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Context: In patients with severe secondary peritonitis, there are 2 surgical treatment strategies following an initial emergency laparotomy: planned relaparotomy and relaparotomy only when the patient's condition demands it ("on-demand"). The on-demand strategy may reduce mortality, morbidity, health care utilization, and costs. However, randomized trials have not been performed.Objective: To compare patient outcome, health care utilization, and costs of on-demand and planned relaparotomy.Design, Setting, and Patients: Randomized, nonblinded clinical trial at 2 academic and 5 regional teaching hospitals in the Netherlands from November 2001 through February 2005. Patients had severe secondary peritonitis and an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 11 or greater.Intervention: Random allocation to on-demand or planned relaparotomy strategy.Main Outcome Measures: The primary end point was death and/or peritonitis-related morbidity within a 12-month follow-up period. Secondary end points included health care utilization and costs.Results: A total of 232 patients (116 on-demand and 116 planned) were randomized. One patient in the on-demand group was excluded due to an operative diagnosis of pancreatitis and 3 in each group withdrew or were lost to follow-up. There was no significant difference in primary end point (57% on-demand [n = 64] vs 65% planned [n = 73]; P = .25) or in mortality alone (29% on-demand [n = 32] vs 36% planned [n = 41]; P = .22) or morbidity alone (40% on-demand [n = 32] vs 44% planned [n = 32]; P = .58). A total of 42% of the on-demand patients had a relaparotomy vs 94% of the planned relaparotomy group. A total of 31% of first relaparotomies were negative in the on-demand group vs 66% in the planned group (P <.001). Patients in the on-demand group had shorter median intensive care unit stays (7 vs 11 days; P = .001) and shorter median hospital stays (27 vs 35 days; P = .008). Direct medical costs per patient were reduced by 23% using the on-demand strategy.Conclusion: Patients in the on-demand relaparotomy group did not have a significantly lower rate of death or major peritonitis-related morbidity compared with the planned relaparotomy group but did have a substantial reduction in relaparotomies, health care utilization, and medical costs.Trial Registration: http://isrctn.org Identifier: ISRCTN51729393. [ABSTRACT FROM AUTHOR]

Objective: To characterize posterior malleolar fracture morphology using Cole fracture mapping and to study reliability of quantification of 3-dimensional computed tomography (CT)-modeling for posterior malleolar fractures with respect to quantification of fragment size (in cubic millimeter) and true articular involvement (in square millimeter)., Methods: CT scans of a consecutive series of 45 patients with an ankle fracture involving the posterior malleolus were reconstructed to calculate (1) fracture maps, (2) fragment volume, (3) articular surface of the posterior malleolar fragment, (4) articular surface of intact tibia, and (5) articular surface of the medial malleolus by 3 independent observers. Three-dimensional animation of this technique is shown on www.traumaplatform.org., Results: Fracture mapping revealed (1) a continuous spectrum of posterolateral oriented fracture lines and (2) fragments with posterolateral to posteromedial oriented fracture lines extending into the medial malleolus. Reliability of measurements of the volume and articular surface of posterior malleolar fracture fragments was defined as almost perfect according to the categorical system of Landis (interclass coefficient, range, 0.978-1.000)., Conclusions: Mapping of posterior malleolar fractures revealed a continuous spectrum of Haraguchi III to I fractures and identified Haraguchi type II as a separate pattern. Quantification of 3-dimensional CT-modeling is reliable to assess fracture characteristics of posterior malleolar fracture fragments. Morphology might be more important than posterior malleolar fracture size alone for clinical decision making.

Background: The aim of this study was to determine the role of surgery in elderly patients with breast cancer., Methods: Between 1999 and 2009, 153 consecutive women, ≥80 years old with breast cancer were treated at our hospital. Surgically and non-surgically treated patients were compared with respect to characteristics and survival., Results: Treatment was surgical in 102 patients (67%). The non-surgically treated patients were older than surgically treated patients, had more co-morbidity and were more often diagnosed with a clinically T3/T4 tumour and distant metastasis. Patients not receiving surgery, had an 11% overall survival rate at 5-year versus 48% in surgically treated patients (P < 0.001). Independent factors for survival were clinical N0 status, M0 status at presentation and surgery., Conclusion: One in three patients of 80 years and older did not have surgical treatment for breast cancer. Patient not treated surgically are older, have more severe co-morbidity and are diagnosed with more advanced disease than patients who underwent surgery.The selection of patients, who have a poor prognosis, is made on clinical grounds not measurable with a common co-morbidity survey. Better and evidence-based selection criteria for surgical and non-surgical treatment in these patients are needed., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: This study evaluates the incidence of delirium and risk factors associated with delirium in elderly patients admitted to a general surgical ward., Methods: Patients aged over 60 years who were admitted with an acute or elective general surgical diagnosis were eligible for this prospective cohort study. Risk factors associated with delirium were analyzed using univariate and multivariate analysis to identify those independently associated with delirium., Results: A total of 209 patients were included in the study. The incidence of delirium was 16.9% (23.2% for acute admission, P < .001). Variables associated with delirium were dementia, presence of an urinary catheter, cognitive decline at admission measured with the mini-mental state examination, white blood cell count >10.0 × 10(9)/L, and urea >7.5 mmol/L. Median length of hospital stay was 13 days (range 3-85) for patients with delirium versus 7 (range 1-54) for patients without (P = .002)., Conclusions: The incidence of delirium is high in elderly patients, especially after an acute admission, leading to an increase in length of hospital stay. To minimize delirium, associated risk factors must be identified and, if possible, treated., (Copyright © 2014 Elsevier Inc. All rights reserved.)

