmonary metastases and minimal consequences for the treatment plan limits the clinical value of routine staging chest CT before operation. It has several disadvantages such as costs, radiation exposure, and prolonged uncertainty because of the frequent finding of indeterminate lesions. Based on this study, a routine staging chest CT in CRC patients is not advocated.

Partial Splenectomy for Splenic Cyst using a Bipolar Radiofrequency Device

The main goals of spleen preserving surgery are control of peroperative bleeding and maintaining the spleen's function postoperatively. Several techniques of spleen preserving surgery have been described. This report presents a new technique to perform partial splenectomy. We performed this partial splenectomy with a bipolar radiofrequency (RF) device in a 21 years old woman with a splenic cyst, with almost no peroperative blood loss.

Collision tumor of the stomach: a case of an adenocarcinoma and a gastrointestinal stromal tumor

A collision tumor of the stomach is a rare event. We report the case of a collision tumor of the stomach consisting of an adenocarcinoma and a gastrointestinal stromal tumor (GIST). This is, to our knowledge, the second report in the literature of such a case. A 71-year-old man with abdominal discomfort underwent an esophagogastroduodenoscopy which revealed a tumor of the oesophagogastric junction. A total gastrectomy was performed. Histologic examination showed a mixed tumor consisting of a primary adenocarcinoma and multiple nodules of GIST. The adenocarcinoma showed both diffuse and intestinal growth, angio-invasion and metastasis to lymph nodes. The GIST tumor cells were strongly immunoreactive to CD117 and CD34. Based on mitotic index, size and cytonuclear details, the biological behavior of this GIST tumor was supposed to be benign. This case reports the rare finding of a collision tumor consisting of an adenocarcinoma and a GIST with an unknown etiology.

[Diagnosis and treatment of patients with spinal epidural metastases]

Three patients with a medical history of malignancy were referred for back pain: two women aged 53 and 43 years respectively, with breast cancer, and a woman of 85 years with rectal carcinoma. All patients suffered from spinal metastasis. Considerable delay occurred between the initial complaint of back pain and the diagnosis. This adversely influenced the outcome after treatment. A reliable differentiation, based on symptoms and signs, between widely occurring non-malignant back pain and back pain due to spinal metastasis is impossible. This confronts physicians with the dilemma of overexposing their patients to diagnostic tests on the one hand and the risk of missing an important diagnosis on the other. Early recognition of warning signs, i.e. previous medical history of malignancy, onset of back pain above 50 years of age, continuous pain not related to posture or movement and nocturnal pain, should alert physicians.

Initial results of in vivo non-invasive cancer imaging in the human breast using near-infrared photoacoustics

Near-infrared photoacoustic images of regions-of-interest in 4 of the 5 cases of patients with symptomatic breasts reveal higher intensity regions which we attribute to vascular distribution associated with cancer. Of the 2 cases presented here, one is especially significant where benign indicators dominate in conventional radiological images, while photoacoustic images reveal vascular features suggestive of malignancy, which is corroborated by histopathology. The results show that photoacoustic imaging may have potential in visualizing certain breast cancers based on intrinsic optical absorption contrast. A future role for the approach could be in supplementing conventional breast imaging to assist detection and/or diagnosis.

[A solitary sternal lesion found by skeletal scintigraphy following treatment for breast carcinoma]

Breast carcinoma frequently metastasises to bone, most often to the thoracic and lumbosacral spine. 3 women, aged 66, 47 and 54 years, who had been previously treated for breast cancer presented with sternal pain. Bone scintigraphy revealed a solitary sternal hot spot in all 3 patients. In the final diagnosis, 1 patient had nonmalignant reactive changes, which required no further therapy; 1 patient had a bone metastasis, which was treated with radiation therapy and tamoxifen; and 1 patient had radionecrotic tissue, which was treated with hyperbaric oxygen therapy. Symptoms resolved in all 3 patients. Skeletal scintigraphy is the most sensitive method for detecting bone metastases, but it is not specific. Bone metastases are usually multifocal, but sometimes a solitary bone lesion is found. A solitary sternal metastasis must be differentiated from other sternal disorders. Various treatment options exist for patients who are ultimately diagnosed with a solitary sternal metastasis.

