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Biomedical subjects

D A Legemate

Publications and source records attributed to D A Legemate.

At least 19 recordsLinked to original sources
PubMed2006

[Comparable results with percutaneous transluminal angioplasty and surgical bypass for critical ischaemia of the leg].

In patients with critical limb ischaemia resulting from arterial occlusion, both percutaneous recanalisation and bypass surgery are potential therapeutic options to avoid amputation. The recently published Bypass versus angioplasty in severe ischaemia of the leg (BASIL) trial is the first randomised study to compare these techniques. The data from this trial show that patients eligible for balloon angioplasty or infra-inguinal bypass surgery fare equally well with percutaneous intervention. In the Netherlands, expertise with percutaneous intervention varies among hospitals. Consequently, the preferred strategy depends on the capabilities of the local hospital. Ideally, patients should be treated in hospitals with expertise in both techniques, because there is a trend towards fewer complications with percutaneous intervention. Moreover, there is a considerable difference in costs during the first year in favour of percutaneous intervention, mainly as a result of a shorter hospital stay.

Angioplasty, Balloon↗
PubMed2006

From innumeracy to insight: the uncertainty of help versus harm in treatment of asymptomatic aortic aneurysms.

There is insufficient evidence that the surgical treatment of asymptomatic infrarenal aneurysms > 5.5 cm. is beneficial to patients. This is the result of serious complications of aneurysm surgery and the dearth of information from randomized trials. Based on evidence from the literature we defined scenarios and translated data into natural frequency trees to improve understanding of the uncertainty of help versus harm due to treatment of aneurysms. Our analysis shows that the majority of patients can expect little on longevity from surgery while they are at risk of dying from surgery or suffering from serious morbidity. We conclude that, as long as uncertainty persist, patients should be treated in hospitals that can show very low surgical mortality and major morbidity rates. To further resolve the problem of uncertainty randomized trials for larger aneurysms should be performed. Important issues to discuss are the lower and upper limits of the diameter of the aneurysms and the age and risk profiles of the patients to be included in such trials.

Aortic Aneurysm↗
PubMed2006

Harm and benefits of short-term pre-operative radiotherapy in patients with resectable rectal carcinomas.

AIM: To weigh the harms and benefits of short-term pre-operative radiotherapy in the treatment of resectable rectal cancer. METHODS: The benefits (reduction of local recurrence) and harm (increase of short-term complications) of short-term pre-operative radiotherapy are balanced using a model which classifies patients in one of five outcome combinations; 1-benefit without additional harm, 2-benefit with additional harm, 3-no benefit, no additional harm, 4-no benefit but additional harm, 5-mortality due to combined treatment. The results of four randomised clinical trials (RCT) which study the addition of short-term pre-operative radiotherapy in rectal cancer were classified according to this model. RESULTS: Five to thirteen percent of the patients have benefit without additional harm of pre-operative radiotherapy, while 0-2% have benefit with additional harm; 74-87% has neither benefit nor additional harm and 6-11% have no benefit but additional harm. A small percentage of patients (1-6%) dies post-operatively as a result of the addition of radiotherapy. CONCLUSION: This model provides a transparent appreciation of the harmful and beneficial effects of any treatment modality investigated by means of a randomised clinical trial. As for short-term pre-operative radiotherapy in resectable rectal cancer is shown, a small percentage of patients benefits from such treatment. Most patients have neither benefit nor additional harm, while a small percentage suffers from additional harm while not receiving any benefit.

Carcinoma↗
PubMed2006

[New evidence for endovascular versus open treatment of patients with an aneurysm of the abdominal aorta].

Recent randomised trials have compared conventional and endovascular repair of asymptomatic abdominal aortic aneurysms (DREAM and EVAR I trials), and endovascular repair with no intervention in high-risk patients (EVAR 2 trial). DREAM and EVAR I showed that endovascular repair is associated with lower perioperative mortality, but overall survival is not improved after mid-term follow-up. EVAR 2 showed that high-risk patients do not benefit from elective endovascular repair. It can be concluded that relatively young and low-risk patients should be treated with open repair and that conservative treatment may be appropriate for high-risk patients. Between these extremes is a large group ofpatients who may benefit from endovascular repair. However, long-term follow-up data are not yet available and costs for endovascular therapy are substantial.

Aortic Aneurysm, Abdominal↗
PubMed2006

Meta-analysis of the clinical effectiveness of venous arterialization for salvage of critically ischaemic limbs.

