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Biomedical subjects

C van der Werken

Publications and source records attributed to C van der Werken.

At least 19 recordsLinked to original sources
PubMed2002

Prediction of serious complications in patients admitted to a surgical ward.

BACKGROUND: Prediction of complications is an essential part of risk management in surgery. Knowing which patients are at high risk of developing complications will contribute to the quality and cost reduction of surgery. METHODS: All patients admitted to a general surgical ward during a 1-year interval were followed until 30 days after discharge. Complications and data on potential risk factors were recorded prospectively. Relative risks were calculated for each risk factor and predictive values for the development of a serious or minor complication were computed using logistic regression analysis. The predictive values of different combinations of variables were expressed as receiver operating characteristic curves. RESULTS: Of 3075 patients, 375 suffered one or more serious complications and 319 experienced a minor complication. A model was developed for prediction of serious complications, consisting of 11 variables, with an area under the curve (AUC) of 0.79 (95 per cent confidence interval (c.i.) 0.76 to 0.81). The prognostic value of the model for minor complications (seven variables) was lower (AUC 0.68 (95 per cent c.i. 0.65 to 0.71)). CONCLUSION: Serious complications in patients admitted to a surgical ward can be predicted using a model consisting of 11 variables. The risk score can be used in the decision-making process before surgery.

Adolescent↗
PubMed2001

The diagnostic value of MRI scans for the diagnosis of chronic exertional compartment syndrome of the lower leg.

OBJECTIVE: A prospective descriptive study to determine the value of magnetic resonance imaging (MRI) as an aid in diagnosing (chronic) exertional compartment syndrome. DESIGN AND PATIENTS: MRI was performed in 21 patients (41 anterior compartments) with chronic compartment syndrome at rest and following physical exercise. Median (T2-weighted) signal intensity on the MRI scan was determined in the anterior and the (superficial) posterior compartment of the lower leg before and after exercise. Postexercise increases in the signal intensity in these two compartments were compared. After fasciotomy, a second MRI scan was performed in 13 patients (25 anterior compartments) on the basis of the same protocol. MR studies were performed in 12 normal controls (24 anterior muscle compartments) on the basis of the same protocol. RESULTS: T2-weighted signal intensity increased by 27.5% (range 13.6-38.6%) following exercise in the anterior compartment of patients with a chronic compartment syndrome. In the posterior compartment this increase amounted to 4.25% (range 0-10.2%). Following fasciotomy, the increase in the anterior compartment was 4.1% (range 1.0-5.2%), while the increase in the posterior compartment amounted to 5.6% (range 0-11.0%), In normal controls, the increase in the anterior compartment was 7.6% (range 0-9. 1%), while in the posterior compartment it was 4.0% (range 0-7.2%). CONCLUSIONS: In patients with a chronic compartment syndrome, the affected (anterior) compartment shows a statistically significant increase in (T2-weighted) signal intensity during exercise compared with both the (superficial) posterior compartment and the anterior compartment of normal controls. This effect disappeared after fasciotomy. In view of the substantial increase in T2-weighted signal intensity, MRI can be used in diagnosing chronic compartment syndrome.

Adolescent↗
PubMed2001

Arthrodesis after osteosynthesis and infection of the ankle joint.

Nineteen patients with a severely infected ankle joint after previous osteosynthesis were treated with arthrodesis in our institution. Their notes and X-rays were reviewed. Goals of treatment were eradication of infection by aggressive débridement of infected tissues, obtaining adequate soft-tissue coverage, preservation/restoration of bonelength, and finally consolidation of the arthrodesis. Thirteen men and six women were treated, with a median age of 46 (17-69) years. Arthrodesis took place after a median of 6 months (0.5-40) post-accident, and after one to six earlier operative procedures. Primarily there had been four bimalleolar, five trimalleolar and ten pilon tibial fractures. Fifteen fractures were open with severe soft tissue damage. Seven free muscle transfers were performed, and ten cancellous bone graftings. Finally 29 attempts at arthrodesis were performed. Ultimately we had to perform two amputations. After a mean follow up of 3.5 years, one patient has an aseptic but asymptomatic pseudarthrosis, for which no further surgery is scheduled. Sixteen extremities are free from infection while full weightbearing is possible. The limb-threatening problem of deep infection after osteosynthesis of an ankle fracture can be resolved by consistent but prolonged treatment. After successful arthrodesis a weightbearing extremity without infection remains in the majority of cases.

