Interobserver variability in the classification of appendicitis during laparoscopy.

BACKGROUND: The intraoperative classification of appendicitis dictates the patient's postoperative management. Prolonged antibiotic prophylaxis is recommended for complex appendicitis (gangrenous, perforated, abscess), whereas preoperative prophylaxis suffices for simple appendicitis. Distinguishing these two conditions can be challenging. The aim of this study was to assess interobserver variability in the classification of appendicitis during laparoscopy. METHODS: Short video recordings taken during laparoscopy for suspected appendicitis were shown to surgeons and surgical residents. They were asked to: classify the appendix as indicative of no, simple or complex appendicitis; categorize the appendix as normal, phlegmonous, gangrenous, perforated and/or abscess; and decide whether they would prescribe postoperative antibiotics. Inter-rater reliability was evaluated using Fleiss' κ score and the S* statistic. RESULTS: Some 80 assessors participated in the study. Video recordings of 20 patients were used. Interobserver agreement was minimal for both the classification of appendicitis (κ score 0·398, 95 per cent c.i. 0·385 to 0·410) and the decision to prescribe postoperative antibiotic treatment (κ score 0·378, 0·362 to 0·393). Agreement was slightly higher when published criteria were applied (κ score 0·552, 0·537 to 0·568). CONCLUSION: There is considerable variability in the intraoperative classification of appendicitis and the decision to prescribe postoperative antibiotic treatment.

The impact of disease severity, age and surgical approach on the outcome of acute appendicitis in children.

PURPOSE: Although a national guideline has been implemented, the optimal approach for appendectomy in children remains subject of debate in the Netherlands. Opponents of laparoscopy raise their concerns regarding its use in complex appendicitis as it is reported to be associated with an increased incidence of intra-abdominal abscesses. The aim of this study was to evaluate the outcome of surgical approaches in both simple and complex appendicitis in paediatric patients. METHODS: A 10-year retrospective cohort study was performed (2001-2010) in paediatric patients treated for suspected acute appendicitis. Patients were divided into either simple or complex appendicitis and into different age groups. Primary outcome parameters were complication rate (intra-abdominal abscess (IAA), superficial surgical site infection (SSI) and readmission) and hospital stay. RESULTS: In total, 878 patients have been treated (median age 12, range 0-17 years). Two-thirds of the patients younger than 6 years had complex appendicitis, compared to one quarter in the group aged 13-18. In the complex appendicitis group, LA was associated with more IAA and early readmissions. In the simple appendicitis group, the complication rate was comparable between the two approaches. Significantly more IAAs were seen after LA in the youngest age group. CONCLUSION: This study demonstrates the unfavourable outcome of LA in the youngest age group and in patients with complex appendicitis. Therefore, we advise to treat these patients with an open approach.

Transanal endoscopic microsurgery is superior to transanal excision of rectal adenomas.

AIM: Comparison of transanal excision (TE) and transanal endoscopic microsurgery (TEM) of rectal adenomas (RA) has rarely been performed. METHOD: From 1990 to 2007, the results of TE (43 RA) and TEM (216 RA) were compared. Rectal adenomas were matched for diameter and distance from the anal verge. RESULTS: Operation time was 47.5 min for TE and 35 min for TEM (P < 0.001). Morbidity was 10% after TE and 5.3% after TEM (P < 0.001). Negative resection margins were observed in 50% after TE and 88% after TEM (P < 0.001). Fragmentation of the excised specimen was observed in 23.8% after TE and 1.4% after TEM (P < 0.001). In cases of fragmentation, positive resection margins were observed more frequently. Recurrence was 28.7% after TE and 6.1% after TEM (P < 0.001). After TE, RA with a negative resection margin had a local recurrence rate of 0%, compared with 59.6% with a positive margin (P < 0.001), and after TEM these rates were 3.2 and 7.7% (P = 0.3), respectively. CONCLUSION: Transanal endoscopic microsurgery is superior to transanal excision of RA.

Do farmers reduce genetic diversity when they domesticate tropical trees? A case study from Amazonia.