OBJECTIVE: The aim of this study is to assess the clinical effectiveness of venous arterialization in patients with critical limb ischaemia not reconstructable by conventional bypass. DESIGN: Meta-analysis of observational studies. MATERIALS: Eligible studies concerning treatment by venous arterialization for chronic critical leg ischaemia were identified from electronic database, cross-reference search and pertinent articles. There was no language restriction. METHODS: All relevant studies were systematically reviewed and data extracted by two independent reviewers. Study endpoints were foot preservation, secondary graft patency, postoperative clinical improvement and complications. RESULTS: A total of 56 studies were selected for comprehensive review. No RCTs were identified. Seven patient series, comprising 228 patients, matched the selection criteria. Overall 1-year foot preservation was 71% (95% CI: 64-77%) and 1-year secondary patency was 46% (95% CI: 39-53%). The large majority of patients in whom major amputation was avoided experienced successful wound healing, disappearance of rest pain and absence of serious complications. CONCLUSION: On the basis of limited evidence, venous arterialization may be considered as a viable alternative before major amputation is undertaken in patients with 'inoperable' chronic critical leg ischaemia.

Arteriovenous Shunt, Surgical↗
PubMed2006

Categorization of major and minor complications in the treatment of patients with resectable rectal cancer using short-term pre-operative radiotherapy and total mesorectal excision: a Delphi round.

BACKGROUND: To properly balance the benefit (reduction of local recurrence) of short-term pre-operative radiotherapy for resectable rectal cancer against its harm (complications), a consensus concerning the severity of complications is required. The aim of this study was to reach consensus regarding major and minor complications after short-term radiotherapy followed by total mesorectal excision in the treatment of rectal carcinoma, using the Delphi technique. METHODS: A Delphi round was performed in cooperation with 21 colo-rectal surgeons from the Netherlands, United Kingdom and Sweden. The key-question was: 'Which of the predefined complications, caused or substantially aggravated by radiotherapy, are so important (major) that they might lead to the decision to abandon short-term pre-operative radiotherapy (5 x 5Gy) when treating patients with resectable rectal cancer (T1-3N0-2M0)?' RESULTS: After three rounds, consensus was reached for 37 (68%) of 54 complications of which 13 were considered major and 24 considered minor. The following complications were considered to be major: mortality, anastomotic leakage managed by relaparotomy, anastomotic leakage resulting in persisting fistula, postoperative haemorrhage managed by relaparotomy, intra-abdominal abscess without healing tendency, sepsis, pulmonary embolism, myocardial infarction, compartment syndrome of the lower legs, long-term incontinence for solid stool, long-term problems with voiding, pelvic fracture with persisting pain, and neuropathy with persisting pain (legs). Three of 17 complications without consensus showed a tendency to be considered as major: perineal wound dehiscence managed by surgical treatment, small bowel obstruction leading to relaparotomy and long-term incontinence for liquid stool. CONCLUSION: The 13 major and three 'accepted as major' complications can be used to properly balance the benefit and harm of short-term pre-operative radiotherapy in resectable rectal cancer. This may eventually lead to improved treatment strategies for these patients.

Belgium↗
PubMed2006

Diagnostic efficacy of SonoVue, a second generation contrast agent, in the assessment of extracranial carotid or peripheral arteries using colour and spectral Doppler ultrasound: a multicentre study.

The purpose of this study was to demonstrate the improvement in diagnostic quality and diagnostic accuracy of SonoVue microbubble contrast-enhanced ultrasound (CE-US) versus unenhanced ultrasound imaging during the investigation of extracranial carotid or peripheral arteries. 82 patients with suspected extracranial carotid or peripheral arterial disease received four SonoVue doses (0.3 ml, 0.6 ml, 1.2 ml and 2.4 ml) with Doppler ultrasound performed before and following each dose. Diagnostic quality of the CE-US examinations was evaluated off-site for duration of clinically useful contrast enhancement, artefact effects and percentage of examinations converted from non-diagnostic to diagnostic. Accuracy, sensitivity and specificity were assessed as agreement of CE-US diagnosis evaluated by an independent panel of experts with reference standard modality. The median duration of clinically useful signal enhancement significantly increased with increasing SonoVue doses (p< or =0.002). At the dose of 2.4 ml of SonoVue, diagnostic quality evaluated as number of inconclusive examinations significantly improved, falling from 40.7% at baseline down to 5.1%. Furthermore, SonoVue significantly (p<0.01) increased the accuracy, sensitivity and specificity of assessment of disease compared with baseline ultrasound. SonoVue increases the diagnostic quality of Doppler images and improves the accuracy of both spectral and colour Doppler examinations of extracranial carotid or peripheral arterial disease.

Adult↗
PubMed2005

Laparoscopic vascular anastomoses: does robotic (Zeus-Aesop) assistance help to overcome the learning curve?

