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ABSTRACT: To examine commonly used scoring systems, designed to predict overall outcome in critically ill patients, for their ability to select patients with an abdominal sepsis that have ongoing infection needing relaparotomy.
Data from a RCT comparing two surgical strategies was used. The study population consisted of 221 patients at risk for ongoing abdominal infection. The following scoring systems were evaluated with logistic regression analysis for their ability to select patients requiring a relaparotomy: APACHE-II score, SAPS-II, Mannheim Peritonitis Index (MPI), MODS, SOFA score, and the acute part of the APACHE-II score (APS).
The proportion of patients requiring a relaparotomy was 32% (71/221). Only 2 scores had a discriminatory ability in identifying patients with ongoing infection needing relaparotomy above chance: the APS on day 1 (AUC 0.61; 95%CI 0.52-0.69) and the SOFA score on day 2 (AUC 0.60; 95%CI 0.52-0.69). However, to correctly identify 90% of all patients needing a relaparotomy would require such a low cut-off value that around 80% of all patients identified by these scoring systems would have negative findings at relaparotomy.
None of the widely-used scoring systems to predict overall outcome in critically ill patients are of clinical value for the identification of patients with ongoing infection needing relaparotomy. There is a need to develop more specific tools to assist physicians in their daily monitoring and selection of these patients after the initial emergency laparotomy.
BMC Surgery 12/2011; 11:38. · 1.33 Impact Factor
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Brent C Opmeer, Kimberly R Boer,
Oddeke van Ruler,
Johannes B Reitsma,
Hein G Gooszen,
Peter W de Graaf,
Bas Lamme,
Michael F Gerhards,
E Philip Steller,
Cecilia M Mahler,
Huug Obertop,
Dirk J Gouma,
Patrick Mm Bossuyt,
Corianne Ajm de Borgie,
Marja A Boermeester
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ABSTRACT: Results of the first randomized trial comparing on-demand versus planned-relaparotomy strategy in patients with severe peritonitis (RELAP trial) indicated no clear differences in primary outcomes. We now report the full economic evaluation for this trial, including detailed methods, nonmedical costs, further differentiated cost calculations, and robustness of different assumptions in sensitivity analyses.
An economic evaluation was conducted from a societal perspective alongside a randomized controlled trial in 229 patients with severe secondary peritonitis and an acute physiology and chronic health evaluation (APACHE)-II score >or=11 from two academic and five regional teaching hospitals in the Netherlands. After the index laparotomy, patients were randomly allocated to an on-demand or a planned-relaparotomy strategy. Primary resource-utilization data were used to estimate mean total costs per patient during the index admission and after discharge until 1 year after the index operation. Overall differences in costs between the on-demand relaparotomy strategy and the planned strategy, as well as relative differences across several clinical subgroups, were evaluated.
Costs were substantially lower in the on-demand group (mean, 65,768 euro versus 83,450 euro per patient in the planned group; mean absolute difference, 17,682 euro; 95% CI, 5,062 euro to e29,004 euro). Relative differences in mean total costs per patient (approximately 21%) were robust to various alternative assumptions. Planned relaparotomy consistently generated more costs across the whole range of different courses of disease (quick recovery and few resources used on one end of the spectrum; slow recovery and many resources used on the other end). This difference in costs between the two surgical strategies also did not vary significantly across several clinical subgroups.
The reduction in societal costs renders the on-demand strategy a more-efficient relaparotomy strategy in patients with severe peritonitis. These differences were found across the full range of healthcare resources as well as across patients with different courses of disease.
ISRCTN51729393.
Critical care (London, England) 01/2010; 14(3):R97. · 4.61 Impact Factor
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ABSTRACT: It can be difficult to distinguish vasovagal syncope, the most common cause of transient loss of consciousness (T-LOC), from other causes of syncope by history taking. The Calgary Syncope Symptom Score (Calgary Score) is a tool developed for this purpose. We studied its performance in a series of patients presenting with T-LOC.
