Biomedical subjects

J G Tijssen

Publications and source records attributed to J G Tijssen.

At least 19 recordsLinked to original sources

PubMed2001

Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis.

There is much controversy about the surgical approach to esophageal carcinoma: should an extensive resection be done to optimize long-term survival or should the extent of the operation be limited to obtain lower perioperative morbidity and mortality rates? We systematically reviewed the English-language literature published during the past decade, with emphasis on the differences between transthoracic and transhiatal resections regarding early morbidity, in-hospital mortality rates, and 3- and 5-year survival. Although transthoracic resections had significantly higher early (pulmonary) morbidity and mortality rates, 5-year survival was approximately 20% after both transthoracic and transhiatal resections.

Esophageal Neoplasms↗

PubMed2001

What happens to patients starting dialysis in the Netherlands?

BACKGROUND: despite improvements in dialysis technology, publications around 1990 showed increasing mortality rates in dialysis patients. The Dialysis Group of the Netherlands initiated the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) to investigate the association of patient and therapy characteristics with outcome. METHODS: 250 patients were included in this prospective multicentre study 3 months after the start of dialysis. We used Cox regression to predict mortality and technique failure and repeated measures analysis of variance to study the time course of continuous parameters. RESULTS: there were considerable differences in patient populations among dialysis centres. Patient survival was 76% at 2 years. Technique survival was higher in haemodialysis. Hospitalisation decreased from 25 days between 3 and 12 months to 19 days per patient year in the third year. Residual renal function decreased at a similar rate in both modalities, but blood pressure tended to increase in females receiving peritoneal dialysis. Outcome was predominantly dependent on patient characteristics. CONCLUSIONS: In the light of the increasing age of patients starting dialysis, increasing mortality can be expected. Furthermore, if outcome is to play a role in the quality assessment of dialysis centres, it is essential to know the characteristics of their patient populations.

Age Factors↗

PubMed2001

Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: results from the Amsterdam Resuscitation Study (ARRESUST).

The objective of this study was to analyze the functioning of the first two links of the chain of survival: 'access' and 'basic cardiopulmonary resuscitation (CPR)'. In a prospective study, all bystander witnessed circulatory arrests resuscitated by emergency medical service (EMS) personnel, were recorded consecutively. Univariate differences in survival were calculated for various witnesses, the performance of basic CPR, the quality of CPR, the performers of CPR and the delays. A logistic regression model for survival was developed from all potential predictors of these first two links. From the 922 included patients, 93 survived to hospital discharge. In 21% of the cases, the witness did not immediately call 112, but first called others, resulting in a longer delay and a lower survival. Family members were frequent witnesses of the arrest (44%), but seldom started basic CPR (11%). Survival, when basic CPR performers were untrained and had no previous experience, was similar to that when no basic CPR was performed (6%). Not performing basic CPR, delay in basic CPR, the interval between basic CPR and EMS arrival, and being both untrained and inexperienced in basic CPR were independent predictors for survival. Basic CPR performed by persons trained a long time ago did not appear to have a negative influence on outcome, nor did basic CPR limited to chest compressions alone. The mere reporting that basic CPR has been performed does not describe adequately the actual value of basic CPR. The interval from collapse to initiation of basic CPR, and the training and experience of the performer must be taken into account. Policy makers for basic CPR training should focus on partners of the patients, who are most likely witness of an arrest.

Cardiopulmonary Resuscitation↗

PubMed2001

Survival models for out-of-hospital cardiopulmonary resuscitation from the perspectives of the bystander, the first responder, and the paramedic.

