Recurrent cholangitis in patients with a non-stenotic hepaticojejunostomy: incidence and risk factors.

BACKGROUND: Cholangitis is a well-known complication after hepaticojejunostomy (HJ), which is mainly caused by a stenotic anastomosis. However, the rate of cholangitis in patients with a non-stenotic (i.e. patent) HJ is unknown. We aimed to evaluate the incidence and risk factors of recurrent cholangitis in patients with a non-stenotic HJ. METHODS: This single-center retrospective cohort study included all consecutive patients who had undergone hepatobiliary or pancreatic (HPB) surgery requiring HJ (2015-2022). Primary outcome was recurrent non-stenotic cholangitis, risk factors for recurrent non-stenotic cholangitis were identified using logistic regression. RESULTS: Overall, 835 patients with a HJ were included of whom 31/698 (4.4%) patients developed recurrent cholangitis with a non-stenotic HJ during a median follow-up of 34 months (IQR 22-50) and 98/796 (12.3%) patients developed a symptomatic HJ stenosis. These 31 patients experienced 205 cholangitis episodes, median 7.0 (IQR 3.8-8.8) per patient, and 71/205 (34.6%) cholangitis episodes required hospitalization. Male sex (aOR 3.17 (95% CI: 1.34-7.49)) and benign disease (aOR 2.97, 95% CI 1.40-6.33) were identified as risk factors for recurrent cholangitis in non-stenotic HJ in both univariate and multivariable analysis. CONCLUSION: This study shows that 4% of patients developed recurrent cholangitis without an underlying HJ stenosis.

Assessment of renal sympathetic control using invasive pressure and flow velocity measurements in humans.

Renal sympathetic innervation is important in the control of renal and systemic hemodynamics and is a target for pharmacological and catheter-based therapies. The effect of a physiological sympathetic stimulus using static handgrip exercise on renal hemodynamics and intraglomerular pressure in humans is unknown. We recorded renal arterial pressure and flow velocity in patients with a clinical indication for coronary or peripheral angiography using a sensor-equipped guidewire during baseline, handgrip, rest, and hyperemia following intrarenal dopamine (30 µg/kg). Changes in perfusion pressure were expressed as the change in mean arterial pressure, and changes in flow were expressed as a percentage with respect to baseline. Intraglomerular pressure was estimated using a Windkessel model. A total of 18 patients (61% male and 39% female) with a median age of 57 yr (range: 27-85 yr) with successful measurements were included. During static handgrip, renal arterial pressure increased by 15.2 mmHg (range: 4.2-53.0 mmHg), whereas flow decreased by 11.2%, but with a large variation between individuals (range: -13.4 to 49.8). Intraglomerular pressure increased by 4.2 mmHg (range: -3.9 to 22.1 mmHg). Flow velocity under resting conditions remained stable, with a median of 100.6% (range: 82.3%-114.6%) compared with baseline. During hyperemia, maximal flow was 180% (range: 111%-281%), whereas intraglomerular pressure decreased by 9.6 mmHg (interquartile range: 4.8 to 13.9 mmHg). Changes in renal pressure and flow during handgrip exercise were significantly correlated (ρ = -0.68, P = 0.002). Measurement of renal arterial pressure and flow velocity during handgrip exercise allows the identification of patients with higher and lower sympathetic control of renal perfusion. This suggests that hemodynamic measurements may be useful to assess the response to therapeutic interventions aimed at altering renal sympathetic control.NEW & NOTEWORTHY Renal sympathetic innervation is important in the homeostasis of systemic and renal hemodynamics. We showed that renal arterial pressure significantly increased and that flow decreased during static handgrip exercise using direct renal arterial pressure and flow measurements in humans, but with a large difference between individuals. These findings may be useful for future studies aimed to assess the effect of interventions that influence renal sympathetic control.

Blood pressure and the risk of rebleeding and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.