We calculated the Calgary Score for 380 patients presenting with T-LOC to a number of departments of our university hospital. Diagnoses of vasovagal syncope based on the Calgary Score were then compared with the final diagnosis, obtained after additional testing and 2 years of follow-up. The sensitivity of the Calgary Score was 87% (95% CI: 82-91%), at a specificity of 32% (95% CI: 24-40%). Most items of the Calgary Score were less discriminative in our study group than in the original population. Incorrectly labelling patients with syncope as vasovagal was most common in patients with psychogenic pseudosyncope (specificity 21%) but also occurred in patients with cardiac syncope (specificity 32%).
The sensitivity of the Calgary Score was comparable with the one in the original study, but its specificity was much lower, limiting its value in patients presenting with T-LOC in a general hospital setting.
European Heart Journal 09/2009; 30(23):2888-96. · 10.48 Impact Factor
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ABSTRACT: The clinical history is the cornerstone of diagnosing patients with transient loss of consciousness (TLOC). Reflex syncope is the most common cause of TLOC in patients across all ages. Knowledge of the variation in incidence and clinical features of reflex syncope by age and gender provides important background information to acquire an accurate diagnosis.
In a cohort of 503 patients presenting with TLOC we established a final diagnosis after systematic evaluation and two years of follow-up. The occurrence of prodromal signs, symptoms, and triggers in patients with reflex syncope was analyzed by both age (< 40 yrs, 40-59 yrs and > or = 60 years) and gender.
Reflex syncope was the most frequently obtained diagnosis (60.2%) in patients of all ages presenting with TLOC. Its occurrence was higher in patients under 40 years (73.4%), than above 60 years of age (45.3%). Pallor (79.9%), dizziness (73.4%), and diaphoresis (63.0%) were the most frequently reported prodromal signs and symptoms. Most triggers and prodromal signs and symptoms were more common in patients under 40 years of age and in women.
Reflex syncope is nearly twice as common in patients under 40 years of age than in patients aged 60 years or above. Typical signs and symptoms of reflex syncope are more common in younger patients and in women. Therefore, age and gender provide important diagnostic information and can help to decide whether additional testing is necessary.
Clinical Autonomic Research 06/2008; 18(3):127-33. · 1.30 Impact Factor
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ABSTRACT: To determine to what extent patients who have survived abdominal sepsis suffer from symptoms of posttraumatic stress disorder (PTSD) and depression, and to identify potential risk factors for PTSD symptoms.
PTSD and depression symptoms were measured using the Impact of Events Scale-Revised (IES-R), the Post-Traumatic Symptom Scale 10 (PTSS-10) and the Beck Depression Inventory II (BDI-II).
A total of 135 peritonitis patients were eligible for this study, of whom 107 (80%) patients completed the questionnaire. The median APACHE-II score was 14 (range 12-16), and 89% were admitted to the ICU.
The proportion of patients with "moderate" PTSD symptom scores was 28% (95% CI 20-37), whilst 10% (95% CI 6-17) of patients had "high" PTSD symptom scores. Only 5% (95% CI 2-12) of the patients expressed severe depression symptoms. Factors associated with increased PTSD symptoms in a multivariate ordinal regression model were younger age (0.74 per 10 years older, p=0.082), length of ICU stay (OR=1.4 per doubling of duration, p=0.003) and having some (OR=4.9, p=0.06) or many (OR=55.5, p<0.001) traumatic memories of the ICU or hospital stay.
As many as 38% of patients after abdominal sepsis report elevated levels of PTSD symptoms on at least one of the questionnaires. Our nomogram may assist in identifying patients at increased risk for developing symptoms of PTSD.
Intensive Care Medicine 04/2008; 34(4):664-74. · 5.40 Impact Factor
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ABSTRACT: Transient loss of consciousness (TLOC) is a common clinical problem.
The aim of this study was to assess the yield and accuracy of the initial evaluation, consisting of standardized history, physical examination, and ECG performed by attending physicians in patients with TLOC.