Survival from out-of-hospital resuscitation depends on the strength of each component of the chain of survival. We studied, on the scene, witnessed, nontraumatic resuscitations of patients older than 17 years. The influence of the chain of survival and potential predictors on survival was analyzed by logistic regression modeling. From 1030 patients, 139 survived to hospital discharge. Three prediction models of survival were developed from the perspective of the different contributors active in out-of-hospital resuscitation: model I, bystanders; model II, first responders; and model III, paramedics. Predictors for survival (with odds ratio) were: in model I (bystanders): emergency medical service (EMS) witnessed arrest (0.50), delay to basic cardiopulmonary resuscitation (CPR) (0.74/min) and delay to EMS arrival (0.87/min); in model II (first responders): initial recorded heart rhythm (0.02 for nonshockable rhythm), delay to basic CPR (0.71/min and 0.87/min for shockable and nonshockable rhythms) and to defibrillation (0.89/min), and in model III (paramedics): need for advanced CPR (4.74 for advanced CPR not-needed), initial recorded heart rhythm (0.05 for nonshockable rhythm), and delay to basic CPR (0.77/min and 0.72/min for shockable and nonshockable rhythms), to defibrillation and to advanced CPR for shockable rhythms (0.85/min), and to advanced CPR for nonshockable rhythm (0.85/min). The area under the receiver-operator characteristic curve for model I was 0.763, for model II was 0.848, and for model III was 0.896. Of survivors, 50% had restoration of circulation without need for advanced CPR. Three survival models for witnessed nontraumatic out-of-hospital resuscitation based on the information known by bystanders, first responders and paramedics explained survival with increasing precision. Early defibrillation can restore circulation without the need for advanced CPR. When advanced CPR is needed, its delay leads to a markedly reduced survival.

Adolescent↗

PubMed2001

Recurrent unstable angina after directional coronary atherectomy is related to the extent of initial coronary plaque inflammation.

OBJECTIVES: This study was performed to evaluate the relationship between plaque inflammation of the initial culprit lesion and the incidence of recurrent angina for one year after directional coronary atherectomy (DCA). BACKGROUND: A positive correlation between coronary plaque inflammation and angiographic restenosis has been reported. METHODS: A total of 110 patients underwent DCA. Cryostat sections were immunohistochemically stained with monoclonal antibodies CD68 (macrophages), CD-3 (T lymphocytes) and alpha-actin (smooth muscle cells [SMCs]). The SMC and macrophage contents were planimetrically quantified as a percentage of the total tissue area. T lymphocytes were counted as the number of cells/mm2. The patients were followed for one year to document recurrent unstable angina pectoris (UAP) or stable angina pectoris (SAP). RESULTS: Recurrent UAP developed in 16 patients, whereas recurrent SAP developed in 17 patients. The percent macrophage areas were larger in patients with recurrent UAP (27 +/- 12%) than in patients with recurrent SAP (8 +/- 4%; p = 0.0001) and those without recurrent angina (18 +/- 14%; p = 0.03). The number of T lymphocytes was also greater in patients with recurrent UAP (25 +/- 14 cells/mm2) than in patients with recurrent SAP (14 +/- 8 cells/mm2; p = 0.02) and those without recurrent angina (14 +/- 12 cells/mm2; p = 0.002). Multiple stepwise logistic regression analysis identified macrophage areas and T lymphocytes as independent predictors for recurrent UAP. CONCLUSIONS: There is a positive association between the extent of initial coronary plaque inflammation and the recurrence of unstable angina during long-term follow-up after DCA. These results underline the role of ongoing smoldering plaque inflammation in the recurrence of unstable angina after coronary interventions.

Aged↗

PubMed2001

Fractional flow reserve, absolute and relative coronary blood flow velocity reserve in relation to the results of technetium-99m sestamibi single-photon emission computed tomography in patients with two-vessel coronary artery disease.

