73 research outputs found
Twenty-Four Hour Tonometry in Patients Suspected of Chronic Gastrointestinal Ischemia
Background and aims: Gastrointestinal tonometry is currently the only clinical diagnostic test that enables identification of symptomatic chronic gastrointestinal ischemia. Gastric exercise tonometry has proven its value for detection of ischemia in this patients group, but has its disadvantages. Earlier studies with postprandial tonometry gave unreliable results. In this study we challenged (again) the use of postprandial tonometry in patients suspected of gastrointestinal ischemia. Methods: Patients suspected for chronic gastrointestinal ischemia had standard diagnostic work up, including gastric exercise tonometry and 24-h tonometry using standard meals. Results: Thirty-three patients were enrolled in the study. Chronic gastrointestinal ischemia was diagnosed in 17 (52%) patients. The 24-h tonometry correctly predicted the presence of ischemia in 13/17 patients, and absence of ischemia in 15/16 patients. Conclusions: The use of 24-h tonometry after meals in patients suspected of gastrointestinal ischemia seems feasible, with promising accuracy for the detection of ischemia
Quality of life temporarily improved in patients in whom the diagnosis chronic mesenteric ischemia wasn’t confirmed after multidisciplinary evaluation in a tertiary referral centre
Objectives: Chronic Mesenteric Ischemia (CMI) is a disease in which abdominal symptoms are caused by insufficient mesenteric blood supply. Treatment results in improved quality of life (QoL). To put these results into perspective, the QoL of patients with symptoms potentially complying with CMI but without confirmation of the diagnosis was studied from six months up to four years.Methods: Between May and July 2020 follow-up questionnaires were sent to 144 patients that were suspected of CMI but in whom the diagnosis was not confirmed after a thorough multidisciplinary evaluation in a CMI expert centre. The baseline QoL was measured at first presentation. Three cohorts were included: 50 patients with a follow-up of six months, 45 patients with a follow-up of two years, and 49 patients with a follow-up of four years were invited to participate. The QoL was measured on a 100 points Visual Analogue Scale (VAS). A minimal clinically important difference of 7.5 was used as non-inferiority threshold.Results: The response rates were 34/50 (68%), 33/45 (73%), and 34/49 (69%). QoL improved in the six months group, with a mean change of 19 in VAS score (95% CI 11-27), in which baseline QoL was inferior to the QoL at follow-up (lower bound 95% CI above >7.5 threshold). The change in QoL was inconclusive in the other two groups, respectively 15 (95% CI 6-24) and 3 (95% CI -6-13). Furthermore, there was no significant change in QoL between patients without mesenteric stenosis and with one or two vessel stenosis (P=0.36) and between patients with occlusive stenosis and anatomic Median Arcuate Ligament Syndrome (MALS) (P=0.53).Conclusion: The QoL of patients suspected for CMI was clinically significantly improved after six months without additional treatment. However, this improvement faded completely after four years
Non-classical clinical presentation at diagnosis by male celiac disease patients of older age
BACKGROUND: . In a biopsy-proven adult celiac disease (CeD) cohort from the Netherlands, male patients were diagnosed with CeD at significantly older ages than female patients. OBJECTIVES: To identify which factors contribute to diagnosis later in life and whether diagnostic delay influences improvement of symptoms after starting a gluten-free diet (GFD). METHODS: . We performed a questionnaire study in 211 CeD patients (67:144, male:female) with median age at diagnosis of 41.8 years (interquartile range: 25-58) and at least Marsh 2 histology. RESULTS: . Classical symptoms (diarrhea, fatigue, abdominal pain and/or weight loss) were more frequent in women than men, but sex was not significantly associated with age at diagnosis. In a multivariate analysis, a non-classical presentation (without any classical symptoms) and a negative family history of CeD were significant predictors of older age at diagnosis (coefficients of 8 and 12 years, respectively). A delay of >3 years between first symptom and diagnosis was associated with slower improvement of symptoms after start of GFD, but not with sex, presentation of classical symptoms or age at diagnosis. CONCLUSION: . Non-classical CeD presentation is more prevalent in men and is associated with a diagnosis of CeD later in life. Recognizing CeD sooner after onset of symptoms is important because a long diagnostic delay is associated with a slower improvement of symptoms after starting a GFD
Covered stents versus Bare-metal stents in c hronic atherosclerotic Gastrointestinal Ischemia (CoBaGI):study protocol for a randomized controlled trial