Adolescent↗
PubMed2001

Grade III open tibial fractures: functional outcome and quality of life in amputees versus patients with successful reconstruction.

The purpose of this study was to assess the long-term functional outcome and the quality of life of patients who were treated for a (Gustilo) Grade III open tibial fracture. We included 43 patients with successful limb salvage (group A) and 21 amputees (group B). The groups were similar with regard to age, sex, and Injury Severity Score (ISS). The functional outcome was scored using the "Guides to the Evaluation of Permanent Impairment". To compare quality of life we used the Nottingham Health Profile (NHP), the SF-36, and a questionnaire especially designed for this study. The mean lower extremity impairment (AMA) of patients in group A was 17.6%, compared to 73.5% for patients in group B. The results with both NHP and SF-36 show that patients in both groups have more problems in most categories than a healthy reference group. With the NHP, the difference in score was largest for the categories of pain, mobility, energy and sleep. The SF-36 scores correlated well with the NHP scores. No significant difference was found between the two groups. This type of injury has an enormous impact on every aspect of life--irrespective of the chosen treatment. A significant difference in lower extremity impairment is found between patients with a successful reconstruction and those who are amputees. However, the quality of life was shown to be the same.

Adult↗
PubMed2001

Quality of life after severe bacterial peritonitis and infected necrotizing pancreatitis treated with open management of the abdomen and planned re-operations.

OBJECTIVE: To determine quality of life after severe bacterial peritonitis and infected necrotizing pancreatitis treated with open management of the abdomen and planned re-operations. DESIGN: Retrospective chart review. SETTING: University hospital intensive care unit, general wards, and outpatient department. PATIENTS: Forty-one patients who survived severe bacterial peritonitis and infected necrotizing pancreatitis treated with open management of the abdomen and planned re-operations. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Over a period of 7 yrs, 95 patients underwent open management of the abdomen and planned re-operations for severe bacterial peritonitis and infected necrotizing pancreatitis. Thirty-nine patients died during the initial intensive care unit stay and 12 as a result of nonperitonitis-related systemic diseases after discharge. Four patients were lost or excluded from final analysis. Long-term morbidity and quality of life using Karnofsky and Rankin scores at discharge and at follow-up at least 1 yr after discharge (mean: 4 yrs) and the Sickness Impact Profile (SIP) were determined. The remaining 41 patients reviewed showed significant long-term morbidity, including dysfunction of the abdominal wall resulting from herniation, persistent polyneuropathy, and mental disorders needing psychiatric support. Patients having persistent polyneuropathy and, to a lesser extent, mental disorders, showed significantly lower Karnofsky, higher Rankin, and higher SIP scores. After discharge, performance status of patients improved significantly, as shown by higher Karnofsky and lower Rankin scores, and, because Karnofsky and Rankin scores are closely related to SIP scores, higher SIP scores. Especially in measuring quality of life in terms of social and role management, assessment of the SIP proved to have additional value. CONCLUSIONS: About three-quarters of patients who survive open management of the abdomen and planned re-operations for severe bacterial peritonitis and infected necrotizing pancreatitis regain a good quality of life. Some patients, especially those who suffer from persistent polyneuropathy and mental disorders, show restrictions in daily life.

Adult↗
PubMed2001

Results of group-circumcision of Muslim boys in Malaysia with a new type of disposable clamp.