OBJECTIVES: We sought to perform a direct comparison between perfusion scintigraphic results and intracoronary-derived hemodynamic variables (fractional flow reserve [FFR]; absolute and relative coronary flow velocity reserve [CFVR and rCFVR, respectively]) in patients with two-vessel disease. BACKGROUND: There is limited information on the diagnostic accuracy of intracoronary-derived variables (CFVR, FFR and rCFVR) in patients with multivessel disease. METHODS: Dipyridamole technetium-99m sestamibi (MIBI) single-photon emission computed tomography (SPECT) was performed in 127 patients. The presence of reversible perfusion defects in the region of interest was determined. Within one week, angiography was performed; CFVR, rCFVR and FFR were determined in 161 coronary lesions after intracoronary administration of adenosine. The predictive value for the presence of reversible perfusion defects on MIBI SPECT of CFVR, rCFVR and FFR was evaluated by the area under the curve (AUC) of the receiver operating characteristics curves. RESULTS: The mean percentage diameter stenosis was 57% (range 35% to 85%), as measured by quantitative coronary angiography. Using per-patient analysis, the AUCs for CFVR (0.70 +/- 0.052), rCFVR (0.72 +/- 0.051) and FFR (0.76 +/- 0.050) were not significantly different (p = NS). The percentages of agreement with the results of MIBI SPECT were 76%, 78% and 77% for CFVR, rCFVR and FFR, respectively. Per-lesion analysis, using all 161 measured lesions, yielded similar results. CONCLUSIONS: The diagnostic accuracy of three intracoronary-derived hemodynamic variables, as compared with the results of perfusion scintigraphy, is similar in patients with two-vessel coronary artery disease. Cut-offvalues of 2.0 for CFVR, 0.65 for rCFVR and 0.75 for FFR can be used for clinical decision-making in this patient cohort. Discordant results were obtained in 23% of the cases that require prospective evaluation for appropriate patient management.

Adult↗

PubMed2001

Impact of experimentally-induced expectancy on the analgesic efficacy of tramadol in chronic pain patients: a 2 x 2 factorial, randomized, placebo-controlled, double-blind trial.

Variations in treatment effects between drug trials are usually attributed to different patient characteristics, variations in outcome assessment, and random error. We have previously hypothesized that part of the variation in treatment effects between drug trials might be caused by differences in nonspecific factors. In a randomized clinical trial, we aimed to investigate whether experimentally induced expectancy can modify the analgesic effect of tramadol relative to placebo in chronic pain patients. In a 2 x 2 factorial, randomized, placebo-controlled, double-blind trial, chronic pain patients attending a chronic pain outpatient clinic were randomized to receive a single oral dose of 50 mg tramadol or placebo, and they were further randomized to receive positive or neutral information, verbally expressed by the physician, regarding the expected analgesic effect of the drug. Pain intensity was measured using a 10 centimeter visual analogue scale at baseline, and 0.5, 1, 2, 4, 6, and 8 hours after baseline. The one-hour pain intensity difference, calculated as the sum of pain intensity differences between baseline and 0.5 and 1 hour, was taken as main outcome measure. The one-hour sum of pain intensity differences of 28 patients treated after positive expectation and randomized to tramadol was 1.4 cm, while in 27 patients randomized to placebo, it was 0.8 cm. This corresponds with an analgesic effect of tramadol relative to placebo of 0.6 cm (95% confidence interval [CI], -0.5 cm to 1.8 cm). The 28 patients in the neutral expectancy group who were randomized to tramadol reported a 1.4 cm decrease on the sum of pain intensity differences, while 28 patients in the placebo group reported a 0.9 cm decrease. This corresponds with an analgesic effect of tramadol relative to placebo of 0.5 cm (95% CI, -0.9 cm to 1.8 cm). The 0.1 cm difference (0.6 cm - 0.5 cm) in analgesic effect between positive and neutral expectancy group was not statistically significant (95% CI, -0.7 cm to 1.0 cm). This trial did not discern a significant difference in the analgesic effect of tramadol between a positive and neutral expectancy group. This means that the phenomenon either does not exist, or we had an inappropriate model to demonstrate it. Regardless, this study demonstrates the type of quality trial that should be done to find out which non-specific factors, such as information regarding the expected effect, can modify treatment effects.

Adult↗

PubMed2001

Morbidity and mortality in patients waiting for coronary artery bypass surgery.