Five hundred and three adult patients (mean age 53 +/- 19; 56% male) presenting with TLOC to the Academic Medical Center Amsterdam between February 2000 and May 2002 were included in this study. After initial evaluation, the physician made a certain, a highly likely (>80% certain), or no initial diagnosis. Initially undiagnosed patients received additional cardiological testing, additional history taking, and autonomic function tests. After 2 years of follow-up, an expert committee determined the final diagnoses. Two-year follow-up was obtained in 99% of the patients. The yield of certain diagnoses after the initial evaluation was 24%, increasing to 63% after including the highly likely diagnoses. The diagnostic accuracy of the initial certain diagnoses was 93% (95% CI 87-97%), decreasing to 88% (95% CI 84-91%) after inclusion of the initial highly likely diagnoses.
Attending physicians can make a diagnosis based on initial evaluation in 63% of patients with TLOC, with an overall diagnostic accuracy of 88%. The use of additional testing, beyond history, physical examination, and ECG can be avoided in many patients with TLOC.
Journal of Cardiovascular Electrophysiology 01/2008; 19(1):48-55. · 3.06 Impact Factor
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ABSTRACT: Palpitations and light-headedness are common symptoms that may be indicative of cardiac arrhythmias. Effective triage by the GP might prevent delayed treatment or inappropriate referrals. The aim of this study was to determine the capability of GPs to assess the presence of cardiac arrhythmias and which signs and symptoms are used in predicting the presence of arrhythmias and which actually are related to the presence of arrhythmias.
A consecutive cohort of 127 patients presenting with palpitations and/or light-headedness to 41 GPs in the Netherlands underwent physical examination, patient history and standard electrocardiogram. The GPs' estimation of the probability of patients having an arrhythmia was compared with the diagnostic result of 30 days of continuous event recording (CER). We assessed discriminating factors that can assist a GP in diagnosing an arrhythmia.
No correlation was found between the GPs' assessment of risk and actual diagnoses. GPs were more likely to predict an arrhythmia in patients who suffer from hypertension (P=0.049) or patients with a history of cardiovascular disease (P=0.006). Vasovagal symptoms [odds ratio (OR)=2.91, 95% confidence interval (CI) 1.1-7.6] and bradycardia (OR=4.2, 95% CI 1.3-14.0) were significantly more common in patients with a CER diagnosis of arrhythmia.
Prediction of arrhythmias by GPs based on history taking and physical examination alone is not accurate. These parameters are insufficient to decide which patients need further diagnostic evaluation. A diagnostic facility with low threshold for GPs is essential for an adequate diagnostic process in patients with palpitations and light-headedness.
Family Practice 01/2008; 24(6):636-41. · 1.50 Impact Factor
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ABSTRACT: Palpitations can generate feelings of anxiety and decrease quality of life (QoL) due to fear of a cardiac abnormality. Continuous event recorders (CERs) have proven to be successful in diagnosing causes of palpitations but may affect patient QoL and anxiety. The aim is to determine anxiety and health-related (HR)-QoL and evaluate the burden of carrying a CER in general practice populations.
Patients (n=244) participated in a randomized trial. One group (n=127) carried a CER during 4 weeks. One hundred and seventeen patients formed the usual care (UC) group. State-Trait Anxiety Inventory (STAI) and the Short Form-36 (SF-36) were administered at study inclusion, after 1, 6 months.
At baseline, patients reported greater anxiety and lower QoL than healthy populations. The CER group had three times more cardiac diagnoses than the UC group. No differences were found between CER group and UC group at 6 weeks. At 6 months, the UC group showed QoL improvement and less anxiety compared to the CER group. Type of diagnosis had influence, but did not fully explain these differences.
A CER does not negatively influence anxiety or QoL. Better outcomes in the UC group might be attributed to less cardiac diagnosis and more emphasis on psychological well-being.
Journal of Clinical Epidemiology 11/2007; 60(10):1060-6. · 4.27 Impact Factor
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ABSTRACT: Patients with transient loss of consciousness (TLOC) have poor health-related quality of life (HR-QoL).
To test the reliability, validity, and responsiveness of the disease-specific Syncope Functional Status HR-QoL Questionnaire (SFSQ), which yields two summary scales--impairment score (IS) and fear-worry score (FWS).
Cohort-study.