This study evaluates the safety and results of surgery usingTaraKlamp Circumcision Device during a group circumcision. Atotal of 64 circumcisions of Muslim boys were performed by Medical Assistants supervised by Medical Doctors in a hall in Kuala Lumpur, Malaysia. A new type disposable clamp was used, which was removed 4 days after the operation. No major complications occurred and the boys experienced in general mild pain postoperatively. Mostly good cosmetic results were obtained and 90% of the parents would recommend this new clamp to others. Group circumcisions withTaraKlamp Circumcision Device (Kuala Lumpur, Malaysia) are safe, although proper patient selection and adequate training in using the device are mandatory.

Child↗
PubMed2001

The floating shoulder. A multicentre study.

The aim of this retrospective study was to review a series of patients with ipsilateral fractures of the neck of the scapula and of the clavicle. Between 1991 and 1996 a total of 79 general and orthopaedic surgeons treated 46 patients with a floating shoulder in The Netherlands. The records and radiographs of these patients were studied. Of the 35 patients available for follow-up, 31 had initially been treated conservatively and four by operation; three underwent secondary reconstructive surgery. The mean Constant score for the 28 patients treated conservatively was 76 and for the seven treated operatively it was 71 at a mean follow-up of 35 months. In six of the 28 patients treated conservatively the glenoid was dislocated caudally at the end of treatment; they had a score of 42. In the 22 patients without this dislocation the score was 85. We conclude that this rare injury is not inherently unstable and, in the absence of caudal dislocation of the glenoid, conservative treatment gives a good functional outcome.

Adolescent↗
PubMed2000

[Methicillin-resistant Staphylococcus aureus in medical and paramedical personnel returned from work in a foreign hospital].

The cultures of two patients of the Surgical Intensive Care Unit (IC) of the Medical Centre of Utrecht University were found positive for methicillin-resistant Staphylococcus aureus (MRSA). A male nurse turned out to be the source, 4 months after his return from working in an English hospital. Cultures were, by mistake, not taken directly on arrival from abroad. Pulsed-field gel electrophoresis proved MRSA strains from both source and the 2 patients to be identical to a strain which was epidemic in Great Britain but had never occurred in the Netherlands. The IC has meanwhile been closed; at source investigation, 14 other patients and six staff members were found MRSA-positive. The policy in the hospital is to screen health care workers for MRSA carriership on return from an hospital abroad. The success of the policy depends strongly on the cooperation of health care workers in this matter.

Adult↗
PubMed2000

[The operating room of the future].

Advances in computer technology will revolutionize surgical techniques in the next decade. The operating room (OR) of the future will be connected with a laboratory where clinical specialists and researchers prepare image-guided interventions and explore the possibilities of these techniques. The virtual reality is linked to the actual situation in the OR with the aid of navigation instruments. During complicated operations the images prepared preoperatively will be corrected during the operation on the basis of the information obtained peroperatively. MRI currently offers maximal possibilities for image-guided surgery of soft tissues. Simpler techniques such as fluoroscopy and echography will become increasingly integrated in computer-assisted peroperative navigation. The development of medical robot systems will make possible microsurgical procedures by the endoscopic route. Tele-manipulation systems will also play a part in the training of surgeons. Design and construction of the OR will be adapted to the surgical technology, and include an information and control unit where preoperative and peroperative data come together and from where the surgeon operates the instruments. Concepts for the future OR should be regularly adjusted to allow for new surgical technology.

Diagnosis, Computer-Assisted↗
PubMed2000

[Fewer x-rays while maintaining quality of clinical care using clinical protocols for physical diagnosis of ankle injuries].