INTRODUCTION AND OBJECTIVE: Blood pressure is presumably related to rebleeding and delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (aSAH) and could serve as a target to improve outcome. We assessed the associations between blood pressure and rebleeding or DCI in aSAH-patients. MATERIALS AND METHODS: In this observational study in 1167 aSAH-patients admitted to the intensive care unit (ICU), adjusted hazard ratio's (aHR) were calculated for the time-dependent association of blood pressure and rebleeding or DCI. The aHRs were presented graphically, relative to a reference mean arterial pressure (MAP) of 100 mmHg and systolic blood pressure (sBP) of 150 mmHg. RESULTS: A MAP below 100 mmHg in the 6, 3 and 1 h before each moment in time was associated with a decreased risk of rebleeding (e.g. within 6 h preceding rebleeding: MAP = 80 mmHg: aHR 0.30 (95% confidence interval (CI) 0.11-0.80)). A MAP below 60 mmHg in the 24 h before each moment in time was associated with an increased risk of DCI (e.g. MAP = 50 mmHg: aHR 2.59 (95% CI 1.12-5.96)). CONCLUSIONS: Our results suggest that a MAP below 100 mmHg is associated with decreased risk of rebleeding, and a MAP below 60 mmHg with increased risk of DCI.

Biliopancreatic and biliary leak after pancreatoduodenectomy treated by percutaneous transhepatic biliary drainage.

BACKGROUND: Complementary to percutaneous intra-abdominal drainage, percutaneous transhepatic biliary drainage (PTBD) might ameliorate healing of pancreatic fistula and biliary leakage after pancreatoduodenectomy by diversion of bile from the site of leakage. This study evaluated technical and clinical outcomes of PTBD for this indication. METHODS: All patients undergoing PTBD for leakage after pancreatoduodenectomy were retrospectively evaluated in two tertiary pancreatic centers (2014-2019). Technical success was defined as external biliary drainage. Clinical success was defined as discharge with a resolved leak, without additional surgical interventions for anastomotic leakage other than percutaneous intra-abdominal drainage. RESULTS: Following 822 pancreatoduodenectomies, 65 patients (8%) underwent PTBD. Indications were leakage of the pancreaticojejunostomy (n = 25; 38%), hepaticojejunostomy (n = 15; 23%) and of both (n = 25; 38%). PTBD was technically successful in 64 patients (98%) with drain revision in 40 patients (63%). Clinical success occurred in 60 patients (94%). Leakage resolved after median 33 days (IQR 21-60). PTBD related complications occurred in 23 patients (35%), including cholangitis (n = 14; 21%), hemobilia (n = 7; 11%) and PTBD related bleeding requiring re-intervention (n = 4; 6%). In hospital mortality was 3% (n = 2). CONCLUSION: Although drain revisions and complications are common, PTBD is highly feasible and appears to be effective in the treatment of biliopancreatic leakage after pancreatoduodenectomy.

Pregnancy in women with an inferior vena cava filter: a tertiary center experience and overview of the literature.

Patients with an inferior vena cava (IVC) filter that remains in situ encounter a lifelong increased risk of deep vein thrombosis and IVC filter complications including fracture, perforation, and IVC filter thrombotic occlusion. Data on the safety of becoming pregnant with an in situ IVC filter are scarce. The objective was to evaluate the risk of complications of in situ IVC filters during pregnancy. We performed a retrospective cohort study of pregnant patients with an in situ IVC filter from a tertiary center between 2000 and 2020. We collected data on complications of IVC filters and pregnancy outcomes. Additionally, we performed a systematic literature search in MEDLINE, Embase, and gray literature. We identified 7 pregnancies in 4 patients with in situ IVC filters with a mean time since IVC filter insertion of 3 years (range, 1-8). No complications of IVC filter occurred during pregnancy. Review of literature yielded five studies including 13 pregnancies in 9 patients. In 1 pregnancy a pre-existent, until then asymptomatic, chronic perforation of the vena cava wall by the IVC filter caused major bleeding and uterine trauma with fetal loss. Overall, the complication rate was 5%. It seems safe to become pregnant with an indwelling IVC filter that is intact and does not show signs of perforation, but because of the low number of cases, no firm conclusions about safety of in situ IVC filters during pregnancy can be drawn. We suggest imaging before pregnancy to reveal asymptomatic IVC filter complications.

Treatment of symptomatic postoperative pelvic lymphoceles: A systematic review.