OBJECTIVES: To describe morbidity and mortality in patients waiting for coronary artery bypass graft (CABG) surgery and to assess determinants for the occurrence of these complications. METHODS: A prospective cohort study was carried out in a tertiary referral general teaching hospital. Three hundred and sixty consecutive patients with a priority of routine or urgent who were accepted for CABG or CABG with additional valve surgery were evaluated. Follow-up began from the moment of acceptance until the procedure took place for cardiac death, myocardial infarction and unstable angina requiring hospital admission. RESULTS: The median (25-75th percentile) waiting time in the two priority groups was 100 (79-119) days for the routine group and 69 (38-91) days for the urgent group. Overall, eight patients died, seven suffered a myocardial infarction, and 33 episodes of unstable angina requiring immediate hospitalization occurred. The majority of events took place during the first 30 days on the waiting list. Unstable angina less than 3 months before acceptance was identified as an independent predictor (hazard ratio 2.5, 95% confidence interval 1.2-5.1) for complications during the wait. The prognostic value of smoking and familial cardiovascular disease was found to vary depending on the priority assigned to the patient. CONCLUSIONS: Complications occur relatively early during the time on the waiting list. If complications in coronary heart disease cannot be predicted more accurately, the only way to diminish the complication rate is drastic reduction of waiting times.

Aged↗

PubMed2001

Relationship between cardiac metaiodobenzylguanidine uptake and hemodynamic, functional and neurohormonal parameters in patients with heart failure.

BACKGROUND: Sympathetic activation plays a pivotal role in heart failure attributing to the disease process and symptoms of the patient. Myocardial sympathetic activity can be visualized using radioiodinated metaiodobenzylguanidine 123I-MIBG, a structural analogue of norepinephrine (NE). AIM OF THE STUDY: We investigated whether a relation exists between myocardial MIBG uptake and different functional, hemodynamic and neurohormonal parameters in patients with chronic heart failure. METHODS AND RESULTS: The study comprised 52 patients with stable congestive heart failure functional class II or III and left ventricular ejection fractions of <35%. The heart/mediastinum ratio (H/M ratio) was calculated to quantify myocardial MIBG uptake. A significant correlation was found between peak oxygen consumption and maximal exercise duration as exercise parameters and H/M ratio of MIBG (R, respectively, 0.36 and 0.4, P<0.05). From all other measured parameters, only plasma NE showed a significant correlation with the H/M ratio of MIBG. CONCLUSION: Cardiac sympathetic activity, as measured by myocardial MIBG uptake, is correlated with peak exercise parameters.

3-Iodobenzylguanidine↗

PubMed2001

Determinants of changes in plasma homocysteine in hyperthyroidism and hypothyroidism.

OBJECTIVE: Hyperhomocysteinaemia is a risk factor for premature atherosclerotic vascular disease and venous thrombosis. The aim of the present study was to assess plasma total homocysteine (tHCys) concentrations in hypo- as well as hyperthyroid patients before and after treatment, and to evaluate the role of potential determinants of plasma tHCys levels in these patients. DESIGN: Prospective follow up study. PATIENTS: Fifty hypothyroid and 46 hyperthyroid patients were studied in the untreated state and again after restoration of euthyroidism. MEASUREMENTS: Fasting plasma levels of tHCys and its putative determinants (plasma levels of free thyroxine (fT4), folate, vitamin B(12), renal function, sex, age, smoking status and the C677T polymorphism in the methylenetetrahydrofolate reductase (MTHFR) gene were measured before and after treatment. RESULTS: Restoration of the euthyroid state decreased both tHCys (17.6 +/- 10.2-13.0 +/- 4.7 micromol/l; P < 0.005) and creatinine (83.9 +/- 22.0-69.8 +/- 14.2 micromol/l; P < 0.005) in hypothyroid patients and increased both tHCys (10.7 +/- 2.5-13.4 +/- 3.3 micromol/l; P < 0.005) and creatinine (49.0 +/- 15.4-66.5 +/- 15.0 micromol/l; P < 0.005) in hyperthyroid patients (values as mean +/- SD). Folate levels were lower in the hypothyroid group compared to the hyperthyroid group (11.7 +/- 6.4 and 15.1 +/- 7.6 nmol/l; P < 0.05). Pretreatment tHCys levels correlated with log fT(4) (r = - 0.47), folate (r = - 0.21), plasma creatinine (r = 0.45) and age (r = 0.35) but not with C677T genotype. Multivariate analysis indicated that pretreatment log(fT(4)) levels and age accounted for 28% the variability of pre-treatment tHCys (tHCys = 14.2-5.50 log(fT(4)) + 0.14 age). After treatment the logarithm of the change (Delta) in fT(4) (expressed as the post-treatment fT(4)/pre-treatment fT(4) ratio) accounted for 45% of the variability in change of tHCys ( tHCys = - 0.07-4.94 log ( fT(4))); there was no independent contribution of changes in creatinine which was, however, strongly related to changes in tHCys (r = 0.61). CONCLUSIONS: Plasma tHCys concentrations increased in hypothyroidism and decreased in hyperthyroidism. Plasma fT(4) is an independent determinant of tHCys concentrations. Lower folate levels and a lower creatinine clearance in hypo-thyroidism, and a higher creatinine clearance in hyperthyroidism only partially explain the changes in tHCys.