Background: Chronic mesenteric ischemia (CMI) is the result of insufficient blood supply to the gastrointestinal tract and is caused by atherosclerotic stenosis of one or more mesenteric arteries in > 90% of cases. Revascularization therapy is indicated in patients with a diagnosis of atherosclerotic CMI to relieve symptoms and to prevent acute-on-chronic mesenteric ischemia, which is associated with high morbidity and mortality. Endovascular therapy has rapidly evolved and has replaced surgery as the first choice of treatment in CMI. Bare-metal stents (BMS) are standard care currently, although retrospective studies suggested significantly higher patency rates for covered stents (CS). The Covered stents versus Bare-metal stents in chronic atherosclerotic Gastrointestinal Ischemia (CoBaGI) trial is designed to prospectively assess the patency of CS versus BMS in patients with atherosclerotic CMI.Methods/design: The CoBaGI trial is a randomized controlled, parallel-group, patient-and investigator-blinded, superiority, multicenter trial conducted in six centers of the Dutch Mesenteric Ischemia Study group (DMIS). Eighty-four patients with a consensus diagnosis of atherosclerotic CMI are 1:1 randomized to either a balloon-expandable BMS (Palmaz Blue with rapid-exchange delivery system, Cordis Corporation, Bridgewater, NJ, USA) or a balloon-expandable CS (Advanta V12 over-the-wire, Atrium Maquet Getinge Group, Hudson, NH, USA). The primary endpoint is the primary stent-patency rate at 24 months assessed with CT angiography. Secondary endpoints are primary stent patency at 6 and 12 months and secondary patency rates, freedom from restenosis, freedom from symptom recurrence, freedom from re-intervention, quality of life according the EQ-5D-5 L and SF-36 and cost-effectiveness at 6, 12 and 24 months.Discussion: The CoBaGI trial is designed to assess the patency rates of CS versus BMS in patients treated for CMI caused by atherosclerotic mesenteric stenosis. Furthermore, the CoBaGI trial should provide insights in the quality of life of these patients before and after stenting and its cost-effectiveness. The CoBaGI trial is the first randomized controlled trial performed in CMI caused by atherosclerotic mesenteric artery stenosis.</p
Cure of Helicobacter pylori infection in patients with reflux oesophagitis treated with long term omeprazole reverses gastritis without exacerbation of reflux disease: results of a randomised controlled trial
BACKGROUND: Helicobacter pylori gastritis may progress to glandular
atrophy and intestinal metaplasia, conditions that predispose to gastric
cancer. Profound suppression of gastric acid is associated with increased
severity of H pylori gastritis. This prospective randomised study aimed to
investigate whether H pylori eradication can influence gastritis and its
sequelae during long term omeprazole therapy for gastro-oesophageal reflux
disease (GORD). METHODS: A total of 231 H pylori positive GORD patients
who had been treated for > or =12 months with omeprazole maintenance
therapy (OM) were randomised to either continuation of OM (OM only; n =
120) or OM plus a one week course of omeprazole, amoxycillin, and
clarithromycin (OM triple; n = 111). Endoscopy with standardised biopsy
sampling as well as symptom evaluation were performed at baseline and
after one and two years. Gastritis was assessed according to the Sydney
classification system for activity, inflammation, atrophy, intestinal
metaplasia, and H pylori density. RESULTS: Corpus gastritis activity at
entry was moderate or severe in 50% and 55% of the OM only and OM triple
groups, respectively. In the OM triple group, H pylori was eradicated in
90 (88%) patients, and activity and inflammation decreased substantially
in both the antrum and corpus (p<0.001, baseline v two years). Atrophic
gastritis also improved in the corpus (p<0.001) but not in the antrum. In
the 83 OM only patients with continuing infection, there was no change in
antral and corpus gastritis activity or atrophy, but inflammation
increased (p<0.01). H pylori eradication did not alter the dose of
omeprazole required, or reflux symptoms. CONCLUSIONS: Most H pylori
positive GORD patients have a corpus predominant pangastritis during
omeprazole maintenance therapy. Eradication of H pylori eliminates gastric
mucosal inflammation and induces regression of corpus glandular atrophy. H
pylori eradication did not worsen reflux disease or lead to a need for
increased omeprazole maintenance dose. We therefore recommend eradication
of H pylori in GORD patients receiving long term acid suppression
The Incidence of Chronic Mesenteric Ischemia in the Well-Defined Region of a Dutch Mesenteric Ischemia Expert Center
INTRODUCTION: This study aimed to determine the incidence of chronic mesenteric ischemia (CMI) and to examine the
influence of the etiological cause, location, and severity of a mesenteric artery stenosis on the
probability of having CMI.
METHODS: A prospective database, containing the details of all patients with suspected CMI referred to a renowned
CMI expert center, was used. Patients residing within the expert centers’ well-defined region, between
January 2014 and October 2019, were included. CMI was diagnosed when patients experienced
sustained symptom improvement after treatment.