PURPOSE: A broad range of therapeutic options exists for symptomatic postoperative lymphoceles. However, no consensus exists on what is the optimal therapy. In this study, we aimed to compare the efficacy of currently available radiologic interventions in terms of number of successful interventions, number of recurrences, and number of complications. METHODS: A systematic review was conducted with a pre-defined search strategy for PubMed, EMBASE, and Cochrane databases from inception until September 2019. Quality assessment was performed using the 'Risk Of Bias In Non-randomized Studies - of Interventions' tool. Statistical heterogeneity was assessed using the I2 and χ2 test and a meta-analysis was considered for studies reporting on multiple interventions. RESULTS: 37 eligible studies including 732 lymphoceles were identified. Proportions of successful interventions for percutaneous fine needle aspiration, percutaneous catheter drainage, percutaneous catheter drainage with delayed or instantaneous addition of sclerotherapy, and embolization were as follows: 0.341 (95% confidence interval [CI]: 0.185-0.542), 0.612 (95% CI: 0.490-0.722), 0.890 (95% CI: 0.781-0.948), 0.872 (95% CI: 0.710-0.949), 0.922 (95% CI: 0.731-0.981). Random-effects meta-analysis of seven studies revealed a pooled relative risk for percutaneous catheter drainage with delayed addition of sclerotherapy of 1.57 (95% CI: 1.17-2.10) when compared to percutaneous catheter drainage alone. The risk of bias in this study was severe. CONCLUSIONS: This systematic review demonstrates that the success rates of percutaneous catheter drainage with sclerotherapy are more favorable when compared to percutaneous catheter drainage alone in the treatment of postoperative pelvic lymphoceles. Overall, percutaneous catheter drainage with delayed addition of sclerotherapy, and embolization showed the best outcomes.

Impaired lymph node stromal cell function during the earliest phases of rheumatoid arthritis.

BACKGROUND: Systemic autoimmunity can be present years before clinical onset of rheumatoid arthritis (RA). Adaptive immunity is initiated in lymphoid tissue where lymph node stromal cells (LNSCs) regulate immune responses through their intimate connection with leucocytes. We postulate that malfunctioning of LNSCs creates a microenvironment in which normal immune responses are not properly controlled, possibly leading to autoimmune disease. In this study we established an experimental model for studying the functional capacities of human LNSCs during RA development. METHODS: Twenty-four patients with RA, 23 individuals positive for autoantibodies but without clinical disease (RA risk group) and 14 seronegative healthy control subjects underwent ultrasound-guided inguinal lymph node (LN) biopsy. Human LNSCs were isolated and expanded in vitro for functional analyses. In analogous co-cultures consisting of LNSCs and peripheral blood mononuclear cells, αCD3/αCD28-induced T-cell proliferation was measured using carboxyfluorescein diacetate succinimidyl ester dilution. RESULTS: Fibroblast-like cells expanded from the LN biopsy comprised of fibroblastic reticular cells (gp38+CD31-) and double-negative (gp38-CD31-) cells. Cultured LNSCs stably expressed characteristic adhesion molecules and cytokines. Basal expression of C-X-C motif chemokine ligand 12 (CXCL12) was lower in LNSCs from RA risk individuals than in those from healthy control subjects. Key LN chemokines C-C motif chemokine ligand (CCL19), CCL21 and CXCL13 were induced in LNSCs upon stimulation with tumour necrosis factor-α and lymphotoxin α1ß2, but to a lesser extent in LNSCs from patients with RA. The effect of human LNSCs on T-cell proliferation was ratio-dependent and altered in RA LNSCs. CONCLUSIONS: Overall, we developed an experimental model to facilitate research on the role of LNSCs during the earliest phases of RA. Using this innovative model, we show, for the first time to our knowledge, that the LN stromal environment is changed during the earliest phases of RA, probably contributing to deregulated immune responses early in disease pathogenesis.