Adult↗

PubMed2001

Is endoscopic balloon dilation for removal of bile duct stones associated with an increased risk for pancreatitis or a higher rate of hyperamylasemia?

BACKGROUND AND STUDY AIMS: We studied the rate of pancreatitis and asymptomatic hyperamylasemia after endoscopic balloon dilation (EBD) and endoscopic sphincterotomy (EST) for removal of bile duct stones. PATIENTS AND METHODS: Patients with bile duct stones of all sizes were randomly allocated to undergo EBD (8-mm dilation balloon) or EST. Pancreatitis was defined as epigastric pain combined with at least a threefold rise in serum amylase at 24 hours after the endoscopic retrograde cholangiopancreatography (ERCP). Asymptomatic hyperamylasemia was defined as a threefold rise in serum amylase without epigastric pain. RESULTS: There were 180 patients (67 men, 113 women; mean age 67, SD 16.2) available for analysis. Complete stone removal after a single ERCP was achieved in 82 (88%) of 93 EBD patients and in 81 (93%) of 87 EST patients (P = 0.38). Mechanical lithotripsy was used more frequently in the EBD group (31% vs. 13%, P = 0.005). Early complications occurred in 16 EBD patients (17%) and in 19 EST patients (22%) (P = 0.46). Pancreatitis was observed in seven patients in each group (8%). Logistic regression identified no significant predictors for the occurrence of pancreatitis. Asymptomatic hyperamylasemia occurred in 21 EBD patients (23%) vs seven EST patients (8%) (P = 0.008). Logistic regression identified EBD as the only significant predictor for asymptomatic hyperamylasemia: odds ratio 2.9 (95% confidence interval (CI) 1.1 to 7.3, R2 = 0.02). CONCLUSIONS: We did not observe a difference in the rate of pancreatitis between EBD and EST. Asymptomatic hyperamylasemia was observed more frequently after EBD. Although asymptomatic hyperamylasemia is not a clinical entity, this finding may indicate that EBD causes more irritation of the pancreas than EST.

Aged↗

PubMed2001

A randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy.

BACKGROUND: A prior Billroth II gastrectomy renders endoscopic sphincterotomy (EST) more difficult in patients with bile duct stones. Endoscopic balloon dilation (EBD) is a relatively easy procedure that potentially reduces the risk of bleeding and perforation. METHODS: Thirty-four patients with bile duct stones and a previous Billroth II gastrectomy were randomized to EST or EBD. Complications were graded in a blinded fashion. Results were compared with those for a group of 180 patients with normal anatomy from a previously reported randomized trial of EBD versus EST. RESULTS: All stones were removed in 1 endoscopic retrograde cholangiopancreatography in 14 of 16 patients who underwent EBD versus 14 of 18 who had EST (p = 1.00). Mechanical lithotripsy was used in 3 EBD procedures versus 4 EST procedures (p = 1.00). Early complications occurred in 3 patients who had EBD versus 7 who underwent EST (p = 0.27). Three patients had bleeding after EST; 1 patient had mild pancreatitis after EBD. The median time required for stone removal was 30 minutes in both groups. Compared with patients with a normal anatomy, patients with a previous Billroth II gastrectomy had a significantly increased risk of bleeding after EST (17% vs. 2%, relative risk = 7.25, p < 0.05). CONCLUSIONS: A prior Billroth II gastrectomy renders EST more difficult and increases the risk of a complication. EBD in these patients is easy to perform and is not associated with an increased need for mechanical lithotripsy or a longer procedure time. The risk of bleeding is virtually absent after EBD and the risk of pancreatitis after EBD seems not significantly increased in these patients.

