Minder onterechte appendectomie door echografie en CT

To evaluate the effect of the use of ultrasonography (US) and optional computed tomography (CT) or diagnostic laparoscopy on the percentage of unnecessary appendectomies in patients with suspected acute appendicitis. Prospective and comparison with a historical control group. Following the introduction of ultrasound imaging as an initial step, the outcomes in all patients presenting with suspected appendicitis in the emergency department were prospectively collected during a period of 18 months (July 2006-December 2007). Results were compared to retrospectively collected data on all patients who had undergone appendectomy for acute appendicitis in 2001, before the introduction of this imaging investigation. Of the 312 consecutive patients in the emergency department with suspected acute appendicitis, the condition was excluded in 51 patients following clinical and laboratory investigation. The diagnostic algorithm was applied in 239 of the 261 patients (92%). All of them had initial US, followed by additional CT in 75 patients (31%) and diagnostic laparoscopy in 12 patients (5%). Appendectomy was performed in 130 patients, and 8 (6%) of the appendices were shown to be healthy following pathological investigation. Before the implementation of preoperative imaging 36 of the 170 appendices (21%) were healthy. Following the introduction of imaging techniques in accordance with the guideline there was a significant reduction in the percentage of unnecessary appendectomies (21% versus 6%; p <0,001). The complete supplementary diagnostic algorithm had a positive and negative predictive value of respectively 90% and 98% for acute appendicitis. Structural implementation of US with optional CT and diagnostic laparoscopy in patients with suspected acute appendicitis resulted in a lower percentage of unnecessary appendectomie

Hospital referral of detainees during police custody in Amsterdam, The Netherlands

This study describes how many detainees have been referred to emergency departments for further evaluation or emergency care while in police custody in Amsterdam (years 2012/2013). It provides insights into the diagnoses assigned by forensic doctors and hospital specialists and the appropriateness of the referrals. We made use of the electronic registration system of the Forensic Medicine Department of the Public Health Service Amsterdam. This department is in charge of the medical care for detainees in the Amsterdam region. Hospital diagnoses were obtained through collaboration with several Amsterdam-based hospitals. According to our results, in 1.5% of all consultations performed, the detainee was referred to hospital. The most frequent reasons for referral were injuries (66%), intoxication/withdrawal (11%) and cardiac problems (7%). In 18% of all referrals, hospital admission (defined as at least one night in the hospital) was the consequence. After review of hospital files, the indication for referral as stated by the forensic physician was confirmed in 77% of all cases. A minority of referrals was considered unnecessary (7%). The identified cases allow for a discussion of cases of over-referral. Future research should focus on the problem of under-referral and associated health risks

The role of plain radiographs in patients with acute abdominal pain at the ED

Item does not contain fulltextOBJECTIVE: The purpose of this study was to evaluate the added value of plain radiographs on top of clinical assessment in unselected patients presenting with acute abdominal pain at the emergency department (ED). METHODS: In a multicenter prospective trial, patients with abdominal pain more than 2 hours and less than 5 days presented at the ED were evaluated clinically, and a diagnosis was made by the treating physician. Subsequently, all patients underwent supine abdominal and upright chest radiographs, after which the diagnosis was reassessed by the treating physician. A final (reference) diagnosis was assigned by an expert panel. The number of changes in the primary diagnosis, as well as the accuracy of these changes, was calculated. Changes in the level of confidence were evaluated for unchanged diagnoses. RESULTS: Between March 2005 and November 2006, 1021 patients, 55% female, mean age 47 years (range, 19-94 years), were included. In 117 of 1021 patients, the diagnosis changed after plain radiographs, and this change was correct in 39 patients (22% of changed diagnoses and 4% of total study population). Overall, the clinical diagnosis was correct in 502 (49%) patients. The diagnosis after evaluation of the radiographs was correct in 514 (50%) patients, a nonsignificant difference (P = .14). In 65% of patients with unchanged diagnosis before and after plain radiography, the level of confidence of that diagnosis did not change either. CONCLUSION: The added value of plain radiographs is too limited to advocate their routine use in the diagnostic workup of patients with acute abdominal pain, because few diagnoses change and the level of confidence were mostly not affected

Impact of secondary transfer on patients with severe traumatic brain injury

BACKGROUND: Within a trauma network in the Netherlands, neurosurgical facilities are usually limited to Level I hospitals. Initial transport to a district hospital of patients who are later found to require neurosurgical intervention may cause delay. The purpose of this study was to assess the influence on outcome and time intervals of secondary transfer in trauma patients requiring emergency neurosurgical intervention. METHODS: In a 3-year period, all patients who sustained a severe traumatic brain injury and underwent a neurosurgical intervention within 6 hours after admission to a Level I trauma center were included. Patients were classified into two groups: direct presentation to the Level I trauma center (TC) group or requiring secondary transport after having been diagnosed for neurosurgical intervention in other hospitals (transfer group). RESULTS: Eighty patients were included for analyses. Twenty-four patients in the transfer group had a better Glasgow Coma Scale on-scene but a higher 30-day mortality compared with patients who were primarily presented to the Level I trauma center (33% vs. 27%; p = 0.553). In the transfer group, time to operation was 304 minutes compared with 151 minutes in the TC group (p <0.001). Most delay occurred during the initial trauma evaluation and the interval between the first computed tomography and the transfer ambulance departure at the referring hospital. CONCLUSION: Patients requiring an emergency neurosurgical intervention appear to have a clinically relevant worse outcome after secondary transfer to a neurosurgical service. Therefore, patient care can probably be improved by better triage on-scene and standardized procedures in case of a secondary transfer. (J Trauma. 2012; 72: 487-490. Copyright (C) 2012 by Lippincott Williams & Wilkins