This study determined inter- and intra-observer reliability for measurement of the angles of Böhler and Gissane, for the decision between surgical or conservative management and for the three mostly used classification systems for calcaneal fractures with the use of 2D-CT imaging versus 2D- and 3D-CT imaging. A consecutive series of 38 fractures in 36 patients, treated at a level II trauma centre between 2005 and 2008, were evaluated in two rounds by five observers. We measured the inter- and intraobserver reliability for the Sanders', Zwipp and Essex-Lopresti classification systems using the kappa values as described by Cohen. The intraclass correlation coefficient as described by Shrout and Fleiss was used to analyze inter- and intra-observer reliability of the angles of Böhler and Gissane. Usage of 2D-CT imaging interobserver reliability was fair for the Sanders' and Zwipp classifications and for measurement of the angle of Gissane, and it was moderate for measurement of the Essex-Lopresti classification system and measurement of the angle of Böhler. With the addition of 3D-CT imaging, the interobserver reliability was fair for the Sanders', Zwipp and Essex-Lopresti classification systems. The intraobserver reliability was fair for measurement of the angle of Gissane and it was moderate for the Sanders', Zwipp and Essex-Lopresti classification systems and for the measurement of the angle of Böhler. The addition of three-dimensional CT imaging did not increase inter- and intraobserver reliability for the classification of calcaneal fractures. Authors commented they experienced no additional benefit from 3D-CT imaging for the assessment of calcaneal fractures., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

A 16-y-old boy presented with complaints of acute abdomen. Ultrasonography showed an enlarged and tender appendix suggestive of acute appendicitis. The patient underwent surgery and during surgery the appendix was found with a red vasculitis-like distal end, not typical for acute appendicitis. Further per operative examination of the intestines revealed a circular, vasculitis-like red band in terminal ileum. Four days after surgery, the patient developed skin purpura and complained of joint pain classical of Henoch-Schönlein disease. Pathological evaluation of the appendix and a skin biopsy confirmed the diagnosis and the patient was managed accordingly.

Background: Acute appendicitis is still a difficult diagnosis. Scoring systems are designed to aid in the clinical assessment of patients with acute appendicitis. The Alvarado score is the most well known and best performing in validation studies. The purpose of the present study was to externally validate a recently developed appendicitis inflammatory response (AIR) score and compare it to the Alvarado score., Methods: The present study selected consecutive patients who presented with suspicion of acute appendicitis between 2006 and 2009. Variables necessary to evaluate the scoring systems were registered. The diagnostic performance of the two scores was compared., Results: The present study included 941 consecutive patients with suspicion of acute appendicitis. There were 410 male patients (44%) and 531 female patients (56%). The area under the receiver operating characteristic curve of the AIR score was 0.96 and significantly better than the area under the curve of 0.82 of the Alvarado score (p < 0.05). The AIR score also outperformed the Alvarado score when analyzing the more difficult patients, including women, children, and the elderly., Conclusions: This study externally validates the AIR Score for patients with acute appendicitis. The scoring system has a high discriminating power and outperforms the Alvarado score.

Background: Complex tibial plateau fractures can be difficult to characterise on plain radiographs and two-dimensional computed tomography (2D CT). The present study evaluated whether three-dimensional computed tomography (3D CT) reconstructions can improve the reliability of complex tibial plateau fracture characterisation and classification., Methods: Forty-five consecutive intra-articular fractures of the tibial plateau were evaluated by six independent observers for classification according to standard systems and for the presence of six characteristics: (1) posteromedial shear fracture; (2) coronal plane fracture; (3) lateral condylar impaction; (4) medial condylar impaction; (5) tibial spine involvement; and (6) separation of tibial tubercle necessitating fixation. Two rounds of characterisation and classification were performed: the first classification after a combination of plain radiographs and 2D CT and the second one after 3D CT information were added., Results: 3D CT improved the average 'inter'-observer reliability of the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification (κ2D=0.536, 95% confidence interval (CI): 0.481-0.591 vs. κ3D=0.545, 95% CI: 0.478-0.612), the Hohl and Moore classification (κ2D=0.668, 95% CI: 0.605-0.732 vs. κ3D=0.746, 95% CI: 0.605-0.732) and of the Schatzker classification (κ2D=0.545, 95% CI: 0.494-0.596 vs. κ3D=0.596, 95% CI: 0.538-0.654). 'Intra'-observer reliability also improved non-significantly for all systems after the addition of 3D CT for individual observers. 3D CT did improve the 'intra'-observer reliability for the identification of the following fracture characteristics: coronal plane fracture (average κ2D=0.700, interquartile range (IQR): 0.551-0.820 vs. average κ3D=0.774, IQR: 0.692-0.847); lateral condylar impaction (average, κ2D=IQR: 0.675-0.901 to 1.000 vs. average, κ3D=0.785, IQR 0.737-0.807); medial condylar impaction (average κ2D=0.631, IQR: 0.537-0.670 vs. κ3D=0.719, IQR: 0.679-0.895); tibial spine involvement average (κ2D=0.621, IQR 0.545-0.678 vs. average κ3D=0.705, IQR: 0.652-0.794); separation of tibial tubercle necessitating fixation (average κ2D=0.332, IQR: 0.080-0.574 vs. average κ3D=0.441, IQR: 0.325-0.681). The only improvement that was found to be statistically significant was for recognition of medial condylar impaction as the IQR did not overlap. 3D CT had limited influence on average 'inter'-observer reliability for the recognition of all specific fracture characteristics (κ2D=0.488 vs. κ3D=0.485, both moderate agreement for all fracture characteristics) but showed a non-significant improvement of the recognition of coronal plane fractures (fair to moderate; κ2D=0.398, 95% CI: 0.273-0.523 to κ3D=0.418, 95% CI: 0.262-0.574) and recognition of impaction of the lateral condyle (κ2D=0.614, 95% CI: 0.467-0.760 to κ3D=0.693, 95% CI: 0.538-0.849)., Conclusions: The added value of 3D CT after 2D CT is limited and does not significantly improve reliability of characterisation and classification of tibial plateau fractures., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