BACKGROUND: Considerable training is necessary to master laparoscopic suturing and knot-tying. Robotic systems are assumed to facilitate these skills and shorten the learning curve. The effect of laparoscopic experience and robotic assistance on the learning curve of vascular anastomoses was studied. METHODS: A laparoscopically experienced surgeon and a laparoscopically inexperienced surgeon made alternating laparoscopic vascular anastomoses and robot-assisted laparoscopic vascular anastomoses using a Zeus-Aesop surgical robotic system with various prosthetic conduits and suture materials in a laparoscopic training box. RESULTS: Neither laparoscopic method influenced the quality score or leakage rate, but with laparoscopic experience, significantly fewer failures were made. Suturing and knot-tying were faster with laparoscopic experience both with and without the robotic system, and fewer stitch actions and knot actions were performed. The learning curves of both surgeons were not improved by the robotic system. CONCLUSIONS: Experience is the most important factor in the performance of laparoscopic vascular anastomoses. The robotic system was not helpful in shortening the learning curve.

Anastomosis, Surgical↗
PubMed2005

Systematic review of dressings and topical agents for surgical wounds healing by secondary intention.

BACKGROUND: The best dressing for postoperative wounds healing by secondary intention is unknown. METHODS: A systematic review was conducted to assess the effectiveness of dressings and topical agents on such wounds. Main endpoints were wound healing, pain, patient satisfaction, costs and hospital stay. Systematic methodological appraisal and data extraction were performed by independent reviewers. RESULTS: Fourteen reports of 13 randomized clinical trials on dressings or topical agents (gauze, foam, bead, alginate and hydrocolloid dressing) for postoperative wounds healing by secondary intention were identified; they were of weak methodological quality. In general, no statistically significant differences in wound healing were found for various dressing comparisons (11 of 13 trials). Patients experienced significantly more pain (four of six trials) and were less satisfied when gauze was used (three of six trials). Gauze was inexpensive, but its use was associated with significantly more nursing time than dressing with foam (two of three trials). No substantial differences in hospital stay were found (four of five trials). CONCLUSIONS: Only small, poor-quality trials exist, rendering the evidence insufficient. Foam is best studied as an alternative to gauze and appears to be preferable in terms of pain reduction, patient satisfaction and nursing time.

Administration, Topical↗
PubMed2005

A comparative study to validate the use of ultrasonography and computed tomography in patients with post-operative intra-abdominal sepsis.

PURPOSE: To validate abdominal ultrasonography and helical computed tomography in detecting causes for sepsis in patients after abdominal surgery and to determine improved criteria for its use. MATERIALS AND METHODS: Eighty-five consecutive surgical patients primarily operated for non-infectious disease were included in this prospective study. Forty-one patients were admitted to the intensive care unit. All patients were suspected of an intra-abdominal sepsis after abdominal surgery. Both ultrasonography (US) and helical abdominal computed tomography (CT) were performed to investigate the origin of an intra-abdominal sepsis. The images of both US and CT were interpreted on a four-point scale by different radiologists or residents in radiology, the investigators were blinded of each other's test. Interpretations of US and CT were compared with a reference standard which was defined by the result of diagnostic aspiration of suspected fluid collections, (re)laparotomy, clinical course or the opinion of an independent panel. Likelihood ratios and post-test probabilities were calculated and interobserver agreement was determined using kappa statistics. RESULTS: The overall prevalence of an abdominal infection was 0.49. The likelihood ratio (LR) of a positive test-result for US was 1.33 (95% CI: 0.8-2.5) and for CT scan 2.53 (95% CI: 1.4-5.0); corresponding post-test probabilities for US 0.57 (95% CI: 0.42-0.70) and for CT 0.71 (95% CI: 0.57-0.83). The LR of a negative test-result was, respectively, 0.60 (95% CI: 0.3-1.3) and 0.18 (95% CI: 0.06-0.5); corresponding post-test probabilities for US 0.37 (95% CI: 0.20-0.57) and for CT 0.15 (95% CI: 0.06-0.32) were calculated. CONCLUSION: Computed tomography can be used as the imaging modality of choice in patients suspected of intra-abdominal sepsis after abdominal surgery. Because of the low discriminatory power ultrasonography should not be performed as initial diagnostic test.

Abdomen↗
PubMed2005

Cognitive changes in cardiovascular patients following a tailored behavioral smoking cessation intervention.