Adult↗

PubMed2001

Twin-twin transfusion syndrome: etiology, severity and rational management.

The twin-twin transfusion syndrome is a serious complication of monochorionic twin pregnancies. Partly as a result of an inadequate understanding of the pathophysiology of the syndrome, there is a lack of consensus in clinical management. We sought to review the available information on the etiology of twin-twin transfusion syndrome, to identify parameters that contribute to the severity of the syndrome, and propose a rational management plan based on pathophysiology, clinical presentation and the efficacy of therapies. We therefore amalgamated recent advances in twin-twin transfusion syndrome computer modelling and clinical studies, particularly on therapeutic outcomes. We found that the oligo-polyhydramnios sequence that defines twin-twin transfusion syndrome prenatally represents a wide continuum of severity in the imbalance between the fetoplacental circulations of both twins. In severe twin-twin transfusion syndrome cases, in which the circulatory imbalance deteriorates beyond fetal control, fetoscopic laser therapy of all anastomoses along the placental vascular equator is predicted to have significantly better survival rates and fewer neurological sequelae than amnioreduction. In contrast, mild twin-twin transfusion syndrome cases have better outcomes after one or at most a few amnioreductions than laser therapy, as a result of significantly fewer procedure-related risks. In conclusion, optimal individual therapy may possibly achieve an 85% survival rate in twin-twin transfusion syndrome, but requires advancement in non-invasive criteria that predict the severity of the syndrome. Identifying such criteria is a future challenge. For the interim, twin-twin transfusion syndrome diagnosed before 26 weeks' gestation has significantly better survival rates and fewer neurological sequelae after laser therapy than amnioreduction. Twin-twin transfusion syndrome diagnosed after 26 weeks can best be treated by amnioreduction, or delivery. Contrary to previous claims, fetoscopic laser therapy has outgrown its experimental status. Although improvements in technique and technology are likely, laser placental ablation has a firm scientific and clinical basis.

Amniotic Fluid↗

PubMed2001

Variability in treatment advice for elderly patients with aortic stenosis: a nationwide survey in The Netherlands.

OBJECTIVE: To determine how the decisions of Dutch cardiologists on surgical treatment for aortic stenosis were influenced by the patient's age, cardiac signs and symptoms, and comorbidity; and to identify groups of cardiologists whose responses to these clinical characteristics were similar. DESIGN: A questionnaire was produced asking cardiologists to indicate on a six point scale whether they would advise cardiac surgery for each of 32 case vignettes describing 10 clinical characteristics. SETTING: Nationwide postal survey among all 530 cardiologists in the Netherlands. RESULTS: 52% of the cardiologists responded. There was wide variability in the cardiologists' advice for the individual case vignettes. Six groups of cardiologists explained 60% of the variance. The age of the patient was most important for 41% of the cardiologists; among these, 50% had a high and 50% a low inclination to advise surgery. A further 24% were influenced equally by the patient's age and by the severity of the aortic stenosis and its effect on left ventricular function; among these, 62% had a high and 38% a low inclination to advise surgery. Finally, 23% of the cardiologists were mainly influenced by the left ventricular function and 12% by the aortic valve area. The presence of comorbidity always played a minor role. CONCLUSIONS: There were systematic differences among groups of cardiologists in their inclination to advise aortic valve replacement for elderly patients, as well as in the way their advice was influenced by the patients' characteristics. These results indicate the need for prospective studies to identify the best treatment for elderly patients according to their clinical profile.

Adult↗

PubMed2000

Prediction of spinal epidural metastases.