503 adult patients presenting with TLOC.
HR-QoL was assessed using the SFSQ and the Short Form-36 (SF-36) after presentation and 1 year later. To test reliability, score distributions, internal consistency, and test-retest reliability were assessed. To assess validity, scores on the SFSQ and the SF-36 were compared. Clinical validity was tested using known-group comparison. Responsiveness was assessed by comparing changes in SFSQ scores with changes in health status and clinical condition.
Response rate was 82% at baseline and 72% at 1-year follow-up. For all scales the full range of scores was seen. Score distributions were asymmetrical. Internal consistency was high (alpha = 0.88 for IS, 0.92 for FWS). Test-retest reliability was moderate to good for individual items and high for summary scales (inter-class correlation = 0.78 for both IS and FWS). Correlations between SFSQ scores and the SF-36 were modest. The SFSQ did not discriminate between patients differing in age and gender but did discriminate between patients differing in number of episodes and comorbid conditions. Changes in SFSQ scores were related to changes in health status and the presence of recurrences but did not vary by TLOC diagnosis.
The SFSQ is an adequately reliable, valid, and responsive measure to assess HR-QoL in patients with TLOC.
Journal of General Internal Medicine 10/2007; 22(9):1280-5. · 2.83 Impact Factor
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Oddeke van Ruler,
Cecilia W Mahler, Kimberly R Boer,
E Ascelijn Reuland,
Hein G Gooszen,
Brent C Opmeer,
Peter W de Graaf,
Bas Lamme,
Michael F Gerhards,
E Philip Steller,
J W Olivier van Till,
Corianne J A M de Borgie,
Dirk J Gouma,
Johannes B Reitsma,
Marja A Boermeester
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ABSTRACT: In patients with severe secondary peritonitis, there are 2 surgical treatment strategies following an initial emergency laparotomy: planned relaparotomy and relaparotomy only when the patient's condition demands it ("on-demand"). The on-demand strategy may reduce mortality, morbidity, health care utilization, and costs. However, randomized trials have not been performed.
To compare patient outcome, health care utilization, and costs of on-demand and planned relaparotomy.
Randomized, nonblinded clinical trial at 2 academic and 5 regional teaching hospitals in the Netherlands from November 2001 through February 2005. Patients had severe secondary peritonitis and an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 11 or greater.
Random allocation to on-demand or planned relaparotomy strategy.
The primary end point was death and/or peritonitis-related morbidity within a 12-month follow-up period. Secondary end points included health care utilization and costs.
A total of 232 patients (116 on-demand and 116 planned) were randomized. One patient in the on-demand group was excluded due to an operative diagnosis of pancreatitis and 3 in each group withdrew or were lost to follow-up. There was no significant difference in primary end point (57% on-demand [n = 64] vs 65% planned [n = 73]; P = .25) or in mortality alone (29% on-demand [n = 32] vs 36% planned [n = 41]; P = .22) or morbidity alone (40% on-demand [n = 32] vs 44% planned [n = 32]; P = .58). A total of 42% of the on-demand patients had a relaparotomy vs 94% of the planned relaparotomy group. A total of 31% of first relaparotomies were negative in the on-demand group vs 66% in the planned group (P <.001). Patients in the on-demand group had shorter median intensive care unit stays (7 vs 11 days; P = .001) and shorter median hospital stays (27 vs 35 days; P = .008). Direct medical costs per patient were reduced by 23% using the on-demand strategy.
Patients in the on-demand relaparotomy group did not have a significantly lower rate of death or major peritonitis-related morbidity compared with the planned relaparotomy group but did have a substantial reduction in relaparotomies, health care utilization, and medical costs.
http://isrctn.org Identifier: ISRCTN51729393.