3 patients, 2 women aged 41 and 47 and one man aged 75 years, presented with abdominal pain and distension. In 2 patients the diagnosis 'sigmoid volvulus' was reached following plain abdominal X-ray. Both patients underwent sigmoidal resection with primary anastomosis after endoscopic deflation. The third patient proved to have a caecal volvulus on emergency laparotomy and underwent ileocaecal resection. In 2/3 of the cases diagnosis can be made by history, physical examination and conventional X-ray. Delay in the diagnosis increases the risk of peritonitis and death due to ischaemia and perforation of the colon. In the absence of peritoneal tenderness, signs of ischaemia or sepsis, the initial treatment consists of endoscopic deflation, which is successful in 68-78% of cases. Resection of the sigmoid colon is recommended a few days after endoscopic decompression in order to prevent recurrence. Caecal volvulus is not suitable for treatment with endoscopic deflation and should be treated with ileocaecal resection.

Introduction: Results of the first randomized trial comparing on-demand versus planned-relaparotomy strategy in patients with severe peritonitis (RELAP trial) indicated no clear differences in primary outcomes. We now report the full economic evaluation for this trial, including detailed methods, nonmedical costs, further differentiated cost calculations, and robustness of different assumptions in sensitivity analyses., Methods: An economic evaluation was conducted from a societal perspective alongside a randomized controlled trial in 229 patients with severe secondary peritonitis and an acute physiology and chronic health evaluation (APACHE)-II score >or=11 from two academic and five regional teaching hospitals in the Netherlands. After the index laparotomy, patients were randomly allocated to an on-demand or a planned-relaparotomy strategy. Primary resource-utilization data were used to estimate mean total costs per patient during the index admission and after discharge until 1 year after the index operation. Overall differences in costs between the on-demand relaparotomy strategy and the planned strategy, as well as relative differences across several clinical subgroups, were evaluated., Results: Costs were substantially lower in the on-demand group (mean, 65,768 euro versus 83,450 euro per patient in the planned group; mean absolute difference, 17,682 euro; 95% CI, 5,062 euro to e29,004 euro). Relative differences in mean total costs per patient (approximately 21%) were robust to various alternative assumptions. Planned relaparotomy consistently generated more costs across the whole range of different courses of disease (quick recovery and few resources used on one end of the spectrum; slow recovery and many resources used on the other end). This difference in costs between the two surgical strategies also did not vary significantly across several clinical subgroups., Conclusions: The reduction in societal costs renders the on-demand strategy a more-efficient relaparotomy strategy in patients with severe peritonitis. These differences were found across the full range of healthcare resources as well as across patients with different courses of disease., Trial Registration: ISRCTN51729393.

Aim: To evaluate the impact of selective imaging on clinical management of patients who present with symptoms suggesting acute appendicitis., Materials and Methods: During a two-and-half year period, 941 consecutive patients with right lower quadrant pain were analyzed. Patients who underwent selective imaging were compared to those treated without further imaging., Results: In 650 (69%) patients with right lower quadrant pain, diagnosis was based on medical history, physical and laboratory examination only. The diagnostic accuracy was 84%. Another 291 patients (31%) underwent selective imaging reaching a diagnostic accuracy of 71%. Ultrasound was conducted in 277 patients (sensitivity: 59%; specificity: 91%). CT scan was conducted in 43 patients (sensitivity: 100%; specificity: 95%)., Conclusion: The present study shows that, in the majority of patients, appendicitis acuta can be diagnosed without the aid of imaging studies. In all these cases, high diagnostic accuracy rates and low morbidity rates were achieved. In all the other cases when clinical diagnosis is uncertain, further evaluation should include imaging. In our series ultrasound is of limited value; CT scan or diagnostic laparoscopy seems superior.

Polydactyly is defined as a congenital anomaly of the hand or foot with the presence of supernumerary digits. The frequency of polydactyly varies widely among populations. It can occur as an isolated condition or as a feature of a congenital condition. In the literature, the condition is commonly described in combination with an apparent congenital deformity. We describe a case of polydactyly with no other obvious, macroscopically visible anomaly. A 21-year-old man presented with a sprained left ankle. On examination, a slightly irregularly shaped fifth digit of the left foot that appeared like a tailor's bunion was observed. The patient reported slight weight-bearing pain and tenderness over the navicular bone. No fractures were seen on radiographs, but they revealed an os tibiale externum, an extra metatarsal bone conjoined distally with the fifth metatarsal, and an extra hypoplastic proximal phalanx. No obvious signs of deformity were present. A bunionette, which was an extra hypoplastic proximal phalanx, was observed at the base of the fifth toe. Few published reports have described isolated polymetatarsia, and none of those describe supernumeral digits. A comprehensive search of the literature found no cases identical to ours.