BACKGROUND: Action aimed at changing smoking behavior to prevent cardiovascular patients from further impairing their health is advisable. Cognitive behavioral interventions can be effective in this regard since they attempt to influence cognitive determinants that presumably lead to smoking cessation. The Minimal Intervention Strategy for Cardiology patients (C-MIS) is such an intervention, tailored to the patients' readiness to change. Our aim is to investigate whether the C-MIS is successful in changing patients' cognitions such as attitudes, social influence, self-efficacy and intention to quit during a 1-year period. METHODS: Smoking outpatients (N = 315) with cardiovascular disease were included. They were randomized and received either Nicotine Replacement Therapy (NRT) or NRT + C-MIS. At baseline (T1), sociodemographic and clinical characteristics were measured. Cognitions and quitting behavior were assessed at baseline and at four follow-up measurements. RESULTS: Comparing treatments, the C-MIS did not affect pros of quitting, pros of smoking and social influence. We did find small effects of the C-MIS on intention to quit and self-efficacy, although only for higher-educated patients. CONCLUSION: The C-MIS appears successful in affecting intention to quit and self-efficacy abilities, but only for patients with higher education levels. Initial positive changes in cognitions may also emerge in a medical intervention, such as the provision of NRT.

Adult↗
PubMed2005

Do patients' preferences predict smoking cessation?

BACKGROUND: Social cognitive theories (e.g., ASE-model) propose that smoking cessation can be accomplished by changing underlying cognitive determinants such as attitudes, social influence, and self-efficacy. Others have argued that people's preferences for a health state can also predict behavior. In this study, preferences constitute the degree to which one is willing to give up a valuable good, that is survival, to obtain a desirable behavior (e.g., to quit smoking). The aim of this study is to investigate the impact of cognitive determinants and patients' preferences on the prediction of smoking cessation. METHODS: Data were collected as part of a randomized clinical trial. Smoking outpatients (N = 217) with cardiovascular disease were included. At baseline (T0), socio-demographic and clinical characteristics were measured. Social cognitions (pros of quitting, pros of smoking, social influence, and self-efficacy) and preferences (using a paper time trade-off measure (TTO)) were assessed at T1 (1 week). Smoking cessation was assessed at T2 (8 weeks). RESULTS: Logistic regression analysis showed that socio-demographic (P = .92) and clinical (P = .26) factors did not predict smoking cessation, whereas social cognitions (P = .02) and preferences did (P = .00). On average, quitters are willing to give up an appreciable amount of survival years in order to quit smoking. CONCLUSION: Preference for quitting was the strongest single predictor of smoking cessation.

Attitude to Health↗
PubMed2004

[Cannabis use and untreated HIV-infection: unknown risk factors for premature peripheral artery disease].

A 32-year-old woman presented with a painful leg and a gangrenous big toe. Her medical history included HIV-infection that had remained untreated for 8 years. In addition, she had smoked about 10 cannabis-cigarettes daily during the previous 15 years. Physical examination and angiography confirmed the presence of severe peripheral artery disease in the left lower leg. She received a femorodistal bypass graft but the gangrene was progressive, ultimately necessitating a lower leg amputation. Histopathological examination revealed intimal fibrosis and thrombosis with recanalisation in combination with fragmentation of the internal elastic membrane. Peripheral artery disease is often associated with lower extremity ischaemia, mostly affecting elderly patients and almost always caused by atherosclerosis. When ischaemic symptoms manifest themselves in young individuals (<40 years), rare causes of obliterative arterial disease, such as inflammation or post-traumatic vascular injury, must be excluded. Use of cannabis and untreated HIV infection are both relatively unknown risk factors for the onset of premature non-atherosclerotic arterial disease. Stopping the smoking of cannabis appears to have a favourable effect on the ischaemic symptoms. Whether treatment of HIV-infection can affect the course of premature peripheral vascular disease is unknown. When deciding whether or not to give antiviral therapy, care providers should also consider the increased cardiovascular mortality rates associated with these treatment regimens. In the case described, the HIV-infection was considered the most likely cause of the peripheral artery disease, based on all the histopathological findings.

Adult↗
PubMed2004

[The practice guideline 'Peripheral vascular disease' (first revision) from the Dutch College of General Practitioners: a response from the perspective of surgery].

The practice guideline 'Peripheral vascular disease' is well written and based on evidence-based principles. In comparison with the previous guideline considerable attention is given to secondary prevention. In this guideline general practitioners are more diffident about prescribing statins than vascular specialists. This is probably related to the fact that this guideline refers to another guideline of the College concerning the treatment of patients with high-cholesterol concentrations and not to recently-published large studies. The guideline advises making a distinction between intermittent claudication stage 2a and 2b. This is impractical as the choice of therapy depends on the subjective feelings of disability. Some controversy remains with respect to the detection of asymptomatic abdominal aneurysms: should there routinely be only physical examination or ultrasonographic screening as well? The guideline advises against routine ultrasonic screening, which is in line with the view held by the author of this commentary.

Anticholesteremic Agents↗