JAMA The Journal of the American Medical Association 09/2007; 298(8):865-72. · 30.03 Impact Factor
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ABSTRACT: The purpose of this study was to examine (1) changes in quality of life (QoL) within 1 year after presentation with transient loss of consciousness (TLOC) and (2) which factors are predictive of these changes. This study was part of the Fainting Assessment Study (FAST), which assessed diagnostic strategies in patients with TLOC. Adult patients presenting to Academic Medical Center, Amsterdam, The Netherlands, with TLOC were included in the study. QoL was assessed with the generic Short Form 36 and the disease-specific Syncope Functional Status Questionnaire at presentation and 1 year of follow-up. Of 468 included patients, 82% completed questionnaires at presentation and 72% after 1-year follow-up. QoL improved on 7 of 8 subscales of the Short Form 36 and on all summary scales of the Syncope Functional Status Questionnaire. Older age, recurrence, higher level of co-morbidity, and a neurologic or psychogenic diagnosis were predictive of poorer QoL. In conclusion, QoL in patients with TLOC improves significantly over time. Physicians should particularly pay attention to patients who are older, have recurrent episodes, a neurologic or psychogenic diagnosis, and a higher level of co-morbidity because these patients are vulnerable to a relatively poorer QoL.
The American Journal of Cardiology 09/2007; 100(4):672-6. · 3.37 Impact Factor
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ABSTRACT: Patient-activated continuous-loop event recorders (CER) are useful as a diagnostic tool in new episodes of palpitations and/or dizziness. So far, no analysis of optimal duration for monitoring in unselected patients has been published.
During a period of 30 days, we prospectively evaluated the time until diagnosis using CER in patients with symptoms of palpitations and/or dizziness in general practice.
In total, 127 patients received an event recorder for a maximum duration of 30 days. Events were recorded by 104 patients (82%), of whom 83 (78%) showed an arrhythmia. After 2 weeks, 75% of all diagnoses and 83.3% of all clinically relevant diagnoses could be established.
The yield of event recording in general practice diminishes with recording time. A minimum recording time of 2 weeks seems necessary.
Family Practice 03/2007; 24(1):11-3. · 1.50 Impact Factor
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Kimberly R Boer,
Oddeke van Ruler,
Johannes B Reitsma,
Cecilia W Mahler,
Brent C Opmeer,
E Ascelijn Reuland,
Hein G Gooszen,
Peter W de Graaf,
Eric J Hesselink,
Michael F Gerhards,
E Philip Steller,
Mirjam A Sprangers,
Marja A Boermeester,
Corianne A De Borgie
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ABSTRACT: To compare health related quality of life (HR-QoL) in patients surgically treated for secondary peritonitis to that of a healthy population. And to prospectively identify factors associated with poorer (lower) HR-QoL.
A prospective cohort of secondary peritonitis patients was mailed the EQ-5D and EQ-VAS 6-months following initial laparotomy.
Multicenter study in two academic and seven regional teaching hospitals.
130 of the 155 eligible patients (84%) responded to the HR-QoL questionnaires.
HR-QoL was significantly worse on all dimensions in peritonitis patients than in a healthy reference population. Peritonitis characteristics at initial presentation were not associated with HR-QoL at six months. A more complicated course of the disease leading to longer hospitalization times and patients with an enterostomy had a negative impact on the mobility (p = 0.02), self-care (p < 0.001) and daily activities: (p = 0.01). In a multivariate analysis for the EQ-VAS every doubling of hospital stay decreases the EQ-VAS by 3.8 points (p = 0.015). Morbidity during the six-month follow-up was not found to be predictive for the EQ-5D or EQ-VAS.
Six months following initial surgery, patients with secondary peritonitis report more problems in HR-QoL than a healthy reference population. Unfavorable disease characteristics at initial presentation were not predictive for poorer HR-QoL, but a more complicated course of the disease was most predictive of HR-QoL at 6 months.
Health and Quality of Life Outcomes 02/2007; 5:35. · 2.11 Impact Factor
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ABSTRACT: The aim of this study was to determine the long-term prevalence of post-traumatic stress disorder (PTSD) symptomology in patients following secondary peritonitis and to determine whether the prevalence of PTSD-related symptoms differed between patients admitted to the intensive care unit (ICU) and patients admitted only to the surgical ward.