Three women, aged 37, 39 and 29 years, presented with unilateral painful swelling of the breast. Ultrasound revealed inflammation with abscess formation. Histological biopsies contained granulomatous tissue without necrosis. Corynebacterium species were cultured in the first two patients. All 3 patients were diagnosed with granulomatous mastitis and were successfully treated with doxycycline. Granulomatous mastitis is a rare disorder that may mimic breast carcinoma. It occurs most frequently in fertile women. Diagnosis is based on histological biopsy which shows granulomas without necrosis, while other causes of granulomatous inflammation, especially tuberculosis, have been excluded. The aetiology is not fully understood. It is hypothesised that the granulomatous mastitis is caused by a type IV allergic reaction. Recently an association with Corynebacterium species was suggested. Best practice treatment methods are unclear. Most patients are treated with surgical intervention and steroids, but the rate of recurrence is high (50%). Treatment with doxycycline must be considered in patients with cultured Corynebacterium species.

Background: To compare health related quality of life (HR-QoL) in patients surgically treated for secondary peritonitis to that of a healthy population. And to prospectively identify factors associated with poorer (lower) HR-QoL., Design: A prospective cohort of secondary peritonitis patients was mailed the EQ-5D and EQ-VAS 6-months following initial laparotomy., Setting: Multicenter study in two academic and seven regional teaching hospitals., Patients: 130 of the 155 eligible patients (84%) responded to the HR-QoL questionnaires., Results: HR-QoL was significantly worse on all dimensions in peritonitis patients than in a healthy reference population. Peritonitis characteristics at initial presentation were not associated with HR-QoL at six months. A more complicated course of the disease leading to longer hospitalization times and patients with an enterostomy had a negative impact on the mobility (p = 0.02), self-care (p < 0.001) and daily activities: (p = 0.01). In a multivariate analysis for the EQ-VAS every doubling of hospital stay decreases the EQ-VAS by 3.8 points (p = 0.015). Morbidity during the six-month follow-up was not found to be predictive for the EQ-5D or EQ-VAS., Conclusion: Six months following initial surgery, patients with secondary peritonitis report more problems in HR-QoL than a healthy reference population. Unfavorable disease characteristics at initial presentation were not predictive for poorer HR-QoL, but a more complicated course of the disease was most predictive of HR-QoL at 6 months.

Introduction: Radial head fractures are common elbow fractures. The Mason classification is used to describe the fracture. As of yet, there is no consensus on optimal treatment strategy for Mason II-IV fractures. The aim of this study was to compare the results of conservative treatment with different surgical strategies for radial head fractures., Materials and Methods: Electronic databases from 1966 to 2004 were screened. Based on our inclusion criteria, 24 studies, describing 825 patients, were included., Results: For Mason type II fractures, residual pain was present in 42% of the conservatively treated of the patients compared to 32% of the surgically treated patients. Good/excellent results for Broberg score were 52 and 88%, respectively. For Mason type III and IV fractures, no conservatively treated patients were described., Conclusions: There is insufficient evidence to be able to draw definitive conclusions on optimal treatment of type II-IV radial head fractures. Evidence is currently limited to a maximum level II evidence. There is great need for sufficiently powered randomized controlled trials.

Background: Subcapital fractures of the fifth metacarpal bone, meaning fractures just below the knuckle of the little finger, account for approximately 20% of all hand fractures. Currently, there is no consensus concerning the optimal management of these fractures. Traditionally, treatment consists of closed reduction and external splinting in a neutral position using plaster of Paris (POP), involving the metacarpal joint, the proximal interphalangeal joint and the carpo-metacarpal joint. An alternative treatment strategy is functional treatment using taping or bracing that does not restrict movement., Objectives: To compare functional treatment with immobilization, and to compare different periods and types of immobilization, for the treatment of closed fifth metacarpal neck fractures in adults., Search Strategy: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (July 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004), OVID OldMEDLINE (1951 to 1965), OVID MEDLINE (1966 to July 2004), OVID MEDLINE In-Process (July 2004), EMBASE (1988 to 2004, week 29), the Internet, and reference lists of articles. No language restrictions were applied., Selection Criteria: All randomized and quasi-randomized controlled trials which compare functional treatment with immobilization or different types of immobilization for closed fifth metacarpal neck fractures., Data Collection and Analysis: Two review authors assessed abstracts of all studies identified by the initial search, identified studies meeting the selection criteria, independently assessed the quality of the trial reports, and extracted and analysed the data., Main Results: Five studies met the inclusion criteria including a total of 252 participants. Most studies were of poor quality. The primary outcome measure, function of the hand, was not used in any studies. There was no evidence that any of the treatment modalities was statistically significantly superior., Authors' Conclusions: No included studies reported our primary outcome measure of interest, validated hand function. There was heterogeneity between the studies, which were of limited quality and size. No single non-operative treatment regimen for fracture of the neck of the fifth metacarpal can be recommended as superior to another in result. Further research is definitely warranted.