High-Dose Nadroparin Following Endovascular Aneurysm Treatment Benefits Outcome After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Delayed cerebral ischemia (DCI) is one of the major causes of delayed morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE: To evaluate the effect of high-dose nadroparin treatment following endovascular aneurysm treatment on the occurrence of DCI and clinical outcome. METHODS: Medical records of 158 adult patients with an aSAH were retrospectively analyzed. Those patients treated endovascularly for their ruptured aneurysm were included in this study. They received either high-dose (twice daily 5700 AxaIE) or low-dose (once daily 2850 AxaIE) nadroparin treatment after occlusion of the aneurysm. Medical charts were reviewed and imaging was scored by 2 independent neuroradiologists. Data with respect to in-hospital complications, peri-procedural complications, discharge location, and mortality were collected. RESULTS: Ninety-three patients had received high-dose nadroparin, and 65 patients prophylactic low-dose nadroparin. There was no significant difference in clinical DCI occurrence between patients treated with high-dose (34%) and low-dose (31%) nadroparin. More patients were discharged to home in patients who received high-dose nadroparin (40%) compared to low-dose (17%; odds ratio [OR] 3.13, 95% confidence interval [95% CI]: 1.36-7.24). Furthermore, mortality was lower in the high-dose group (5%) compared to the low-dose group (23%; OR 0.19, 95% CI: 0.07-0.55), also after adjusting for neurological status on admission (OR 0.21, 95% CI: 0.07-0.63). CONCLUSION: Patients who were treated with high-dose nadroparin after endovascular treatment for aneurysmal SAH were more often discharged to home and showed lower mortality. High-dose nadroparin did not, however, show a decrease in the occurrence of clinical DCI after aSAH. A randomized controlled trial seems warranted.

Coiling and clipping of middle cerebral artery aneurysms: a systematic review on clinical and imaging outcome.

BACKGROUND: There is an ongoing debate on the preferred treatment of middle cerebral artery (MCA) aneurysms. The purpose of this study was to assess the clinical and imaging outcomes comparing conventional coiling and clipping of unruptured and ruptured MCA aneurysms. METHODS: We searched the electronic databases PubMed, EMBASE, and Cochrane from January 1990 to May 2014. RESULTS: 51 studies were included in the analysis. Favorable outcome was reported in 97.0% and 77.1%, and in 97.2% and 72.8% of patients after coiling and clipping of unruptured and ruptured aneurysms, respectively. Death rates were 1.1% and 8.4% after coiling and 0.3% and 14.7% after clipping of unruptured and ruptured aneurysms, respectively. Initial adequate occlusion was obtained in 89.6% and 92.1% after coiling of unruptured and ruptured aneurysms, respectively. Only three studies on clipping reported on aneurysm occlusion during follow-up. CONCLUSIONS: Both coiling and clipping are procedures with low mortality and morbidity rates and, although it may seem that coiling is better for ruptured aneurysms and clipping for unruptured aneurysms, no firm conclusions can be drawn due to the variation in study design and lack of standardized reporting on MCA aneurysm treatments. Standardized observational studies from prospectively kept databases are needed to allow stronger conclusions to be drawn on what is the best treatment for MCA aneurysms. Comparable with aneurysms in other locations, a multidisciplinary approach is therefore recommended with selection of treatment modality based on the clinical condition of the patient and the morphological aspects of the aneurysm.

Predicting the need for abdominal hemorrhage control in major pelvic fracture patients: the importance of quantifying the amount of free fluid.

BACKGROUND: In our institution, the computed tomographic (CT) scan has largely replaced the ultrasound for the rapid detection of intraperitoneal free fluid (FF) and abdominal injuries in severely injured patients.We hypothesized that in major pelvic fracture patients, quantifying the size of FF on CT improves the predictive value for the need for abdominal hemorrhage control (AHC). METHODS: The CT scans of major pelvic fracture (pelvic ring disruption) patients (January 1, 2004, to June 31, 2012) were reviewed for the presence of FF (small, moderate, or large amount) and abdominal injuries. AHC was defined as requiring a surgical intervention for active abdominal bleeding or angiographic embolization for an abdominal arterial injury.Positive predictive value (PPV) and negative predictive value (NPV) (95% confidence interval [CI]) were calculated for all patients and in a subgroup of patients with a high risk for significant hemorrhage (base deficit ≥ 6 mEq/L). RESULTS: Overall, 160 patients were included in the study. Of the 62 FF patients, 26 required AHC (PPV, 42%, 95% CI, 30-55%). Of the 98 patients without FF, none required AHC (NPV, 100%; 95% CI, 95-100%). For a moderate-to-large amount of FF, the PPV and NPV in all patients were 81% (95% CI, 60-93%) and 96% (95% CI, 91-99%), respectively.In the subgroup of 49 high-risk patients (31%), 17 of 26 FF patients required AHC (PPV, 65%; 95% CI, 44-82%), and none of the 23 patients without FF required AHC (NPV, 100%; 95% CI, 82-100%). For a moderate-to-large amount, the PPV and NPV in high-risk patients were 93% (95% CI, 64-100%) and 89% (95% CI, 72-96%), respectively. CONCLUSION: In major pelvic fracture patients, the predictive value of FF on CT for the need for AHC is closely related to the amount present. A moderate-to-large amount of FF is highly predictive for the presence of abdominal bleeding that requires hemorrhage control. LEVEL OF EVIDENCE: Therapeutic study, level IV; prognostic study, level III.