Agroforestry ecosystems may be an important resource for conservation and sustainable use of tropical trees, but little is known of the genetic diversity they contain. Inga edulis, a widespread indigenous fruit tree in South America, is used as a model to assess the maintenance of genetic diversity in five planted vs. five natural stands in the Peruvian Amazon. Analysis of five SSR (simple sequence repeat) loci indicated lower allelic variation in planted stands [mean corrected allelic richness 31.3 (planted) and 39.3 (natural), P = 0.009]. Concerns regarding genetic erosion in planted Amazonian tree stands appear valid, although allelic variation on-farm is still relatively high.

[Replacement of the femoral head due to fracture of the hip: prognostic factors for the duration of hospitalisation, institutionalisation and mortality]. / Vervanging van de dijbeenkop wegens een heupfractuur; prognostische factoren voor opnameduur, opname in een verpleeg- of verzorgingshuis en sterfte.

OBJECTIVE: To identify preoperative factors affecting length of hospital stay, residential status and mortality after replacement of the femoral head for a hip fracture. DESIGN: Prospective. METHOD: Of the 146 consecutive patients who had hemiarthroplasty for a displaced femoral neck fracture in the period 1996-1998, data were recorded on age, sex, the residential situation, ambulation, ADL dependency, the presence of dementia and the classification according to the American Society of Anesthesiologists (ASA). The operations were carried out in the IJsselland Hospital, Capelle aan den IJssel, the Netherlands. The study was terminated in October 2001. With the aid of uni- and multivariate analysis, the relationship was determined between the pre-operative factors and the length of hospital stay, need for institutional care, and mortality within 3 years after the operation. RESULTS: The study population consisted of 146 patients: 33 men and 113 women with an average age of 82 years (range: 60-98). The length of hospital stay averaged 21 days (range: 2-98). Independent pre-operative predictors for a longer period of hospitalisation were ADL dependency (OR: 1.3; 95% CI: 1.1-15.2), residence at home (0.7; 0.6-0.8), and poor ambulation (1.1; 1.0-1.3). The predictors for permanent institutionalisation were: prior stay in an institution (4-7; 1.1-19.5) and the presence of dementia (3.9; 1.0-1.5). Compared to the general Dutch population of the same age and sex, there was a significant excess mortality during the 3 years after the operation and especially during the first 12 months. Unfavourable prognostic factors for mortality within 3 years after the operation were: poor ambulation before the fracture (3.1; 1.8-5.3), an ASA classification of 3 or 4 (2.0; 1.2-3.1) and an age over 80 years (2.0; 1.2-3.3). CONCLUSION: The risk factors for a longer stay in hospital, placement in an institution or decreased survival in patients who underwent hemiarthroplasty as part of the treatment of a hip fracture can already be identified at the time of admission. The patients with these risk factors should be given special attention during the period of hospitalisation and after-care.

Conservation genetics of bush mango from central/west Africa: implications from random amplified polymorphic DNA analysis.

Genetic variation was assessed in the two bush mango species, Irvingia gabonensis and I. wombolu, valuable multipurpose fruit trees from central and west Africa that are currently undergoing domestication. A total of 130 individuals sampled from Cameroon, Nigeria and Gabon were analysed using 74 random amplified polymorphic DNAs (RAPDs). Significant genetic integrity was found in the two morphologically similar species (among-species analysis of molecular variance [AMOVA] variance component 25.8%, P < 0.001), with no evidence of hybridization, even between individuals from areas of sympatry where hybridization was considered probable. Results suggest that large-scale transplantation of either species into new habitats will probably not lead to genetic introgression from or into the other species. Therefore, subsequent cultivation of the two species should not be hindered by this consideration, although further studies on the potential for hybridization/introgression between these species would be prudent. Significant genetic differentiation of both species (among-countries within species, nested AMOVA variance component 9.8%, P < 0.001) was observed over the sampled regions, and genetic similarity of samples decreased significantly with increasing geographical distance, according to number of alleles in common (NAC) analysis. 'Hot spots' of genetic diversity were found clustered in southern Nigeria and southern Cameroon for I. wombolu, and in southern Nigeria, southern Cameroon and central Gabon for I. gabonensis. The possible reasons for this distribution of genetic variation are discussed, but it may reflect evolutionary history, as these populations occur in areas of postulated Pleistocene refugia. The application of these results to domestication programmes and, in the light of extensive deforestation in the region, conservation approaches, is discussed.