Introduction: It is not known how the described methods of reduction and dynamic hip screw (DHS) fixation of displaced intracapsular femoral neck fractures translate into proper assessment of the postoperative radiographs. At teaching or evaluation sessions in daily practice, frequent discussion arises about postoperative technical assessment. The assessment of correct reduction and DHS fixation using the described methods in the literature may be subject to differences between observers. The aim of this study was to assess the extent of inter- and intraobserver agreement on technique, based on the methods in the literature, in a simulated daily practice setting., Materials and Methods: The postoperative anteroposterior (AP) and lateral radiographs of 35 randomly selected patients aged 60-90 years were rated twice, 2 months apart, by six surgical observers from three institutions with similar views on reduction and DHS fixation for this fracture type. The radiographs were of sufficient quality for proper assessment. Criteria for reduction and fixation could be rated as either adequate or inadequate. An adequate rating was assigned if in the observer's opinion, regardless of likely outcome, technical perfection according to the described methods had been achieved. The kappa statistic was calculated as a measure of agreement., Results: Fracture reduction on the AP view approached a good kappa value (0.54). Poor to moderate interobserver agreement was found for fracture reduction on the lateral view and aspects of DHS fixation (kappa 0.10-0.36). Intraobserver agreement was good for five out of six observers for reduction and DHS fixation aspects (kappa 0.51-0.81)., Conclusion: During routine practice six surgical observers can nearly agree on adequate fracture reduction on the AP view, but do not agree on adequate reduction on the lateral view and adequate DHS fixation on the postoperative radiographs of displaced intracapsular femoral neck fractures.

In three men, aged 81, 66 and 58 years, breast cancer was diagnosed. All three were treated by modified radical mastectomy and axillary-node dissection. They received tamoxifen and the first and the third patient also received radiotherapy. Presentation of these patients is usually delayed, because of the rarity of and unfamiliarity with the disease. Consequently, the disease is often in a more advanced stage at presentation and overall mortality is higher in comparison with women with breast cancer. However, survival of male patients is similar to survival of female patients when matched for age and stage. This stresses the importance of a timely diagnosis. As in women, of the known risk factors for male breast cancer, a positive family history is one of the most important ones. Modified radical mastectomy, combined with sentinel-node biopsy by experienced teams, is the standard treatment. Criteria for adjuvant systemic treatment are identical for men and women, although hormonal therapy (tamoxifen) has a more prominent place in the adjuvant setting because of the high percentage of positive hormone receptors in men.

With sufficient experience, sentinel node biopsy has a high identification rate for several techniques in the case of colorectal cancer. However, the sensitivity of the procedure seems to be too low to justify the replacement of routine pathological examination of the whole mesentery by sentinel node biopsy. Unexpected lymphatic drainage patterns can be found in about 5% of the patients. Therefore, the role of sentinel node biopsy in determining the extension of the resection is minimal in the case of colorectal cancer. In contrast, sentinel node biopsy is helpful in identifying the lymph nodes with the highest risk of harbouring metastases and it facilitates the scrutinising of the lymph node by the pathologist. This will lead to more micrometastases being detected. The prognostic significance of micrometastases and the impact on survival of adjuvant systemic therapy in such patients should be investigated in randomised controlled trials. At present, sentinel node biopsy in colorectal cancer should be restricted to a research setting.

Background: The management of the subcapital fracture of the fifth metacarpal bone, the boxer's fracture, is still a matter of debate. Besides the question of which rate of angulation is acceptable before a reduction becomes necessary, recommendations for further treatment of this fracture vary as well. Therefore, the aim of our study was to compare randomly and prospectively the results of an immobilization treatment for 3 weeks with cast with a functional treatment, all with accepted angulations up to 70 degrees., Patients and Methods: Between June 1997 and June 1998, 40 patients were randomly allocated either to treatment with an ulnar gutter plaster cast for a period of 3 weeks followed by mobilization, or a pressure bandage for 1 week and immediate mobilization within limits imposed by pain. All patients were monitored at the outpatient clinic 6 and 12 weeks after the fracture. Clinical outcome was measured by the range of motion (ROM) of the fifth metacarpal phalangeal (MCP) joint, and by interviewing the patients about their satisfaction, pain perception, return to work and hobby, and need for physiotherapy., Results: A total of 35 patients with a mean age of 29 years (range 15-84) completed the required follow-up program. The mean angulation of the fracture was 39 degrees (range 15-70 degrees ). Between the two groups, no statistical differences were scored with respect to ROM, satisfaction, pain perception, return to work and hobby, and need for physiotherapy. According to a sample size calculation (power 90%, alpha 0.05, to detect 5 degrees difference in ROM), 12 patients needed to be included in each group to reach significance., Conclusions: A pressure bandage for 1 week, followed by immediate mobilization, is a sufficient alternative treatment for a boxer's fracture, if it is not angulated greater than 70 degrees and not rotated. This treatment resulted in satisfied patients who perceived no more pain and had a good ROM of the fifth MCP joint. Reduction of angulated fractures of less than 70 degrees seems not of value, with respect to ROM of the fifth MCP joint.

Epidemiological studies have found that long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) is associated with a lower risk of colorectal cancer (CRC). Cyclooxygenase (COX)-2 expression is present in colorectal cancer and overexpression is associated with metastases and poorer prognosis in multivariate analysis. NSAID treatment results in a reduction of the incidence of colorectal adenoma in patients with familial adenomatous polyposis, in patients with a history of colorectal adenomas and in patients with a history of CRC. Pre-clinical research shows that COX-2 expression is associated with cell proliferation, angiogenesis, apoptosis inhibition and local immune-down modulation. An anticarcinogenic effect has been shown specifically in selective COX-2 inhibitors in animal models. Selective COX-2 inhibitors have fewer adverse effects than the non-selective NSAIDs and are promising chemopreventative and chemotherapeutical agents. The effects of selective COX-2 inhibition in the prevention of and treatment for colorectal carcinoma will be investigated in clinical randomized multicentre trials.