OBJECTIVE: To determine whether it is possible to decrease the number of X-rays in acute ankle injury while keeping the health care constant, using a scoring system. DESIGN: Prospective. METHOD: Patients presenting in the emergency department of the University Hospital Utrecht (AZU), the Netherlands, over a one-year period of time with acute ankle injuries were subjected to a thorough physical examination based on a scoring system developed at Leiden University Hospital. The score was calculated and X-ray examination was indicated when this score was > or = 8 points. Radiological investigation or telephone interviews six weeks after injury achieved verification of the clinically relevant ankle fractures. Specificity and sensitivity were calculated from every possible cut-off point and drawn in a 'receiver operating characteristics' (ROC) curve. RESULTS: Of the 514 patients included 81 patients had a score of 8 or higher and 24 of them had a clinically relevant fracture. In 34 patients an ankle X-ray was made although their score was < 8 points. The positive and negative predictive values of the system were 30% (95% confidence interval (95% CI): 20-41) and 99% (95% CI: 97-100) respectively. The score yielded an area under the ROC curve of 91% (95% CI: 84-98). A cut-off point of 8 led to a reduction of X-rays by 60% (using the 'Ottawa ankle rules' the decrease in this population would have been 28%). On the other hand, 5 clinically relevant fractures were missed. CONCLUSION: Radiological examination in patients wit acute ankle complaints was reduced while health care remained almost constant. In the AZU, a decision was made for a major reduction in X-rays while accepting that some fractures would be missed.

Adult↗
PubMed2000

[Biodegradable implants in fracture fixation: state of the art].

Operative fracture repair in trauma surgery is currently performed using metal implants. These metal implants often are removed during a second, retrieval operation. Biodegradable fracture fixation devices have been used clinically since the late seventies. Most bioresorbable implants are manufactured from polymers. The polylactides, polyglycolides and co-polymers slowly degrade into small components that are excreted from the human body via natural pathways and removal operations after fracture surgery are not necessary. Due to the limited mechanical properties, the polymer screws and pins are mostly used in the treatment of non weight-baring simple fractures of the ankle, elbow, hand and foot. In view of the progressing technical developments, new materials will be developed and tested for clinical use in the coming decades.

Absorbable Implants↗
PubMed2000

Functional results after treatment of hip fracture: a multicentre, prospective study in 215 patients.

OBJECTIVE: To find out which factors influence outcome after a fractured hip, so that the optimum treatment may be chosen for each patient. DESIGN: Prospective cohort study. SETTING: 3 teaching and 2 rural hospitals, The Netherlands. SUBJECTS: 215 patients aged 55-102 years (median 82) who presented with a fractured hip during 1994. INTERVENTIONS: Interviews shortly after the injury and 4 and 12 months later, study of radiographs, and evaluation of casenotes. MAIN OUTCOME MEASURES: Mobility and functional recovery. RESULTS: 38 patients had died by the 4-month follow up, at which time 64/177 (36%) had regained the level of mobility that they had before the injury. At 12 months the figure was 58/148 (39%). The corresponding figures for functional recovery were 52/177 (29%) and 36/148 (24%). Factors that militated against recovery were increasing age, coexisting diseases, general complications and local complications. CONCLUSIONS: The chance of a patient with a hip fracture making any further recovery after 4 months is minimal. Local complications are the most important risk factor.

Aged↗
PubMed2000

Twelfth rib resection: a direct posterior surgical approach for subphrenic abscesses.

OBJECTIVE: To assess the results of twelfth rib resection as a direct posterior surgical approach to subphrenic abscesses in case of failure of percutaneous drainage, abandonment of percutaneous drainage in view of a too high risk of perforation of adjacent organs, or contamination of the pleural space, or an inaccessible abdomen. DESIGN: Retrospective study. SETTING: University hospital, The Netherlands. PATIENTS: 17 patients who required rib resection for subphrenic abscesses that developed after infected necrotising pancreatitis, splenectomy, or anastomotic disruption. INTERVENTIONS: 18 rib resections. MAIN OUTCOME MEASURES: Outcome and morbidity. RESULTS: Twelfth rib resection was successfully in 13 of 17 patients. Four patients died from multiple organ failure despite subsequent (re) laparotomies for additional surgical drainage. CONCLUSION: Twelfth rib resection can be useful for the treatment of subphrenic abscesses in selected patients.

Adult↗
PubMed2000

Open management of the abdomen and planned reoperations in severe bacterial peritonitis.