Management of pelvic ring fracture patients with a pelvic "blush" on early computed tomography.

BACKGROUND: The sliding computed tomographic (CT) scanner in our trauma resuscitation room can be used early in the assessment of pelvic ring fracture patients. We determined the association between the presence of a pelvic blush on CT scan and the need for pelvic hemorrhage control (PHC). We hypothesized that many pelvic blushes found early in the resuscitation phase can be safely managed without intervention. METHODS: Contrast-enhanced CT scans of pelvic ring fracture (pelvic ring disruption) patients admitted from January 1, 2004, to June 31, 2012, were reviewed for the presence of a pelvic blush. PHC was defined as requiring a surgical or radiologic intervention for pelvic bleeding. A subanalysis was performed in "isolated" pelvic fracture/ blush patients (absence of a major nonpelvic bleeding source). RESULTS: Overall, 68 (42%) of 162 pelvic ring fracture patients and 53 (40%) of 134 isolated pelvic fracture patients had a pelvic blush. Of those 32 (47%) and 27 (51%) patients, respectively, required PHC. In the absence of a pelvic blush, 87 (93%) of 94 of all and 77 (95%) of 81 of isolated pelvic fracture patients did not require PHC. Of all patients with a pelvic blush and of isolated pelvic blush, those with PHC had a higher Injury Severity Score (ISS) (p = 0.01 and p = 0.05), base deficit (p = 0.03 and p = 0.01), as well as 24-hour and any packed red blood cells requirement (p <0.001 and p = 0.05; p <0.001 and p = 0.02). In isolated pelvic blush patients, there was a trend toward a higher hospital and hemorrhage-related mortality in patients with PHC (p = 0.06 and p = 0.06). CONCLUSION: In pelvic ring fracture patients, a pelvic blush on early contrast-enhanced CT is a frequent finding. Many patients with (particularly isolated) pelvic blushes have stable vital signs and can be managed without surgical or radiologic PHC. The need for an intervention for a pelvic blush seems to be determined by the presence of clinical signs of ongoing bleeding. LEVEL OF EVIDENCE: Therapeutic study, level IV. Prognostic/epidemiologic study, level III.

The utility of FAST for initial abdominal screening of major pelvic fracture patients.

BACKGROUND: Focused Assessment with Sonography for Trauma (FAST) is widely used in pelvic fracture patients. We examined the performance of FAST for detecting hemoperitoneum and predicting the need for intra-abdominal hemorrhage control in major pelvic fracture patients. METHODS: A 5-year retrospective study of major pelvic fracture patients was performed. The presence of hemoperitoneum was confirmed on CT or at laparotomy. The need for hemorrhage control was defined as requiring a surgical or radiological intervention for intra-abdominal bleeding. Hemorrhagic shock (HS) patients had a systolic blood pressure ≤ 90 mmHg or base deficit of ≥ 6 mEq/L on admission. RESULTS: A total of 120 patients were included, 42 (35 %) of which had any hemoperitoneum and 21 (18 %) had a moderate-large amount. The sensitivity, specificity, and positive and negative predictive values of FAST for any hemoperitoneum were 64, 94, 84, and 83 % and for a moderate-large amount they were 86, 86, 56, and 97 %. In HS patients the indices were 68, 93, 88, and 78 % for any hemoperitoneum and 79, 83, 65, and 91 % for a moderate-large amount. For the need for hemorrhage control, FAST had a positive predictive value of 50 % (16/32) in all and 71 % (12/17) in HS patients. The negative predictive value was 99 % (87/88) in all and 97 % (31/32) in HS patients. CONCLUSION: FAST had a good to excellent diagnostic accuracy, depending on the size of hemoperitoneum. A positive FAST result (even in HS patients) does not reliably predict the need for immediate intra-abdominal hemorrhage control but a negative FAST result renders the need for an intervention highly unlikely.