Following a total hip prosthesis, a 52-year-old Turkish man with Behçet's disease developed persistent ileus due to intestinal perforations. Resection of the intestine was followed by new perforations, resulting in resection of another portion of the intestine and the start of immunosuppressive medication. Following the 5th resection for a perforated ulcer in the space of two weeks, an ileostomy was performed. One year later the stoma could be eliminated and the patient remained symptom-free. Behçet's disease is relatively rare in the Netherlands. However, the gastrointestinal complications may be life-threatening. Surgical intervention is then often necessary. Complications and recurrences are frequent.

A 22-year-old homeless male psychiatric patient of Ghanaian origin was diagnosed with severe frostbite in both lower legs. The lesion consisted of haemorrhagic blistering with already visible demarcation. When sepsis developed both lower legs had to be amputated as a matter of urgency.

Background: Ankle fractures have a significantly worse functional outcome when they include a posterior tibial fragment. In 57 trimalleolar fractures, the effect of size, internal fixation, and anatomic reduction of the posterior fragment on the prognosis was evaluated., Methods: A modified Weber protocol was used, providing a rating system for subjective, objective, and radiographic results. A visual analogue scale for subjective actual pain was also scored., Results: The involvement of the articular surface ranged from 8% to 55%. Size or fixation of the fragment did not influence prognosis. Joint congruity in fragments >or= 10% of the articular surface was a significant factor influencing prognosis. Overall, the modified Weber protocol result was excellent in 10%, good in 15%, fair in 25%, and poor in 50% of patients. However, the low average visual analogue scale of 3.0 in the whole group does not appear representative of 50% poor results, indicating that the modified Weber protocol is fairly strict and overestimates the number of poor results., Conclusion: Joint congruity with or without fixation was a significant factor influencing prognosis. Congruity should be achieved for fragments >or= 10% of the tibial articular surface.

Objective: To gain insight into the shortage in health care capacity for patients who require immediate admission to hospital., Design: Prospective, descriptive., Method: During the period 1 March-30 November 2001, data were collected on all patients presenting at the casualty department at the Sint Lucas Andreas Hospital in Amsterdam, the Netherlands, who had a surgical, internal medicine or neurological condition which required immediate admission and who could not be admitted due to a shortage in health care capacity. The following data were registered: date of transfer, age, gender, diagnosis, referring specialty, time of telephone call, accepting hospital and time of acceptance. During the same period, the surgery department also noted details of patients requiring immediate admission or transfer whom they turned away after presentation via the telephone by either the general practitioner or a different hospital., Results: 131 patients could not be admitted, 68 men and 63 women with a mean age of 69 years. The distribution across the specialties was as follows: surgery: 63 patients (48%; mean age: 68 years); internal medicine: 48 patients (37%; 65 years); neurology: 20 patients (15%; 74 years). The most common reasons for admission were proximal femur fractures (24; 18%) and gastrointestinal disorders (27; 21%). Mean duration from making the telephone call until acceptance elsewhere was 70 min (range: 1-330) for surgery, 42 min (5-180) for internal medicine and 116 min (10-870) for neurology. The transfer of patients with proximal femur fractures (97 min) and cerebrovascular accident (129 min) took the longest. During the same period, 170 patients were refused by the department of surgery for first-time admission or transfer.

Interleukin-2 (IL-2) and lymphokine-activated killer (LAK) cells were used in intraperitoneal and pulmonary tumor models in C57BL/6 mice. To maintain the immunotherapeutic effects of IL-2 plus LAK treatment but reduce its toxicity, ways were sought to augment IL-2 effects. The investigation showed that the adoptive transfer of LAK cells was a prerequisite for successful therapy of intraperitoneal cancer. When LAK cells were given on consecutive days within one course of immunotherapy, antitumor efficacy was augmented with additional doses of LAK cells. However, with the reduction of 1 complete cycle of IL-2 + LAK cells, no further reduction in intraperitoneal tumor was observed as compared to the reduction after 2 or 4 cycles. LAK cells generated from splenocytes of mice that had received an allogeneic tumor challenge 1 week earlier exerted a highly increased cytotoxicity as compared to normal LAK cells. Furthermore, the potentiation effect of an allogeneic response of the host at the tumor site was demonstrated by decreased numbers of lung implants and improved survival in mice given mixtures of syngeneic and allogeneic tumor cell suspensions. An alloimmune response within the microenvironment of tumor tissue markedly enhanced the antitumor effect of IL-2 against the syngeneic tumor. It was concluded that there is a fundamental need to improve the recruitment of adoptively transferred LAK cells or LAK precursors into tumor tissue. This may be the next step required in the further development of IL-2 and LAK immunotherapy.