Fibrin glue treatment for simple and complex anal fistulas

BACKGROUND/AIMS

Surgical management of anal fistulas is associated with considerable morbidity, mainly related to anal sphincter injury. However, treatment with fibrin glue is a safe and simple method associated with less discomfort and complications. A prospective trial was conducted at our institute to evaluate the use of fibrin glue (Tissucol, Baxter, The Netherlands) for simple and complex anal fistulas.

METHODOLOGY

From November 2001 until March 2004, 34 patients (22 male, 12 female, median age 40 years) were treated with Tissucol. Twenty-three (67%) fistulas were classified as simple (subcutaneous, intersphincteric and transsphincteric) and 11 (33%) as complex (suprasphincteric, extrasphincteric and/or associated with Crohn's disease, ulcerative colitis or HIV).

RESULTS

Twenty-six patients were treated once, 5 patients were treated twice, 2 patients were treated 3 times and 1 patient underwent 4 Tissucol treatments. After a median follow-up of 7 months, 13 of 23 simple fistulas (56%) and 6 out of 11 complex fistulas (54%) healed, accounting for an overall closure rate of 55%. Complications occurred in two patients, who both developed a perineal abscess after glue instillation.

CONCLUSIONS

Fibrin glue treatment is safe and effective in 55% of the patients with anal fistulas. It is a good alternative to conventional surgery.

Botulinum toxin A injection in ISDN ointment-resistant chronic anal fissures

BACKGROUND

In the treatment of chronic anal fissures (CAFs), surgical sphincterotomy is more commonly being replaced by chemical sphincterotomy. After the good results of our pilot study including 32 patients, we now describe the effect of botulinum toxin A (BT-A) in a consecutive series of 100 patients with isosorbide dinitrate (ISDN) ointment-resistant CAFs.

METHODS

From October 2002 until August 2005, 100 patients (52 males, 48 females) with a median age of 45 (20-79) years were treated with an injection of 40-100 IU BT-A (Dysport, Ipsen, The Netherlands) in the internal anal sphincter.

RESULTS

After a median follow-up of 10 (4-38) months, 77 of the 100 CAFs (77%) were cured. 20 patients were given a second injection, 1 a third and 1 a fourth injection. In 11 patients a fissure recurred (14%). In 1 patient (1%) there was temporary incontinence due to flatus.

CONCLUSION

With an early response rate of 77% and an overall success rate of 66%, BT-A injections appear to be effective in patients with ISDN ointment-resistant CAFs if initial non-responders are retreated. These results are in concordance with the results of our pilot study. It is a simple technique with little or no side effects, that does not compromise future treatments. Its place in the first-line treatment of CAFs should be investigated further.

[Favourable results with local injections of botulinum-A toxin in patients with chronic isosorbide dinitrate ointment-resistant anal fissures]

OBJECTIVE

To determine the effectiveness of injection of botulinum-A toxin in the internal anal sphincter as a treatment for chronic therapy-resistant anal fissures.

DESIGN

Prospective.

METHODS

In the period October 2002-February 2005, 32 consecutive patients (15 men and 17 women), with a median age of 44 years (range: 23-78 years) and suffering from chronic isosorbide dinitrate ointment-resistant anal fissures, were treated with an injection of 40 IU botulinum-A toxin (Dysport, Ipsen, The Netherlands) in the ventral side of the internal anal sphincter. The injection was given as an outpatient procedure under general or spinal anaesthesia.

RESULTS

After a median follow-up of 14 months (range: 2-28 months), the chronic anal fissures were cured in 24 ofthe 32 patients (75%). Twenty-two patients were given a second or a third injection. A fissure recurred in one of the cured patients (4%), and one patient suffered from temporary flatus incontinence.

CONCLUSION

Botulinum-A toxin injections were effective in 75% of patients with isosorbide dinitrate ointment-resistant chronic anal fissures. This is a simple technique with fewer side effects than local application of NO donors and fewer complications and less morbidity than surgical sphincterotomy.

