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Biomedical subjects

E J van Beek

Publications and source records attributed to E J van Beek.

At least 19 recordsLinked to original sources
PubMed2000

Upper thoracic spinal fractures in trauma patients - a diagnostic pitfall.

The diagnosis of upper thoracic spinal fractures in multiple-trauma patients remains a challenge. The clinical findings are often difficult to detect, especially in the presence of other (extremity) fractures, head injuries or in patients on respiratory support. The findings of chest radiographs and plain spinal films are described in a series of 23 patients with an upper thoracic spinal fracture. Radiographs were retrospectively reviewed by an orthopaedic surgeon and a skeletal radiologist. Fractures were classified according to Magerl and type A1 and A2 compression fractures were excluded. The neurological outcome was assessed using the Frankel scale.Initially, the fracture was missed in 5 patients (22%), mainly due to concomitant life-threatening injuries. Fractures consisted of type A, B and C in one, 10 and 12 patients, respectively. The main findings were: loss of vertical height of vertebra with or without malalignment (21), widened paraspinal line (21), widened mediastinum (4) and no gross abnormalities (2). Neurological lesions were Frankel A, B, C and E in respectively 14, 1, 1 and 7 patients.Upper thoracic spinal fractures are easily missed in patients with multiple injuries. In patients with neurological symptoms CT and/or MRI is required as soon as the general condition of the patient permits this.

Adolescent↗
PubMed2000

Value of chest X-ray combined with perfusion scan versus ventilation/perfusion scan in acute pulmonary embolism.

BACKGROUND: The main purpose of ventilation scanning, as adjunct to perfusion lung scintigraphy, in acute pulmonary embolism is to allow for the classification of segmental perfusion defects as mismatched, which is generally accepted as proof for the presence of pulmonary embolism. We examined whether this function of the ventilation scan could be replaced by the chest X-ray. METHODS: In 389 consecutive patients with suspected pulmonary embolism and at least one segmental perfusion defect we classified the ventilation/perfusion (V/Q) scan and chest X-ray/perfusion (X/Q) scan as either mismatched or matched. Furthermore we analyzed whether this comparison was different in subgroups of patients with concomitant congestive heart failure or chronic obstructive pulmonary disease. RESULTS: Overall agreement between the X/Q and V/Q scan diagnostic category was found in 341 of 389 patients (88%; 95% CI 84-92%). The positive predictive value for obtaining a mismatched V/Q scan result in case of a mismatched X/Q scan result was 86% (95% CI 81-90%). If the X/Q scan yielded only matched defects the V/Q scan resulted in the same classification in 90% (95% CI 85-95%). Analysis of the small subgroup of patients with chronic obstructive pulmonary disease showed that a mismatched X/Q scan was confirmed by V/Q scanning in 21 of 34 cases (62%; 95% CI 45-78%). CONCLUSION: This study shows that in the great majority of patients with clinically suspected acute pulmonary embolism combination of chest X-ray with perfusion scintigraphy reliably replaced ventilation/perfusion scintigraphy in defining (mis)-matching of segmental perfusion defects. These results need confirmation before the chest X-ray can fully obviate the use of ventilation scintigraphy.

Adult↗
PubMed1999

The value of pulmonary angiography for the differential diagnosis of pulmonary embolism.

The aim this study was to evaluate potential additional information of pulmonary angiography in patients with suspected pulmonary embolism and non-diagnostic lung scan findings. In a series of 150 patients who underwent pulmonary angiography for suspected venous thromboembolism, the images for potential alternative diagnoses other than pulmonary embolism were evaluated. All patients had non-diagnostic lung scan findings. Angiography was performed both by conventional and by digital subtraction angiography techniques. Images were evaluated by at least two experienced readers. Angiograms were scored for both presence or absence of pulmonary embolism, as well as other diagnoses. Pulmonary embolism was proven in 40 patients (27 %) and excluded in 105 patients (70 %), whereas non-interpretable images were obtained in 5 patients (3 %). A range of alternative diagnoses were detected by angiography: atelectasis (n = 24), pleural effusion (n = 15), pneumonia (n = 11), emphysematous bullae (n = 8), neoplasm (n = 3), atrial septum defect (n = 2), chronic thromboembolism (n = 1), and other diagnoses (n = 3). Overall, only 54 patients (36 %) had completely normal angiograms. Although pulmonary angiography remains the reference method for the diagnosis of pulmonary embolism, one has to be aware of other, often unexpected, but equally important findings which could influence the management of the patient. This aspect of pulmonary angiography has been insufficiently emphasized in the literature.