RESULTS: This study included 358 patients, 75 had a ‡50% atherosclerotic stenosis of 1 vessel (CMI 16%), 96 of
2 or 3 vessels (CMI 81%), 81 celiac artery compression (CMI 25%), and 84 no stenosis (CMI 12%). In
total, 138 patients were diagnosed with CMI, rendering a mean incidence of 9.2 (95% confidence
interval [CI] 6.2–13.7) per 100,000 inhabitants. Atherosclerotic CMI was most common, with a mean
incidence of 7.2 (95% CI 4.6–11.3), followed by median arcuate ligament syndrome 1.3 (95% CI
0.5–3.6) and chronic nonocclusive mesenteric ischemia 0.6 (95% CI 0.2–2.6). The incidence of CMI
was highest in female patients (female patients 12.0 [95% CI 7.3–19.6] vs male patients 6.5 [95% CI
3.4–12.5]) and increased with age. CMI was more prevalent in the presence of a ‡70% atherosclerotic
single-vessel stenosis of the superior mesenteric artery (40.6%) than the celiac artery (5.6%).
DISCUSSION: The incidence of CMI is higher than previously believed and increases with age. Probability of CMI
seems highest in suspected CMI patients with multivessel disease or a ‡70% atherosclerotic singlevessel superior mesenteric artery stenosis
Triggering for Submaximal Exercise Level in Gastric Exercise Tonometry: Serial Lactate, Heart Rate, or Respiratory Quotient?
European guidelines on chronic mesenteric ischaemia - joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia
Chronic mesenteric ischaemia is a severe and incapacitating disease, causing complaints of post-prandial pain, fear of eating and weight loss. Even though chronic mesenteric ischaemia may progress to acute mesenteric ischaemia, chronic mesenteric ischaemia remains an underappreciated and undertreated disease entity. Probable explanations are the lack of knowledge and awareness among physicians and the lack of a gold standard diagnostic test. The underappreciation of this disease results in diagnostic delays, underdiagnosis and undertreating of patients with chronic mesenteric ischaemia, potentially resulting in fatal acute mesenteric ischaemia. This guideline provides a comprehensive overview and repository of the current evidence and multidisciplinary expert agreement on pertinent issues regarding diagnosis and treatment, and provides guidance in the multidisciplinary field of chronic mesenteric ischaemia
Development and measurement of guidelines-based quality indicators of caesarean section care in the Netherlands: A RAND-modified delphi procedure and retrospective medical chart review
Background
There is an ongoing discussion on the rising CS rate worldwide. Suboptimal guideline adherence may be an important contributor to this rise. Before improvement of care can be established, optimal CS care in different settings has to be defined. This study aimed to develop and measure quality indicators to determine guideline adherence and identify target groups for improvement of care with direct effect on caesarean section (CS) rates.
Method
Eighteen obstetricians and midwives participated in an expert panel for systematic CS quality indicator development according to the RAND-modified Delphi method. A multi-center study was performed and medical charts of 1024 women with a CS and a stratified and weighted randomly selected group of 1036 women with a vaginal delivery were analysed. Quality indicator frequency and adherence were scored in 2060 women with a CS or vaginal delivery.
Results
The expert panel developed 16 indicators on planned CS and 11 indicators on unplanned CS. Indicator adherence was calculated, defined as the number of women in a specific obstetrical situation in which care was performed as recommended in both planned and unplanned CS settings. The most frequently occurring obstetrical situations with low indicator adherence were: 1) suspected fetal distress (frequency 17%, adh
Fluid hydration to prevent post-ERCP pancreatitis in average- to high-risk patients receiving prophylactic rectal NSAIDs (FLUYT trial): Study protocol for a randomized controlled trial
Background: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common complication of ERCP and may run a severe course. Evidence suggests that vigorous periprocedural hydration can prevent PEP, but studies to date have significant methodological drawbacks. Importantly, evidence for its added value in patients already receiving prophylactic rectal non-steroidal anti-inflammatory drugs (NSAIDs) is lacking and the cost-effectiveness of the approach has not been investigated. We hypothesize that combination therapy of rectal NSAIDs and periprocedural hydration would significantly lower the incidence of post-ERCP pancreatitis compared to rectal NSAIDs alone in moderate- to high-risk patients undergoing ERCP. Methods: The FLUYT trial is a multicenter, parallel group, open label, superiority randomized controlled trial. A total of 826 moderate- to high-risk patients undergoing ERCP that receive prophylactic rectal NSAIDs will be randomized to a control group (no fluids or normal saline with a maximum of 1.5 mL/kg/h and 3 L/24 h) or intervention group (lactated Ringer's solution with 20 mL/kg over 60 min at start of ERCP, followed by 3 mL/kg/h for 8 h thereafter). The primary endpoint is the incidence of post-ERCP pancreatitis. Secondary endpoints include PEP severity, hydration-related complications, and cost-effectiveness. Discussion: The FLUYT trial design, including hydration schedule, fluid type, and sample size, maximize its power of identifying a potential difference in post-ERCP pancreatitis incidence in patients receiving prophylactic rectal NSAIDs
- …