Five patients with colorectal cancer widely metastatic to peritoneal surfaces have been treated i.p. with infusions of autologous blood monocytes made cytotoxic by in vitro incubation with human gamma-interferon. The monocytes were purified by a combination of cytapheresis and counter-current centrifugal elutriation procedures; each week approximately 350 million activated monocytes were given to patients as adoptive immunotherapy by a single i.p. instillation. On the eighth cycle of treatment the trafficking of i.p. infused blood monocytes was studied in two patients by prelabeling the cells with 111In. These activated cells became distributed widely within the peritoneal cavity. Two and 5 days after infusion their position within the peritoneum had not changed. When peritoneal specimens were obtained 36 h after 111In-labeled monocyte infusion, labeled monocytes were demonstrated to be associated with the serosal surfaces by autoradiographic analysis. Scintiscanning structures outside the abdominal cavity revealed that 111In-labeled monocytes infused i.p. did not traffic to other organs during the 5 days of the study. We conclude that i.p. adoptive transfer of autologous killer blood monocytes is an effective way of delivering these cytotoxic cells to sites of tumor burden on peritoneal surfaces in these cancer patients.

Various investigators have shown that tumor growth can be facilitated by surgery, that an operation can suppress immune functions, and that these phenomena may be related. With a murine intraperitoneal (i.p.) tumor model, we investigated whether an operation could promote tumor growth and, if so, whether this effect could be successfully overcome by immunotherapy with interleukin-2 (IL-2) and lympokine activated killer (LAK) cells. Treatment with IL-2 and LAK cells was highly effective in unoperated mice. When a laparotomy was done 4 days before i.p. tumor inoculation, tumor growth was enhanced in all experiments, and the effect of immunotherapy was completely abrogated. This effect was local regional; an incision on the back of the mice did not affect tumor growth or outcome of treatment. Tumor growth in the scar area was usually excessive. Furthermore, these effects were found to be temporary. Promotion of tumor growth and abrogation of IL-2 + LAK effects were seen only from 4 days to up to 2 weeks after laparotomy but were lost 5 weeks after surgery. These results suggest that growth factors present in healing wounds may cause promotion of tumor growth and are dominant over the effects of IL-2 and LAK cell therapy.

In a significant proportion of patients with gastrointestinal and ovarian malignancy the peritoneal cavity is a prominent site at which surgical treatment fails. Adjuvant treatments directed at this site should be investigated in an attempt to improve survival in patients with these cancers. In the study reported here, a model of intraperitoneal tumor in the mouse was established and shows the effectiveness of lymphokine activated killer (LAK) cells and exogenous interleukin-2 (IL-2) in the control of intraperitoneal tumor. A standard regimen was used to treat seven different tumors in three different mouse strains. In all seven cases a significant reduction in the intraperitoneal tumor mass was observed when LAK cells plus IL-2 were used as immunotherapy. A prolonged survival was also demonstrated in mice with intraperitoneal tumor. The relevance of these observations to patients with cancer was demonstrated in that allogeneic and syngeneic LAK cells were equally effective, LAK cells generated from normal and from tumor-bearing donors showed equal reactivity, and this treatment was successful in the immuno-compromised host. Both IL-2 derived from an IL-2-producing subline of the EL-4 thymoma and recombinant IL-2 were equally effective in the control of intraperitoneal tumor. The local-regional effects of the intraperitoneal administration of IL-2 were demonstrated by high levels of LAK cell cytotoxicity in peritoneal exudate cells. Intraperitoneal IL-2 or IL-2 plus LAK cell regimens should be investigated in the treatment of malignancy that spreads by implantation onto peritoneal surfaces.

Not all cancer-bearing hosts respond to interleukin-2 (IL-2) and lymphokine-activated killer (LAK) cell immunotherapy. We wished to determine if modification of the host could change the immunotherapeutic effects. Alloimmunization of the host was used to study the suppression observed when LAK cells were generated in the presence of cytotoxic T lymphocytes (CTL). If C57BL/6 (BL/6, H-2b) mice were given P815 (H-2d) tumor prior to syngeneic tumor challenge, the immunotherapeutic effects of IL-2 were lost. Cells taken from mixed lymphocyte culture and incubated 3 days in IL-2 showed a reduced capability of generating LAK. However, their cytotoxicity toward an alloimmunogeneic target was markedly increased by 3 days of incubation in IL-2. In mixing experiments alloimmune cells from in vitro culture were markedly inhibitory to normal splenocytes in the generation of LAK cell cytotoxicity; they also interfered with the maintenance of LAK cell cytotoxicity. A T cell was responsible for the suppressive effects on LAK generation because suppression was abrogated by treatment of alloimmune cells with anti-T serum plus complement. The cytotoxic T cell did not lyse the LAK cell. If IL-2 was serially diluted and incubated with CTLs, the IL-2 titer was substantially reduced by 72 h incubation. If supernatants from CTLs were added to serially diluted IL-2, the IL-2 titer increased; this suggested that a soluble suppressor factor produced by CTLs did not cause the diminished IL-2 plus LAK effects. These in vitro experiments suggest that CTLs compete with normal lymphocytes or LAK cells for IL-2 and thereby suppress LAK cell responses. These studies are important in attempting to elucidate the role the host's immune system may play in IL-2 plus LAK immunotherapy of cancer or infectious disease processes.