Adult↗
PubMed1999

Requirements for appropriate evaluation of diagnostic tests in suspected pulmonary embolism.

In contrast to the development of new drugs, strict guidelines for the development of new diagnostic methods do not exist. A diagnostic test can be made available without proper evaluation of its clinical utility, which can lead to its premature introduction and inappropriate use. In this review suggestions are made regarding the criteria that should be met during the various phases of development of new diagnostic techniques. It is suggested that a new diagnostic test should only be implemented in routine clinical use after all phases of development have been properly performed with good results. Several diagnostic tests for pulmonary embolism (pulmonary angiography, ventilation-perfusion scintigraphy, D-dimer assays, and spiral computed tomography), and the studies evaluating them, are thereafter reviewed. It is concluded that present pulmonary angiography and ventilation-perfusion scintigraphy are the only properly evaluated diagnostic tests for pulmonary embolism. Although new developments, such as D-dimer assays and the spiral computed tomographic scan are certainly promising, further studies are needed to determine their real value and safety in the diagnostic work-up of patients suspected of pulmonary embolism.

Angiography↗
PubMed1998

Diagnostic management of venous thromboembolism.

The accuracy of diagnostic methods for the diagnosis of deep vein thrombosis and pulmonary embolism in symptomatic patients is critically reviewed. In addition, the safety of withholding anticoagulant therapy from patients with suspected deep vein thrombosis or pulmonary embolism in whom the qualified diagnostic strategy was normal is evaluated by determining the frequency of venous thromboembolic complications during 3 months of follow-up. It is shown that the currently used available diagnostic techniques for deep vein thrombosis are all able to identify the majority of patients who indeed have venous thrombosis. However, as result of its accuracy and practical advantages, compression ultrasound is the test of choice in the evaluation of symptomatic patients. Patients with a normal test outcome should be re-tested to detect the small proportion of patients with proximally extending calf vein thrombosis. In the strategy of repeated diagnostic testing, impedance plethysmography could be used as an alternative to ultrasonography. To obtain a reduction in repeat tests various diagnostic strategies have been evaluated and it was shown that these strategies, using non-invasive tests, can be as accurate and safe as the invasive reference strategy. The safeties of the various strategies were very similar; however, important differences were observed with respect to the practical implementation of the various diagnostic strategies. Simplification of the repeated testing strategy by using a D-dimer assay and/or a clinical decision rule seems to be promising. The reference standard for the diagnosis of pulmonary embolism remains pulmonary angiography. Several strategies based on non-invasive diagnostic methods have been evaluated for their safety and complexability. Perfusion-ventilation lung scanning is the most thoroughly evaluated non-invasive technique so far. It seems safe to withhold anticoagulant therapy in patients suspected of pulmonary embolism with a normal perfusion lung scan result; however, further testing is needed in the case of a non-diagnostic perfusion-ventilation lung scan result. At this moment angiography is the method of choice in this category of patients. D-dimer assays, clinical decision rules and ultrasound examinations of the legs seem to have a high potential to limit the need for angiography. Also, spiral computerized tomography and magnetic resonance imaging are promising techniques, but their role in the diagnostic management of pulmonary embolism is still uncertain.

Diagnostic Techniques and Procedures↗
PubMed1998

Symptoms and signs related to the trigeminal nerve: diagnostic yield of MR imaging.

PURPOSE: To assess the diagnostic yield of magnetic resonance (MR) imaging in patients with symptoms and signs related to the trigeminal nerve. MATERIALS AND METHODS: Medical records and MR imaging studies in 112 consecutive patients referred for MR imaging over 5 years were evaluated. MR images were independently reviewed by two neuroradiologists unaware of the clinical findings. Signs and symptoms at presentation were associated with either a positive or negative MR imaging outcome. Logistic regression analysis was performed to identify clinical variables related to imaging results. RESULTS: Sixty-eight (61%) patients had positive MR imaging findings related to symptoms and signs. Trigeminal neuralgia was correlated with a negative MR imaging outcome (P < .001). Numbness (P < .01), impaired sensation (P < .001), other neurologic symptoms and signs (P < .01), progression of symptoms and signs (P < .001), and duration of symptoms of less than 1 year (P < .001) corresponded to a positive MR imaging outcome. Two regression models, each with three clinical parameters (progression, duration < 1 year, and trigeminal neuralgia or impaired sensation), had comparable accuracy for prediction of the MR imaging outcome. CONCLUSION: Clinical findings can be used to identify groups in which a high or a low yield of MR imaging is correlated with symptoms and signs related to the trigeminal nerve.