A retrospective cohort of consecutive patients treated for secondary peritonitis was sent a postal survey containing a self-report questionnaire, namely the Post-traumatic Stress Syndrome 10-question inventory (PTSS-10). From a database of 278 patients undergoing surgery for secondary peritonitis between 1994 and 2000, 131 patients were long-term survivors (follow-up period at least four years) and were eligible for inclusion in our study, conducted at a tertiary referral hospital in Amsterdam, The Netherlands.
The response rate was 86%, yielding a cohort of 100 patients; 61% of these patients had been admitted to the ICU. PTSD-related symptoms were found in 24% (95% confidence interval 17% to 33%) of patients when a PTSS-10 score of 35 was chosen as the cutoff, whereas the prevalence of PTSD symptomology when borderline patients scoring 27 points or more were included was 38% (95% confidence interval 29% to 48%). In a multivariate analyses controlling for age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, number of relaparotomies and length of hospital stay, the likelihood of ICU-admitted patients having PTSD symptomology was 4.3 times higher (95% confidence interval 1.11 to 16.5) than patients not admitted to the ICU, using a PTSS-10 score cutoff of 35 or greater. Older patients and males were less likely to report PTSD symptoms.
Nearly a quarter of patients receiving surgical treatment for secondary peritonitis developed PTSD symptoms. Patients admitted to the ICU were at significantly greater risk for having PTSD symptoms after adjusting for baseline differences, in particular age.
Critical care (London, England) 02/2007; 11(1):R30. · 4.61 Impact Factor
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NYNKE VAN DIJK M.D,
MIRJAM A. SPRANGERS Ph.D,
NANCY COLMAN M.D,
KIMBERLY R. BOER M.Sc,
Ph.D. WOUTER WIELING M.D,
MARK LINZER M.D,
NYNKE VAN DIJK,
MIRJAM A. SPRANGERS,
NANCY COLMAN, KIMBERLY R. BOER,
WOUTER WIELING,
MARK LINZER
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ABSTRACT: Introduction: Transient loss of consciousness (TLOC) is common and can be lethal. Although the patients with the most prevalent causes of TLOC have a benign prognosis, morbidity is considerable. Aim of this article, therefore, was to compare the generic quality of life (QoL) of patients presenting with TLOC with that of the general population, to compare the disease-specific QoL with that of an American referral sample, and to examine which sociodemographic and clinical factors are associated with QoL in these patients.Methods: This study was part of the fainting assessment study (FAST), which assessed diagnostic strategies for adult patients presenting with TLOC to the Academic Medical Center Amsterdam, between February 2000 and May 2002. The generic short form-36 (SF-36) health survey and the disease-specific syncope functional status questionnaire (SFSQ) were used to assess QoL.Results: Of 468 included patients, 82% completed the questionnaires. Patients with TLOC scored poorer on all scales of the SF-36 than the Dutch population, with effect sizes ranging from 0.43 to 1.11 (>0.5 = moderate effect; >0.8 = large effect). The SFSQ indicated mean impairment in 33% of the listed activities (such as driving). Female gender, higher level of comorbidity, shorter duration of complaints, having had more than one syncopal episode, and the presence of presyncopal episodes were associated with poorer QoL.Conclusion: TLOC seriously affects QoL, especially in patients with a recent onset of clinical symptoms and those suffering from both syncopal and presyncopal episodes.
Journal of Cardiovascular Electrophysiology 08/2006; 17(9):998 - 1003. · 3.06 Impact Factor
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ABSTRACT: Background. Patient-activated continuous-loop event recorders (CER) are useful as a diagnostic tool in new episodes of palpitations and/or dizziness. So far, no analysis of optimal duration for monitoring in unselected patients has been published. Methods. During a period of 30 days, we prospectively evaluated the time until diagnosis using CER in patients with symptoms of palpitations and/or dizziness in general practice. Results. In total, 127 patients received an event recorder for a maximum duration of 30 days. Events were recorded by 104 patients (82%), of whom 83 (78%) showed an arrhythmia. After 2 weeks, 75% of all diagnoses and 83.3% of all clinically relevant diagnoses could be established. Conclusion. The yield of event recording in general practice diminishes with recording time. A minimum recording time of 2 weeks seems necessary.