Production of biological response modifiers through recombinant techniques has stimulated interest in immunotherapy of cancer. One of these, interleukin-2 (IL-2), will induce in vivo as well as in vitro proliferation of noncommitted T lymphocytes into lymphokine-activated killer (LAK) cells: cells cytolytic for a broad range of tumor cells. We have demonstrated earlier that immunotherapy with IL-2 and LAK cells will reduce tumor load and prolong survival in a significant way in an intraperitoneal (ip) tumor model as well as in other models. Nevertheless, mice die of one or two metastases escaping immunotherapy. Activation of the host immune system might boost endogenous IL-2 production. Activation might also enhance immunotherapy by increasing the necessary cofactors. Loco-regional allogeneic pretreatment ip 14 days prior to syngeneic tumor challenge did not enhance, but completely abrogated, ip IL-2 and LAK cell therapy (peritoneal cancer index, 0.6 +/- 0.3 vs 2.6 +/- 0.2, P2 = 0.003). Tumor bulk is not the reason for escape of immunotherapy either. One week after intracutaneous (ic) tumor inoculation a noncurative or sham tumor resection was performed, followed by IL-2 and LAK cell therapy either ip or in and around the tumor nodule. No significant difference in tumor diameter or survival of mice was seen. Allogenic tumor cells admixed with syngeneic tumor cells will induce an inflammatory reaction locally and regionally. This inflammatory reaction in the syngeneic host will enhance the treatment with IL-2. The allogeneic (P815) and syngeneic (MCA-105) tumor cell mixture was injected ic. Growth rate was retarded and survival prolonged in a significant way when the cell mixture was treated with ip IL-2 injections; no difference was seen when the admixture was not treated or the syngeneic ic tumor alone was treated with IL-2. We conclude that host immune status and recruitment of immunocompetent cells locally to the tumor site determine the outcome of immunotherapy with IL-2 and LAK cells.

Interleukin-2 (IL-2) is a potent immunotherapeutic agent in murine models of intraperitoneal, pulmonary, and hepatic tumor implantation. Because of the systemic toxicity documented at doses of IL-2 required to control tumor growth, potentiation of the effects of low dose IL-2 is an important problem in immunotherapy. To address this problem, we attempted to recruit lymphocytes into a tumor mass. Allogeneic P185 (H-2d) tumor was mixed with MCA-105 (H-2b) tumor and injected s. c. into C57BL/6 (H-2b) mice. Mice were treated with 50,000 units of IL-2 twice daily from day 0 to day 6. When IL-2 alone was used to treat s. c. tumor, there was no reduction in the size of tumor implants. When allogeneic tumor was mixed with syngeneic tumor, there was a reduction in tumor size at the high dose of allogeneic tumor but not at the low dose. When allogeneic tumor was mixed with syngeneic tumor and the mice treated with IL-2, the immunotherapeutic effects of IL-2 were markedly increased. These studies show that an immune response to alloantigens, generated within tumor tissue can augment the immunotherapeutic effects of exogenous IL-2.

The interrelationship between host resistance to cancer and the trauma of a surgical procedure is the subject of much speculation. Extensive study of animal models and human subjects is required to define these effects and to provide a theoretical model by which to interpret these data. We used a murine model of intraperitoneal cancer to demonstrate the augmentation of tumor growth by surgical trauma. In this intraperitoneal tumor model, a surgical procedure that included entry into the abdominal cavity resulted in augmented tumor growth; a surgical incision on the skin of the animal's back did not promote tumor growth. The immunotherapeutic effects of interleukin-2 and lymphokine-activated killer cells were significantly reduced by the performance of a laparotomy. This abrogation of the effects of the immunotherapeutic regimen was observed for up to 14 days after laparotomy but was lost by days 35 to 42. Healing tissue may promote tumor growth, and these effects are dominant over immunotherapy with interleukin-2 plus lymphokine-activated killer cells.

In a prospective randomised study the use of an elemental versus a nonelemental diet for early postoperative enteral feeding by needle catheter jejunostomy was investigated. After extensive gastrointestinal surgery, 25 patients received an elemental and 24 patients a nonelemental diet. The incidence of diarrhoea, the effects of the feeding and the costs were evaluated. The occurrence of diarrhoea was observed more frequently in the elemental diet group (14 25 ) compared to the nonelemental diet group (7 24 ), although this difference was statistically not significant (p > 0.05). No difference was found between the two groups in postoperative restoration of total protein and serum albumin levels and the extent of the postoperative weight loss. The costs showed a clear difference: the nonelemental diet was three times cheaper than the elemental diet. For early postoperative enteral feeding by needle catheter jejunostomy we therefore recommend the use of a nonelemental diet.

The control of malignancy disseminated within the peritoneal cavity is an important problem in the management of low-grade gastrointestinal and ovarian neoplasms. A model of peritoneal carcinomatosis in the mouse was used to investigate the potential of lymphokine-activated killer (LAK) cells and exogenous interleukin 2 (IL-2) to control intraperitoneal tumor. LAK cells are splenocytes activated in vitro by IL-2. C57BL/6 mice were injected intraperitoneally with a lethal inoculum of syngeneic MCA-105 tumor. Three days later, the established tumor was treated with adoptively transferred LAK cells and/or exogenous IL-2 administration. LAK cells alone were ineffective in reducing intraperitoneal tumor. Administration of IL-2 alone resulted in limited tumor reduction. Treatment with exogenous IL-2 in conjunction with LAK cells resulted in the greatest reduction of intraperitoneal tumor. The larger the number of LAK cells given, the greater the reduction in tumor. Frequent intraperitoneal bolus administration of IL-2 was more effective than a single daily intraperitoneal injection and intraperitoneal administration of IL-2 and LAK was more effective than systemic treatments. Marked prolongation of life was seen in mice treated with LAK cells plus exogenous IL-2. We conclude that intraperitoneal LAK cells plus exogenous IL-2 is an effective treatment regimen for reducing intraperitoneal tumor in this murine model.