Cranial Nerve Diseases↗
PubMed1998

Observer and biological variation of a rapid whole blood D-dimer test.

In consecutive patients with suspected venous thromboembolism the interobserver variability of the SimpliRED D-dimer test was evaluated by two observers who independently scored one plate, the between assay variation was performed simultaneously by a third independent observer, who assessed a second plate. The biological variation was studied, 1-4 hours later by an independent evaluation. A total of 155 patients entered the study, venous thromboembolism was present in 42 patients (28%). The interobserver variability was 2/83 samples, with a kappa of 0.95 (95% confidence interval 0.88-1.0). The between assay variation was 2/98, with a kappa value of 0.96 (95% confidence interval 0.90-1.0). When testing the biological variation the observers disagreed in 2 of 69 patients (3%). The SimpliRED D-dimer assay has a good to excellent interobserver variability, between assay variation and reproducibility.

Adolescent↗
PubMed1997

Diagnostic utility of ultrasonography of leg veins in patients suspected of having pulmonary embolism.

BACKGROUND: The standard diagnostic approach in patients suspected of having pulmonary embolism starts with perfusion-ventilation lung scanning. If the resulting scan is not diagnostic, pulmonary angiography should be done. The use of tests for deep venous thrombosis has been advocated as an adjunct to establishing the diagnosis of pulmonary embolism, but no prospective studies have provided adequate information about the value of these tests. OBJECTIVE: To determine the accuracy and potential clinical utility of compression ultrasonography in the diagnosis of pulmonary embolism. DESIGN: Prospective cohort study with blinded assessment of ultrasonographic results. SETTING: Teaching hospital. PATIENTS: 397 consecutive inpatients and outpatients in whom pulmonary embolism was clinically suspected. MEASUREMENTS: Sensitivity and specificity of compression ultrasonography. Perfusion-ventilation scanning and angiography were the conjoint gold standard for determining the presence or absence of pulmonary embolism. Also calculated were the number of angiograms and lung scans avoided and the number of patients unnecessarily treated when compression ultrasonography was included in the diagnostic strategy. RESULTS: The overall sensitivity of compression ultrasonography for deep venous thrombosis in patients with pulmonary embolism was 29% (95% CI 22% to 37%); the specificity was 97% (CI, 94% to 99%). Adding ultrasonography to the diagnostic approach before lung scanning would avoid approximately 14% of lung scans and 9% of angiograms but would lead to unnecessary treatment of 13% of patients who have an abnormal ultrasonographic result (2% to 4% of all those receiving anticoagulation). When compression ultrasonography is done only in patients with a nondiagnostic lung scan, 9% of angiographies are prevented at the cost of unnecessarily treating 26% of patients who have an abnormal ultrasonographic result (2% of all patients receiving anticoagulation). CONCLUSION: The diagnostic value of compression ultrasonography for the detection of deep venous thrombosis in patients suspected of having pulmonary embolism is limited; the gain in diagnostic efficiency obtained through the use of ultrasonography may be offset by a loss in diagnostic accuracy.

Adolescent↗
PubMed1997

[Reserve concerning pulmonary angiography in pulmonary embolism is not justified].

OBJECTIVE: Evaluation of the safety of pulmonary angiography in patients with clinically suspected pulmonary embolism. DESIGN: Retrospective cohort study. SETTING: Academic Hospital, Rotterdam, the Netherlands. METHOD: The data on complications of pulmonary angiography were collected from four Dutch hospitals over a period of about five years (Academic Medical Centre and Slotervaart Hospital, Amsterdam; St. Elisabeth Hospital, Tilburg and Dr. Daniel den Hoed Cancer Centre/University Hospital Rotterdam). RESULTS: Pulmonary angiography was performed in 697 patients. No fatal complications were noted (mortality: 0%; 95% confidence interval (95% CI); 0.00-0.53). Complications were seen in 3 patients; dissection of the pulmonary artery in I patient and contrast extravasation in 2 patients (morbidity: 0.4%; 95% CI: 0.09-1.25). CONCLUSION: In patients with clinically suspected pulmonary embolism, pulmonary angiography is a safe diagnostic modality. It is recommended that, in patients in whom the diagnosis of pulmonary embolism cannot be confirmed or excluded by noninvasive diagnostic methods, pulmonary angiography should be performed (according to the Dutch consensus "Diagnostic pulmonary embolism').