Reintervention and mortality after infrainguinal reconstructive surgery for leg ischaemia.

BACKGROUND: Progression of atherosclerosis and graft-related complications are common indications for late vascular intervention. The aim of this study was to determine the cumulative risk of late reintervention or death after infrainguinal bypass grafting. METHODS: Some 205 consecutive patients with limb-threatening ischaemia were included. All data were recorded prospectively. The principal endpoint was reintervention for a graft-related complication or recurrent leg ischaemia. Mean follow-up was 3.3 years. Life-table and multivariate analyses were employed to estimate the cumulative risk of reintervention or death during follow-up and to assess factors influencing this risk. RESULTS: Beyond 30 days after insertion of the infrainguinal bypass, 67 patients (33 per cent) had 112 subsequent vascular interventions in the ipsilateral extremity. The cumulative reintervention rate was 25 per cent at 1 year and 40 per cent at 5 years. Poor run-off (P < 0.005) and prosthetic grafts (P < 0.001) were significant and independent risk factors. Long-term survival was poor and affected by the presence of diabetes (P < 0.01) and renal insufficiency (P < 0.01). CONCLUSION: Late reinterventions are common after infrainguinal bypass for limb-threatening ischaemia, and contribute to morbidity and discomfort. Such information is of particular relevance to patients in high-risk groups and should be explained as an integral part of informed consent.

Vascular morbidity and mortality during long-term follow-up in claudicants selected for peripheral bypass surgery.

OBJECTIVES: To identify claudicants at high risk (and low risk) of late vascular morbidity and mortality after peripheral bypass surgery. DESIGN: Prospective cohort study with mean follow-up of 8.6 years. PATIENTS: One-hundred and fifty-five claudicants selected for peripheral bypass surgery. Only three patients were lost to follow-up. End points were major vascular events, additional interventions, all-cause mortality, and functional outcome. RESULTS: Major vascular events occurred in 59 patients. Life-table analysis revealed an annual risk increase of 3.5%. Strong predictors were hypertension (hazard ratio (HR) 2.7; 95% confidence interval (CI) 1.5-4.8), diabetes (HR 2.4; 95% CI 1.0-5.4) and cardiac disease (HR 2.2; 95% CI 1.2-4.0). Sixty patients needed additional interventions with a highest incidence (17%) in the first year, and thereafter 2.8% each year. None of the known risk factors were associated with an altered incidence of interventions. Approximately 3.5% of patients died per year compared with 2% per year in the control group. Prominent high-risk factors for mortality were cardiac disease (HR 3.3; 95% CI 1.8-6.0) and diabetes (HR 3.0; 95% CI 1.5-7.1). CONCLUSION: Major vascular events and additional interventions are common and serious in claudicants. However, it is possible to select low-risk patients in which peripheral bypass surgery is justified.

Ruptured popliteal artery aneurysm. An insidious complication.

OBJECTIVES: To evaluate the incidence and clinical presentation of ruptured popliteal aneurysms. METHODS: The records of 89 consecutive patients, all males, seen between 1958 and 1995 with 124 arteriosclerotic popliteal aneurysms were reviewed retrospectively. Most aneurysms were symptomatic (69/124; 55.6%). In six cases (6/124; 4.8%) a rupture was present. RESULTS: There was a wide range in primary diagnosis varying from deep venous thrombosis to peroneal nerve palsy. In all cases primary reconstructive surgery was performed. No primary or secondary amputations were necessary. Surgical outcome was good in four cases. In the remaining cases one patient suffered from a permanent peroneal nerve palsy and one from non-disabling claudication. Review of the literature showed a rupture incidence of 2.5% (range 0-16%) and amputation rates as high as 100%. CONCLUSION: An acute rupture of a popliteal aneurysm is rare. Although the clinical presentation can be non-specific, this possibility must be especially taken into account when dealing with older male patients presenting with signs and symptoms of generalised atherosclerosis and non-specific pain in the popliteal region.

Atherosclerotic popliteal aneurysm.

