Search

There is a suggestion that the medical disciplinary committees (MDC) in the Netherlands are making more severe rulings on medical professionals. In a 10-year analysis of MDC rulings, it appears that complaints made by patients are more frequently being judged to be well-founded, and that the measures being taken are more severe. The authors conclude that there is a numerical basis for the increasing severity of the rulings. However, a numerical trend as such does not constitute proof of this, as the way in which the ruling is arrived at is unknown. A more thorough analysis of the patient complaints, the ruling and the underlying arguments is necessary. The authors also make some other statements that can be refuted. The importance of the possible influence of the increasing complexity of health care as a factor in the increase in complaints to the MDC is not addressed.

All abdominal surgical procedures have a certain risk/benefit ratio. Recently, the way surgeons come to a decision whether to operate, or not, was discussed in the Annals of Surgery. First, the assessment of the decision for an operative versus a non-operative strategy was addressed on the basis of clinical vignettes. The perceptions concerning risk/benefit balance varied considerably between surgeons and these perceptions predicted the decision to operate. In a second paper, surgeons were randomized to either an arm in which they were exposed to a risk calculator or to a control arm. The decisions of the risk-calculator arm were less varied, but did not alter the likelihood of recommending an operation. Perhaps surgeons decide to operate or not rather intuitively, based on clinical and laboratory information. Alternatively, they may consider the statistically significant difference in risk/benefit to be less relevant. A better insight into surgeons' decision making and the way in which they weigh benefits against risks is very useful, but it is proving to be a considerable research challenge.

Structured assessments form a mandatory part of Dutch Medical Specialist Training, but create administrative workload for both the staff and supervisors. One could argue that the quality of the narrative feedback is more important than the extensive reporting in learning portfolios, and that the focus should be on continuous on-the-job coaching.

In 2 patients, men aged 73 and 66 undergoing physical and ultrasound examinations for complaints of abdominal pain, an aneurysm of the abdominal aorta (AAA) with a diameter of 7-8 cm was discovered. Both their blood pressure and heart rate were normal. The older man then underwent a CT scan as did the younger man after being observed overnight. They both proved to have a ruptured AAA. They were operated on and recovered well. It can be problematic to diagnose a ruptured AAA quickly in patients with abdominal and back pain, AAA on ultrasound and normal haemodynamic parameters. In this situation an emergency CT scan will visualize any retroperitoneal haematoma and the patient can undergo an emergency operation. If the CT scan does not show any rupture there is time for preoperative preparations before performing a semi-elective procedure.

To assess the necessity to operate on non-incarcerated inguinal hernia in children within 7 days of diagnosis.Retrospective.Data on 360 children, 0-10 years old (104 girls and 256 boys) who were operated on for inguinal hernia between 1 January 1993-31 December 2001 at the St. Elisabeth Hospital in Tilburg, the Netherlands, were collected from the medical records. These data included sex, age, interval between diagnosis and repair, recurrence, incarceration, length of hospitalisation and complications.In the group of 113 children 0-1 years old, 137 inguinal hernias were repaired, ofwhich 16 were incarcerated on presentation. The interval between diagnosis and repair was known in 93 of 121 cases: 37 hernias were repaired within 7 days and 56 at a later stage. In the latter group, there was one case of secondary incarceration (1.8%; 95% CI: 0-5.4). The number needed to treat was 56. In the group of 247 children 1-10 years old, 269 inguinal hernias were repaired, of which 8 were primarily incarcerated. The interval between diagnosis and repair was known in 208 of 261 cases: 34 hernias were repaired within 7 days and 174 at a later stage. In the latter group, 3 hernias incarcerated secondarily (1.7%; 95% CI: 0-3.7). The number needed to treat was 58. In the group of non-incarcerated hernias 1 complication occurred, in the group of incarcerated hernias none. The mean length of hospitalisation of children with non-incarcerated hernia was 0.85 days, and of children with incarcerated hernia 2.4 days.In children with a non-incarcerated inguinal hernia who are waiting for an operation, the risk of secondary incarceration and complications is 2% which we do not think is enough reason to carry out an elective hernia-repair procedure within 7 days.