CONTEXT: Early diagnosis and treatment of spinal epidural metastases (SEM) is of the utmost importance to prevent neurological deficit due to spinal cord compression. Magnetic resonance imaging (MRI) has become the final tool in that diagnostic process. However, access to MRI is still limited in The Netherlands, requiring cost-effective use. It is generally acknowledged that patients with systemic cancer who present with a radiculopathy or myelopathy should undergo an MRI. However, the diagnostic policy in patients with systemic cancer who present with recently developed back pain is still a matter of debate. OBJECTIVE: To identify the patients with back pain in whom MRI can safely be omitted because of a low risk of SEM. METHODS: In a prospective series of 170 consecutive patients with cancer with recently developed back pain, prediction of spinal metastatic disease (SMD) and especially SEM was studied by means of a multivariate risk analysis of the parameters of the standard neurological evaluation (medical history, neurological examination, and plain films of the whole spine). Magnetic resonance imaging was used as the criterion standard. We calculated the risk implications of omitting MRI in patients with an estimated risk below different cutoff points. RESULTS: Spinal metastatic disease was diagnosed in 80 patients (47%); of these, 31 had SEM. A metastatic abnormality on plain films was the strongest independent predictor for SMD. Other important predictors were night pain, progressive pain, and Karnofsky score. Advanced age, exacerbation of pain during recumbency, and osteoporotic fracture imply a low risk of SMD. Night pain and the Karnofsky score proved to be the main predictors for SEM. A plain film showing an osteoporotic fracture strongly decreased the risk of SEM. The discriminating value of the multivariate analysis was too low, and too few patients can be excluded from undergoing MRI on the basis of the standard neurological checkup. To identify all the patients with SMD (P<.01), MRI would be excluded in only 7 patients. Identification of all patients with SEM (P<.001) reduced the number of MRIs by 21 at the expense of plain films of the whole spine for any patient. CONCLUSIONS: Selection of patients with cancer with back pain at risk of SEM was not possible with the standard neurological checkup. After intake by the neurologist, the next step should be MRI of the whole spine.

Adult↗

PubMed2000

Placebo effect in the acute treatment of migraine: subcutaneous placebos are better than oral placebos.

We carried out a meta-analysis of 22 trials to determine the comparative placebo effect of (a) subcutaneous vs. oral and (b) in-hospital vs. at-home administration in the treatment of migraine. The headache relief rates were combined from the placebo arms of these randomised clinical trials assessing the value of sumatriptan in acute treatment of migraine. The main outcome measure was the proportion of patients reclassified from severe or moderate headache severity to no or mild headache severity 2 h after the beginning of treatment. In the oral regimen 222 of 865 patients (25.7%) reported no or mild headache severity after 2 h, compared to 279 of 862 patients (32.4%) of those receiving subcutaneous placebo (6.7% difference; 95% CI 2.4-11.0%). Adjusting for treatment setting and severity of headache at baseline did not change the observed difference. After placebo treatment at home 285 of 1,054 patients (27.0%) reported no or mild headache severity after 2 h, compared to 216 of 673 patients (32.1%) among those receiving placebo in hospital (5.1 % difference; 95% CI 0.6-9.5%). When adjusted for route of administration and severity of headache at baseline, the difference in relief rates between home and hospital setting disappeared. These findings indicate that subcutaneous administration enhances the placebo effect of acute treatment of migraine. Future trials of antimigraine drugs assessing the relative efficacy of various routes of administration should use a double-dummy technique. The interpreting of placebo-controlled trial results must therefore consider that the effect in the drug arm of the trial depends in part on the route of administration.

Administration, Oral↗

PubMed2000

The recurrence pattern of esophageal carcinoma after transhiatal resection.