BACKGROUND: A popliteal artery aneurysm (PAA) has been described as a 'sinister harbinger of sudden catastrophe'. This review seeks to provide data regarding the epidemiological aspects, natural history, clinical presentation and results of treatment to help clinicians make appropriate decisions. METHODS: A systematic review of data in the English language literature published since 1980. RESULTS: The authors include 29 studies containing 1673 patients with 2445 PAAs. No controlled trials exist regarding the management of PAAs. CONCLUSION: (1) At most, only four or five patients are seen each year by a major vascular centre; (2) aortic aneurysms are found in 37 per cent and bilateral PAAs in 50 per cent of patients; (3) more than 95 per cent of patients are men with a mean age of 65 years and 45 per cent have hypertension; (4) approximately one-third of patients are asymptomatic at the time of initial diagnosis; (5) the risk of ischaemic complications after conservative follow-up varies from 8 to 100 per cent (mean 36 per cent), depending on the selection of patients and duration of follow-up; (6) elective surgical reconstruction is recommended for all asymptomatic aneurysms; (7) 5-year graft patency rates after surgical repair range from 29 to 100 per cent, with 5-year limb salvage ranging from 75 to 98 per cent; (8) patient survival rates at 5 and 10 years are 70 and 44 per cent respectively; (9) lifelong, careful patient surveillance is essential to detect and treat new aneurysms at other sites.

Accuracy and cost-effectiveness of exercise echocardiography for detection of coronary artery disease in patients with mitral valve prolapse.

Mitral valve prolapse is sometimes associated with chest pain, but this symptom may also be caused by coexisting coronary disease. The accuracy of exercise echocardiography in diagnosing coronary disease in these patients and the most cost-efficient diagnostic approach are unclear. We studied 96 patients (aged 59 +/- 12 years; 70 men) with mitral valve prolapse who underwent exercise electrocardiography, exercise echocardiography, and coronary angiography. The accuracies of seven diagnostic strategies based on the current and expected use of exercise electrocardiography and exercise echocardiography in patients with mitral valve prolapse were examined, with the costs calculated based on Medicare reimbursement. Thirteen (13.5%) patients had significant coronary artery disease. The sensitivity and specificity of exercise electrocardiography in the 71 patients with interpretable electrocardiograms were 50% and 72%, respectively. For the 73 patients who achieved >85% of maximal heart rate, 52 had interpretable exercise electrocardiograms (sensitivity 50%; specificity 69%). Exercise echocardiography had a sensitivity of 69% and a specificity of 98% in the 96 patients and a sensitivity of 82% and a specificity of 96% in patients who achieved >85% of maximal heart rate. Approaches adopting Bayes' theorem and restricting further investigation to patients with at least intermediate pretest probability of coronary disease were the least costly. When combined with exercise echocardiography as the initial test, clinical stratification was associated with a false-negative rate of 21%. The utility of exercise electrocardiography is limited by the high prevalence of resting electrocardiographic abnormalities and suboptimal sensitivity and specificity. The best balance of cost and diagnostic accuracy is to perform exercise echocardiography in patients with at least intermediate probability of coronary artery disease.

Detection and pattern of interspecific hybridization between Gliricida sepium and G. maculata in Meso-America revealed by PCR-based assays.

Gliricidia sepium provides a variety of products important for rural communities in tropical countries. Native populations in Meso-America currently form an important source of seed for distribution to farmers, but concerns centre on mechanisms which may lead to their genetic erosion, including anthropogenic dispersal and subsequent introgression from the related species, G. maculata. Populations of Gliricidia were examined genetically using approaches based on the polymerase chain reaction to test for interspecific hybridization and introgression between G. sepium and G. maculata. Analysis involved 13 RAPD and two RFLP-PCR markers which were identified to have species-diagnostic distributions. Data from both approaches corresponded and indicated three locations where multilocus genotypes were consistent with an hybrid origin. Data at one of these sites was consistent with introgression following hybridization. The hybrid origin of populations was supported by the intermediate geographical location of these sites to 'pure' populations of each species. Analysis of maternally inherited organellar DNA, which involved the detection of SSCPs in mitochondrial DNA amplification products, allowed further delineation of genetic structure among Gliricidia populations. Mitochondrial data indicated a high degree of organelle differentiation between sampled locations and identified G. sepium- and G. maculata-diagnostic haplotypes. This data supported the interpretation of genetic structure based on RAPDs and RFLP-PCR. In addition, cytonuclear analysis allowed the directionality of gene transfer during the formation of hybrid populations to be described. Despite evidence for the occurrence of interspecific hybridization and introgression in Gliricidia, important resource populations of G. sepium on the Pacific coast appear to have retained their genetic integrity. Implications in terms of the conservation and utilization of genetic resources within the genus are discussed.