Two patients, a man aged 65 years and a woman aged 75 years, developed chylous ascites after emergency abdominal aortic aneurysm repair. Both patients were still on artificial ventilation at the time of diagnosis. The first symptoms were high ventilation pressure, elevated diaphragm and abdominal distension. The patients were treated conservatively with drainage, and the man was also given tube feeding without long-chain triglycerides. The man recovered, while the woman died of sepsis. Chylous ascites is an unusual complication of retroperitoneal surgery. Abdominal paracentesis is a simple means to confirm the diagnosis. Initial treatment consists of draining the chylus, and a medium-chain triglyceride diet or total parenteral nutrition. When this fails, more invasive treatment is required, consisting of direct lymphatic repair or peritoneovenous shunting. In mechanically ventilated patients, gradually progressive symptoms of abdominal hypertension after surgery in the retroperitoneal space should arouse suspicion of this complication.

To evaluate the treatment of patients with differentiated (papillary or follicular) thyroid cancer in general hospitals in the south-east of the Netherlands during the period 1983-1996, in relation to the 1987 national consensus recommendations.Population-based, retrospective, descriptive.For the period 1 January 1983-31 December 1996, data on the histology, TNM-stage and treatment (hospital, specialist, type of operation, referral for 131I therapy) of all 236 patients with differentiated thyroid cancer were obtained from the cancer registry of the Comprehensive Cancer Centre South, Eindhoven, the Netherlands. The treatment was compared with the recommendations from the consensus meeting in 1987.Data on 219 patients (137 papillary, 82 follicular thyroid carcinoma) treated in the general hospitals in the region were studied; the 17 remaining patients had been referred from outside the region. Patients were treated at all hospitals in the region; the number of specialists per hospital able to treat thyroid carcinoma (internist and/or surgeon) was limited. In total 79% of the patients underwent a (near-)total thyroidectomy, half of them in two phases, and in 12% of the cases combined with regional lymph node dissection. In the majority of cases, surgical treatment was in accordance with the consensus recommendations: 65-100% of the cases per hospital. The proportion of patients referred for 131I therapy varied from 17% to 90%; referral was more frequent in the case of larger tumours and/or metastases. Of the 24 patients with a small papillary carcinoma without metastases, 79% were not referred for 131I therapy.The recommendations laid down in the consensus meeting in 1987 were known and appeared to be followed for surgical treatment but for subsequent 131I therapy they appeared to be interpreted differently. A review of the consensus guidelines seems to be worthwhile.

The accuracy of clinical diagnosis and fine-needle aspiration biopsy (FNAB) was evaluated in a total of 495 patients of whom 183 were operated upon within 6 months after FNAB and 312 were not. Operated patients were divided into three subgroups with high, moderate or low suspicion of malignant neoplasms on clinical grounds. Histological examination revealed an overall malignant neoplasm rate of 23%. The rate, i.e. the positive predictive value, was 74% for the subgroup with high clinical suspicion, vs 14% and 10% respectively for the subgroups with moderate and low clinical suspicion. The sensitivity of a high clinical suspicion was 60% and the specificity 93%. The overall sensitivity of FNAB was 93% in the operated group and probably not less than 87% in all patients studied; specificity was 71% and 84% respectively for these groups. The overall positive predictive value of a positive cytology result (malignant or uncertain) was 48%. In the subgroups with moderate or low clinical suspicion which are more representative of a non-university setting, the average predictive value was 27%. In our opinion all patients in the group with high clinical suspicion need surgical treatment, regardless of the FNAB result; those with lower degrees of clinical suspicion and malignant or uncertain FNAB result should also undergo diagnostic surgical exploration.