Acute pulmonary embolism: effect of a computer-assisted detection prototype on diagnosis--an observer study.

PURPOSE: To assess the effect of a computer-assisted detection (CAD) prototype on observer performance for detection of acute pulmonary embolism (PE) with computed tomographic (CT) pulmonary angiography. MATERIALS AND METHODS: In this institutional review board-approved retrospective study, six observers with varying experience evaluated 158 PE-negative and 51 PE-positive CT pulmonary angiographic studies (mean age, 57 years; 111 women, 98 men) obtained consecutively during nights and weekends. Observers were asked to determine the presence of PE and to rank their diagnostic confidence without CAD and subsequently with CAD within a single reading session. Reading time was separately measured for both readings. Reader data were compared with an independent standard established by two readers, with a third in case of discordant results. Statistical evaluation was performed on a per-patient basis by using logistic regression for repeated measurements and Pearson correlation. RESULTS: With CAD, there was a significant increase in readers' sensitivity (P = .014) without loss of specificity (P = .853) on a per-patient basis. CAD assisted the readers in correcting an initial false-negative diagnosis in 15 cases, with the most proximal embolus at the segmental level in four cases and at the subsegmental level in 11 cases. In eight cases, readers accepted false-positive CAD candidate lesions on scans negative for PE, and in one case, a reader dismissed a true-positive finding. Reading time was extended by a mean of 22 seconds with the use of CAD. CONCLUSION: At the expense of increased reading time, CAD has the potential to increase reader sensitivity for detecting segmental and subsegmental PE without significant loss of specificity.

Evaluation of a standardized CT colonography training program for novice readers.

PURPOSE: To determine how many computed tomographic (CT) colonography training studies have to be evaluated by novice readers to obtain an adequate level of competence in polyp detection. MATERIALS AND METHODS: The study was approved by the Institutional Review Board. Informed consent was obtained from all participants. Six physicians (one radiologist, three radiology residents, two researchers) and three technicians completed a CT colonography training program. Two hundred CT colonographic examinations with colonoscopic verification were selected from a research database, with 100 CT colonographic examinations with at least one polyp 6 mm or larger. After a lecture session and short individual hands-on training, CT colonography training was done individually with immediate feedback of colonoscopy outcome. Per-polyp sensitivity was calculated for four sets of 50 CT colonographic examinations for lesions 6 mm or larger. By using logistic regression analyses, the number of CT colonographic examinations to reach 90% sensitivity for lesions 6 mm or larger was estimated. Reading times were registered. RESULTS: The average per-polyp sensitivity for lesions 6 mm or larger was 76% (207 of 270) in the first set of 50 CT colonographic examinations, 77% (262 of 342) in the second (P = .96 vs first set), 80% (310 of 387) in the third (P = .67 vs first set), and 91% (261 of 288) in the fourth (P = .018). The estimated number of CT colonographic examinations for a sufficient sensitivity was 164. Six of nine readers reached this level of competence within 175 CT colonographic examinations. Reading times decreased significantly from the first to the second set of 50 CT colonographic examinations for six readers. CONCLUSION: Novice CT colonography readers obtained sensitivity equal to that of experienced readers after practicing on average 164 CT colonographic studies.

Reliability and validity of the Buruli ulcer functional limitation score questionnaire.

The reliability and validity of the earlier developed Buruli ulcer functional limitation score (BUFLS) questionnaire was assessed. Of 638 former Buruli ulcer patients (of 678 individuals examined), sufficient items on daily activities (>or= 13 of the 19) were applicable to calculate a score. To determine the validity, the functional limitation scores of the 638 individuals were compared with the global impression of the limitations, range of motion (ROM), and the social impact (change of occupation or education) of Buruli ulcer. To determine inter-observer reliability, the functional limitation score was reassessed in 107 participants within one and three weeks after the first interview by another interviewer and interpreter. Both global impression and ROM correlated well with the functional limitation scores (rho = 0.66 and rho = 0.61). The inter-observer reliability of 107 participants as measured by an intra-class correlation coefficient of 0.86 was very good. The functional limitation scores measured in the second assessment were significantly higher than in the first assessment. This should be taken into account when the functional limitation score is used for the individual patient. The BUFLS can be used as for between group comparisons of endpoints in clinical trials and in the planning of resources.