The Drosophila cell cycle gene fizzy is required for normal degradation of cyclins A and B during mitosis and has homology to the CDC20 gene of Saccharomyces cerevisiae.

The Drosophila cell cycle gene fizzy (fzy) is required for normal execution of the metaphase-anaphase transition. We have cloned fzy, and confirmed this by P-element mediated germline transformation rescue. Sequence analysis predicts that fzy encodes a protein of 526 amino acids, the carboxy half of which has significant homology to the Saccharomyces cerevisiae cell cycle gene CDC20. A monoclonal antibody against fzy detects a single protein of the expected size, 59 kD, in embryonic extracts. In early embryos fzy is expressed in all proliferating tissues; in late embryos fzy expression declines in a tissue-specific manner correlated with cessation of cell division. During interphase fzy protein is present in the cytoplasm; while in mitosis fzy becomes ubiquitously distributed throughout the cell except for the area occupied by the chromosomes. The metaphase arrest phenotype caused by fzy mutations is associated with failure to degrade both mitotic cyclins A and B, and an enrichment of spindle microtubules at the expense of astral microtubules. Our data suggest that fzy function is required for normal cell cycle-regulated proteolysis that is necessary for successful progress through mitosis.

Late outcomes of limb loss after failed infrainguinal bypass.

PURPOSE: Most reports regarding infrainguinal bypass surgical procedures demonstrate benefits well but pay less attention to adverse outcomes and consequences of failure for the patient. For a wider scope of infrainguinal bypass surgical procedures, we evaluated patient-oriented outcomes of limb loss occurring after failed infrainguinal bypass operations. METHODS: Eighty-one patients with vascular amputations were identified in a retrospective study. Follow-up was complete with a mean of 3.6 years. Life-table and multivariate analyses were used to assess factors influencing the desired outcome goals of rehabilitation. Mortality rates, social function, risk of contralateral amputation, and the ability to walk were used to measure the late outcome. RESULTS: The long-term survival rate was poor (72% at 1 year; 53% at 3 years) and was not related to traditional risk factors for atherosclerosis. Moreover the risk for contralateral amputation was 10% per year. One year after amputation 81% (47 of 58) of the surviving amputees were walking independently, and 73% (42 of 58) were living at home, 32 with their spouse. At 3 years these results were 73% (27 of 37) and 78% (29 of 37), respectively. In addition, the level of self-care changed significantly (p < 0.001) after amputation. Advanced age (older than 65 years), self-care performance, and living with someone were important predictors of late outcome. CONCLUSIONS: It is possible for a high percentage of patients with vascular amputations to return home successfully, either walking or in a wheelchair. Moreover this result can be predicted based on preoperative clinical variables. These data may be helpful to guide fitting of prosthetic devices, planning of discharge home, and use of health care resources.

Diversity and genetic differentiation among subpopulations of Gliricidia sepium revealed by PCR-based assays.

Randomly amplified polymorphic DNA (RAPD), and a mitochondrial marker based on amplification of the V7 region of the mitochondrial small ribosomal RNA (srRNA) gene, were used to partition genetic variation within a single population of Gliricidia sepium sampled from Guatemala. Seventeen per cent of the variation detected with RAPDs was partitioned among subpopulations and indicated a greater level of discrimination than previously detected with isozymes. Cluster analysis indicated a direct relationship between this variation and the geographical distance between subpopulations. A polymorphism identified within the maternally inherited mitochondrial V7 srRNA product, which relied on digestion with restriction endonucleases, confirmed the genetic subdivision identified with RAPDs, and suggested a relatively limited role for seed in gene dispersal.