Adolescent↗
PubMed1997

A survey of the diagnostic and therapeutic management of patients with suspected pulmonary embolism in the Netherlands.

BACKGROUND: Pulmonary embolism (PE) remains a complex diagnostic problem. Many diagnostic modalities are available. Several published guidelines have failed to yield a uniform approach. We have assessed the current diagnostic and therapeutic management of patients with clinically suspected PE in the Netherlands. METHODS: A questionnaire was sent to internists and pulmonologists, who were then asked to detail their diagnostic and therapeutic management in their last patient seen with suspected PE. RESULTS: 1571 questionnaires were sent out (response rate 64%). 95% of the patients with suspected PE underwent a perfusion scan (in 91% within 24 h). 1.6% of the respondents had no available perfusion scan facility. Of those who underwent a perfusion scan, 62% had ventilation scan (66% with segmental defects, 80% with subsegmental defects, 27% with a normal perfusion scan). Tests for deep vein thrombosis were performed in 58% of the patients and pulmonary angiography was carried out in 6.1%. Anticoagulant treatment was instituted in 73.2% of all patients. CONCLUSIONS: The perfusion lung scan is appropriately used as the initial step in the diagnostic workup of patients with suspected PE. Ventilation scanning is overused in patients with subsegmental perfusion defects and normal scan results, whereas it is underused in patients with segmental defects. Additional ventilation scan results had a limited influence on treatment decisions. There is still considerable overtreatment of patients with suspected PE.

Humans↗
PubMed1997

Pulmonary embolism in deep venous thrombosis of the upper extremity: more often in catheter-related thrombosis.

BACKGROUND: Pulmonary embolism (PE) is a major complication of deep venous thrombosis (DVT) of the lower extremities. The incidence is approximately 50%. The incidence of DVT of the upper extremity (DVTUE) is increasing mainly due to the increasing use of central venous catheters. The percentage of PE secondary to DVTUE is still being investigated. METHODS: The occurrence of PE in DVTUE was retrospectively analyzed in 78 patients with proven DVTUE. Furthermore, the literature was reviewed. RESULTS: Of the identified patients with DVTUE 16 showed a primary DVTUE and 62 a secondary DVTUE. Secondary DVTUE was catheter-related in 41 (60%), which is 53% of all DVTUE. In this study the percentage of PE as a complication of DVTUE was 6 (95% CI: 0.2-30) in primary DVTUE, 13 (95% CI: 6-24) in secondary DVTUE and 17 (95% CI: 7-32) in catheter-related DVTUE. The relative risk for PE of catheter-related DVTUE versus other causes was 3.4 (95% CI: 0.4-53.5). The overall percentage was 12 (95% CI: 5-21). The literature review showed a percentage of 7 (95% CI: 4-9) in the retrospective studies and 17 (95% CI: 12-23) in the prospective studies. CONCLUSIONS: Indwelling catheters are the most common cause of DVTUE. PE is not an uncommon complication of DVTUE, and is more common in catheter-related DVTUE. The difference between the incidence of PE in DVTUE and DVT of the lower extremity may be explained by a number of factors, such as differences in fibrinolytic activity, mechanical forces and venous flow patterns.

Adult↗
PubMed1997

Trigeminal neuralgia: comparison of two MR imaging techniques in the demonstration of neurovascular contact.

PURPOSE: To compare two magnetic resonance (MR) imaging techniques for demonstration of vascular contact with the trigeminal nerve. MATERIALS AND METHODS: Thirteen patients with unilateral trigeminal neuralgia and 50 control subjects underwent three-dimensional fast inflow with steady-state precession (FISP) and contrast material-enhanced magnetization-prepared rapid acquisition gradient-echo (MP-RAGE) MR imaging. The images were independently reviewed by two neuroradiologists, who were blinded to the clinical details. Six of the 13 patients underwent surgery. RESULTS: Vascular contact with the trigeminal nerve at the root entry zone was seen on FISP images in 10 of 13 (77%) symptomatic nerves and in eight of 113 (7%) asymptomatic nerves (P < .001). MP-RAGE and FISP images demonstrated arterial contacts equally well. MP-RAGE images demonstrated one additional venous contact at the root entry zone in a patient with ipsilateral trigeminal neuralgia. Interobserver agreement was good for both FISP (kappa = 0.69) and MP-RAGE (kappa = 0.78) images. The presence of vascular contact at the root entry zone, seen on preoperative MR images, was confirmed in all six patients who underwent surgery. CONCLUSION: Both FISP and MP-RAGE MR imaging are useful in demonstrating vascular contact with the trigeminal nerve at the root entry zone in patients with trigeminal neuralgia.