[Distinguishing nodal naevus from melanoma metastases in the sentinel node in patients with melanoma]

OBJECTIVE

Establishing the frequency of nodal naevi in lymph-node dissections from patients with a melanoma who have undergone a sentinel-node procedure and/or regional node dissection and distinguishing naevi from melanoma metastases.

DESIGN

Retrospective and descriptive.

METHODS

Patients with a nodal naevus in the sentinel node were selected from a database containing clinical and pathological data on all 65 patients who underwent a sentinel-node procedure for melanoma at our hospital between 1998 and 2001. Also data from the pathology department on the case frequency and the nodal frequency of nodal naevi in the total number of patients with melanoma in whom a sentinel-node procedure and/or therapeutic node dissection had been carried out during the same period, were examined.

RESULTS

In 5 patients a nodal naevus was found in the sentinel node. The case frequency was 6.2% and the nodal frequency 0.65%. Distinction from melanoma metastases was made by the use of H&E colouring, localization, architectural and morphological features of the melanocyte cell clusters in the lymph node and sometimes after consultation with the National Melanoma Panel. Immunohistochemical markers provided supplementary information only.

CONCLUSION

Nodal naevi in lymph nodes were not uncommon in people with melanoma and can be distinguished from the micrometastases from melanoma.

Factors influencing the local failure rate of radiofrequency ablation of colorectal liver metastases

BACKGROUND

The prognosis of patients with colorectal cancer is poor, especially when there is distant metastatic disease. Local ablation of tumor by radiofrequency ablation (RFA) has emerged as a safe and effective new treatment modality, but its long-term efficacy may be hindered by renewed local tumor growth at the site of RFA. The objectives of this study were to identify risk factors for local RFA failure and to define exclusion criteria for RFA treatment of colorectal liver metastases.

METHODS

A total of 199 lesions in 87 patients were ablated with RFA. Factors influencing local failure rates were identified and compared with data from the literature.

RESULTS

The local failure rate was 47.2%, and the average time to local disease progression was 6.5 months. Factors that significantly correlated with increased failure rates were metachronous occurrence of liver metastases, large mean lesion size, and central tumor location.

CONCLUSIONS

Because accurate electrode placement is pivotal in achieving adequate tumor necrosis, RFA should not be performed percutaneously when electrode placement is impaired. We suggest that lesions >5 cm and lesions located near great vessels or adjacent organs should be treated with open RFA, thus allowing vascular inflow occlusion and complete mobilization of the liver. Lesions that are difficult to reach by electrodes should be approached by an open procedure.

Validation of open-surgery VR trainer

VREST (Virtual Reality Educational Surgical Tools) is developing a universal and autonomous simulation platform which can be used for training and assessment of medical students and for continuing education of physicians. With the VREST - Virtual Lichtenstein Trainer, simulating the open surgery procedure of the inguinal hernia repair according to Lichtenstein, the validation of the simulator is ongoing. Part of this trajectory is the evaluation of the transfer of training of the virtual incision making. One group of students trained incision making on the VREST platform where the control group did not. In an experiment both groups has to perform several incision tasks on a manikin. The results are not available yet but will be presented at the MMVR14 conference.

Open surgery in VR: inguinal hernia repair according to Lichtenstein

VREST (Virtual Reality Educational Surgical Tools) is developing a universal and autonomous simulation platform which can be used for training and assessment of medical students and for continuing education of physicians. A workstation consisting of two haptic devices and a 3D vision system is part of the VREST platform. Another part of the platform is a generic software environment in which lessons can be built by the teacher and performed by their students. Using the platform one can see, feel and decide as in reality. With the assessment tool the progress and skills of the students can be supervised. The first lesson build on the VREST platform is an inguinal hernia repair according to Lichtenstein. This is an open surgery procedure. The VREST platform is used prior to the first operating room surgery of the resident. Interactive models and case dependent feedback is used to enlarge the residents' cognition. This should reduce the training time in the operating room.