OBJECTIVE: To assess the results of open management of the abdomen and planned re-operations in severe bacterial peritonitis after perforation or anastomotic disruption of the digestive tract. DESIGN: Retrospective study. SETTING: University Hospital, The Netherlands. SUBJECTS: 67 consecutive patients. INTERVENTIONS: Open management of the abdomen and planned reoperations. MAIN OUTCOME MEASURES: Hospital morbidity and mortality, long-term follow-up. RESULTS: 38 patients developed multiple organ failure (MOF), but 29 needed only ventilatory and inotropic support. The mean number of re-operations was nine. 16 patients developed severe bleeding and 16 fistulas. In-hospital mortality was 42% (n = 28). Long-term morbidity, particularly the number of abdominal wall defects (n = 10), was considerable. CONCLUSION: Despite open management of the abdomen and planned re-operations, mortality of severe bacterial peritonitis still continues to be too high, and both short and long-term morbidity are appreciable. The value of open management of the abdomen and planned re-operations rests only on the clinical observation that other conventional surgical treatments of severe bacterial peritonitis often fail.

Abdomen↗
PubMed2000

Pulse oximeter-induced digital injury: frequency rate and possible causative factors.

OBJECTIVE: To study the frequency rate of and factors associated with pulse oximeter-induced digital injury (PIDI). DESIGN: Prospective descriptive study. SETTING: Surgical intensive care unit of a university hospital. PATIENTS: All patients with a length of stay of >2 days. INTERVENTIONS AND MAIN RESULTS: We monitored 125 patients by using a pulse oximeter with a nondisposable clip-on probe changed every 3-4 hrs from one finger to another. Daily inspection was performed with special attention to digital injury. Factors implicated in the pathogenesis of PIDI, such as vasopressor therapy, hypotension, hypoxia, hypothermia, and arterial cannulation of the radial or ulnar artery were recorded daily. A total of 22 patients received norepinephrine and dopamine, 34 patients were given dopamine, and 69 patients did not receive vasoactive drugs. PIDI developed in 6 of 125 patients, five in the norepinephrine/dopamine group, one in the dopamine group, and none in the patients not receiving vasopressors. When comparing the frequency rate of PIDI in patients receiving norepinephrine (5 of 22) with patients not receiving norepinephrine (1 of 103) the relationship between the use of norepinephrine and PIDI is significant (p < .001). However, this relationship may also be explained by the fact that patients in the norepinephrine group were more severely ill than patients not requiring norepinephrine were. This is reflected by a higher median severity of illness score (Simplified Acute Physiology Score II) (p = .001), median duration of hypotension (p < .001), median number of saturation drops (p < .001), and higher mortality rate (p < .001). Hypothermia did not occur in any of the patients. There was no significant difference between the median right-left difference in duration of arterial cannulation between the two subgroups (p = .8). In all surviving patients, PIDI healed without permanent damage. CONCLUSIONS: In the studied population of critically ill patients in a surgical intensive care unit, the frequency rate of PIDI was 5% (6 of 125). Although an association with the use of norepinephrine was found, this small number of cases does not allow definite statistical conclusions concerning a relationship between the possible causative factors and PIDI. However, severely ill patients, as indicated by their need for more aggressive vasopressors, are more likely to develop PIDI. In survivors, PIDI healed without sequelae.

APACHE↗
PubMed1999

[Intra-osseus gas formation in osteomyelitis of vertebrae and pelvis by Klebsiella pneumoniae].

A 59-year-old woman had persistent sepsis after abdominal operations because of a volvulus and subsequently a retroperitoneal abscess, in spite of antibiotic treatment against Klebsiella pneumoniae, which grew in blood cultures. During abscess drainage, a haemorrhage from the infrarenal part of the aorta had occurred; in view of a presumed aortitis this part had been replaced by a bifemoral bypass. Computer tomography revealed intraosseous formation of gas in vertebrae and pelvis. At operation, abscesses were drained and necrotomy and sequestrotomy of the bone were performed. Cultures of the pus from the iliac crests showed K. pneumoniae. The antibiotic management was changed; the wounds were flushed regularly. After exposure of the wounds still draining after 6 months and vascular surgery because of occlusion of the bypass after 7 months, the patient recovered well. She died 2 years later from a cerebral haemorrhage.

Abscess↗