Case-Control Studies↗
PubMed1997

Effects of heparin therapy on fibrinolysis in patients with pulmonary embolism.

Previous investigations suggested that heparin administration to humans enhances the tissue type plasminogen activator (tPA) levels in blood, but it remains uncertain whether this effect induces fibrinolysis. We studied the effect of therapeutic levels of heparinization on plasma markers for fibrinolysis in patients suspected of pulmonary embolism (PE). Blood samples were taken from 49 consecutive patients; 28 had confirmed PE, 21 had PE excluded. On admission, the plasma levels of plasmin-alpha 2antiplasmin complexes and D-dimer were significantly higher in the patient group with PE compared to those in whom PE was excluded. After heparinization the tPA levels increased in both groups, showing that this effect was not dependent on the initial level of activity of fibrinolysis. In spite of this increment in tPA levels, the concentrations of plasmin-alpha 2antiplasmin complexes and D-dimer decreased. In conclusion, although heparinization in patients with or without pulmonary embolism does lead to elevated tPA:Ag levels, this is not accompanied by enhanced fibrinolysis.

Adult↗
PubMed1997

The role of a decision rule in symptomatic pulmonary embolism patients with a non-high probability ventilation-perfusion scan.

BACKGROUND: In order to improve the use of information contained in the medical history and physical examination in patients with suspected pulmonary embolism and a non-high probability ventilation-perfusion scan, we assessed whether a simple, quantitative decision rule could be derived for the diagnosis or exclusion of pulmonary embolism. METHODS: In 140 consecutive symptomatic patients with a non-high probability ventilation-perfusion scan and an interpretable pulmonary angiogram, various clinical and lung scan items were collected prospectively and analyzed by multivariate stepwise logistic regression analysis to identify the most informative combination of items. RESULTS: The prevalence of proven pulmonary embolism in the patient population was 27.1%. A decision rule containing the presence of wheezing, previous deep venous thrombosis, recently developed or worsened cough, body temperature above 37 degrees C and multiple defects on the perfusion scan was constructed. For the rule the area under the Receiver Operating Characteristic curve was larger than that of the prior probability of pulmonary embolism as assessed by the physician at presentation (0.76 versus 0.59; p = 0.0097). At the cut-off point with the maximal positive predictive value 2% of the patients scored positive, at the cut-off point with the maximal negative predictive value pulmonary embolism could be excluded in 16% of the patients. CONCLUSIONS: We derived a simple decision rule containing 5 easily interpretable variables for the patient population specified. The optimal use of the rule appears to be in the exclusion of pulmonary embolism. Prospective validation of this rule is indicated to confirm its clinical utility.

Adult↗
PubMed1996

[Costs of diagnosis and treatment for pulmonary embolism lower due to application of consensus strategy].

OBJECTIVE: To compare the costs of diagnosis and treatment of patients clinically suspected of pulmonary embolism, before and after the adoption of the Dutch consensus for the diagnosis of pulmonary embolism. DESIGN: Study of the records, followed by a prospective study with a follow-up lasting 6 months. SETTING: Academic Medical Centre and Slotervaart Hospital, Amsterdam, the Netherlands. METHOD: Data were collected on 120 patients from the preconsensus period and on 452 patients examined according to the consensus strategy. This established the average patterns of medical consumption of patients before and after adoption of consensus. The mean costs per patient were then estimated. RESULTS: Diagnosis and treatment of a patient according to the consensus strategy on the basis of our estimates were considerably less expensive than non-protocolled diagnosis and treatment (Dfl. 4,413 as against Dfl. 5,115 per patient). This difference mainly resulted from shorter hospital stays owing to more rapid completion of the diagnosis. Considering the large number of annual hospital admissions in the Netherlands in connection with this diagnosis, savings of up to Dfl. 26 million would appear possible if the consensus were followed nationwide. CONCLUSION: Considerable amounts are involved in the diagnosis and treatment of pulmonary embolism in the Netherlands. Accordingly, further research into possibilities to make these more efficient would appear advisable.

Clinical Protocols↗