BACKGROUND: There is much controversy about the optimal resection for carcinoma of the esophagus. Little is known about the pattern of recurrence after transhiatal resection for esophageal carcinoma. STUDY DESIGN: We retrospectively reviewed the charts of 149 patients who underwent transhiatal esophagectomy for carcinoma of the mid or distal esophagus or gastroesophageal junction between June 1993 and June 1997. Recurrence was classified as locoregional or distant recurrence. Nine patients with macroscopically evident tumor left after resection and three patients (2.0%) who died in the hospital were excluded from the analysis. This left 137 patients; 105 men and 32 women with a median age 65 years (range 37 to 84 years). RESULTS: There were 95 adenocarcinomas (69.3%) and 42 squamous cell carcinomas (30.7%). Overall the median followup was 24.0 months (range 1.4 to 69.2 months). For patients alive at the end offollowup without recurrence, the median followup was 36.5 months (range 23.6 to 69.2 months). Seven patients died of other causes. The median interval between operation and recurrence was 11 months (range 1.4 to 62.5 months) for patients who had recurrence, with no significant difference in interval between locoregional and systemic recurrence. Seventy-two of the 137 patients (52.6%) developed recurrent disease. Thirty-two patients (23.4%) developed locoregional recurrence only, 21 patients (15.3%) developed systemic recurrence only, and 19 patients (13.9%) had a combination of both. In only 8.0% of all patients was there recurrence in the cervical lymph nodes. The most frequent sites of distant recurrence were liver (37.5%), bone (25.0%), and lung (17.5%). Recurrence was related to postoperative lymph node status (p<0.001) and the radicality of the operation (p<0.001) in multivariate analysis. Recurrence was not associated with localization or histologic type of the tumor. CONCLUSIONS: Recurrence after transhiatal resection is an early event. Almost 40% of patients developed locoregional recurrent disease. For this patient group a more extended procedure may be of benefit, especially in the patients (23.4%) with locoregional recurrence in whom this is the only site of recurrent disease. But the potential benefit of a more extended procedure has to be balanced against a possible increase in perioperative morbidity and mortality.

Adenocarcinoma↗

PubMed2000

Evaluation of the long-term functional outcome assessed by myocardial perfusion scintigraphy following excimer laser angioplasty compared to balloon angioplasty in longer coronary lesions.

OBJECTIVES: Evaluation of the long-term functional outcome assessed by exercise myocardial perfusion imaging following excimer laser angioplasty compared to balloon angioplasty in coronary lesions > 10 mm in length. BACKGROUND: Previous randomized studies evaluating the effect of coronary interventions mainly focused on the long-term clinical and angiographic outcome. The functional outcome, assessed by myocardial perfusion scintigraphy, has not been evaluated in a randomized setting. METHODS: A total of 308 patients with stable angina and a longer coronary lesion (> 10 mm) were randomized to excimer laser angioplasty or balloon angioplasty. A 99mTechnetium-2-methoxy isobutyl isonitrile (MIBI) single-photon emission computed tomography (SPECT) study was performed in 139 patients before the initial angioplasty procedure and at 6 months follow-up (73 patients in the laser group versus 66 patients in the balloon group, respectively). Exercise tolerance at follow-up was compared to baseline values by means of exercise duration and double product at peak exercise. Myocardial perfusion of the randomized vascular bed was assessed semi-quantitatively on the MIBI SPECT images. The reversible defects were graded as mild, moderate or severe. Myocardial perfusion at follow-up was expressed as a percentage reduction in incidence and grading of the reversible defects compared to baseline values. RESULTS: Forty-four (61%) patients assigned to laser angioplasty were asymptomatic at 6 months follow-up compared to 34 (52%) patients assigned to balloon angioplasty (p = NS). Improvement in exercise duration and double product were 0.7 +/- 2.1 min and 4.3 +/- 6.2 min/mmHg/l,000, respectively, in the laser group, versus 0.3 +/- 2.5 min and 3.1 +/- 5.5 min/mmHg/1,000, respectively, in the balloon group (both p = NS). The percentage reduction of reversible defects was 23% in patients assigned to laser angioplasty vs. 29% in patients assigned to balloon angioplasty (Relative risk [RR]: 0.79, 95% confidence interval [CI]: 0.40-1.57; p = 0.50). The mild, moderate and severe reversible defects improved in 44.4, 63.6 and 66.6%, respectively, in the laser angioplasty group vs. 66.6, 53.8 and 90%, respectively, in the balloon angioplasty group. None of the comparisons were significantly different. CONCLUSION: Excimer laser angioplasty compared to balloon angioplasty in coronary lesions > 10 mm in length yields a similar long-term functional outcome assessed by anginal status, exercise tolerance and myocardial perfusion.

Adult↗