http://repub.eur.nl/res/aut/2171/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/17573/ 2009-09-01T00:00:00Z Purpose: To determine the effectiveness, costs, and cost-effectiveness of strategies for the management of hepatocellular adenoma (HA) in women who are otherwise healthy. Materials and Methods: A Markov model was developed to estimate the quality-adjusted life expectancy (in quality-adjusted life-years [QALYs]), lifetime costs (in 2007 U.S. dollars), and net health benefits (QALY equivalent) of surgery, transarterial embolization (TAE), radiofrequency ablation (RFA), and watchful waiting. Model parameters and their distributions were derived from the literature and the hospital database. Results: In patients with HA tumors suitable for RFA, RFA had the highest effectiveness (23.89 QALYs) and lowest costs ($2965). The treatment decision was sensitive to RFA-related mortality. In patients with tumors unsuitable for RFA, watchful waiting combined with TAE in cases of hemorrhage had the highest effectiveness (23.83 QALYs) and lowest costs ($8493). The treatment decision was sensitive to probability of tumor growth, probability of hemorrhage, and hemorrhage-related mortality. Conclusion: According to the model results, the most favorable treatment strategy for patients with small HAs was RFA. In patients with HA unsuitable for RFA, watchful waiting was the optimal strategy. http://repub.eur.nl/res/pub/24457/ 2009-05-01T00:00:00Z Background: Cardiac rehabilitation (CR) is of proven benefit for patients with coronary artery disease. Patients who successfully complete CR have a statistically significant reduction in the risk of fatal myocardial infarction (MI) and all-cause mortality. Peripheral arterial disease (PAD) is common in patients with coronary artery disease. Objectives: We investigated whether PAD prevents the successful completion of CR and cardiac risk reduction and whether invasive treatment of claudicant patients who cannot walk sufficiently to successfully complete CR is indicated. Methods: The records of 230 consecutive CR patients were reviewed for attendance, target heart rate, and Walking Impairment Questionnaire (WIQ) values to compare PAD among successes and failures. Failure of CR was defined as inability to walk sufficiently to achieve target heart rate. Markov decision analysis using published data for endovascular and open intervention for claudication was used to compare outcomes of treatment strategies in which PAD is untreated (current standard), PAD is treated only if it interfered with CR, and treatment of PAD in all patients before initiating CR. Results: Of 230 patients, 126 had complete records for analysis. Ankle-brachial indices (ABIs) were documented for 39 patients. Overall, 40% of patients failed CR. Failure was significantly more common in patients with claudication (76%) than in those without (26%; odds ratio [OR], 8.9; 95% confidence interval [CI], 3.7-21.7; P < .001). The presence of PAD, determined by the WIQ walking distance score, was significantly higher in the failure group (34%) vs the success group (17%; OR, 2.5; 95% CI, 1.1-6.0; P = .03). The presence of PAD, determined by ABI, was higher in the failure group (39%) vs the success group (14%; OR, 3.8; 95% CI, 0.8-17.9; P = .08). Logistic regression analysis when CR failure was adjusted for age and gender was significantly associated with presence of PAD based on WIQ walking distance score (OR, 2.8; 95% CI 1.1-7.1; P = .03). A strategy of invasive therapy only if PAD interfered with the successful completion of CR would save an additional 54 lives per 10,000 patients compared with no intervention. Conclusions: PAD is a significant cause of CR failure, preventing patients from successfully completing the program and achieving a reduction in risk of fatal cardiac events. Invasive treatment of PAD in patients who fail CR is indicated, with an expected lifesaving outcome. http://repub.eur.nl/res/pub/24458/ 2009-05-01T00:00:00Z Objective: To validate the Glasgow Aneurysm Score (GAS) in patients with ruptured abdominal aortic aneurysms (AAAs) treated with endovascular repair or open surgery and to update the GAS so that it predicts 30-day mortality for patients with ruptured AAA treated with endovascular repair or open surgery. Methods: In a multicenter prospective observational study, 233 consecutive patients with ruptured AAAs were evaluated; 32 patients did not survive to repair and statistical analysis was performed using collected data on 201 patients. All patients who were treated with endovascular repair (n = 58) or open surgery (n = 143) were included. The GAS was calculated for each patient. The area under the receiver operating characteristics curve (AUC) was used to indicate discriminative ability. We tested for interactions between risk factors and the procedure performed. The GAS was updated to predict 30-day mortality after endovascular repair or open surgery in patients with ruptured AAAs using logistic regression analysis. Results: Thirty-day mortality was 15/58 (26%) for patients treated with endovascular repair and 57/143 (40%) for patients treated with open surgery (P = .06). The AUC for GAS was 0.69. No relevant interactions were found. The updated prediction rule (AUC = 0.70) can be calculated with the following formula: + 7 for open surgery + age in years + 17 for shock + 7 for myocardial disease + 10 for cerebrovascular disease + 14 for renal insufficiency. Conclusion: We showed limited discriminative ability of the GAS and therefore updated the GAS by adding the type of procedure performed. This updated prediction rule predicts 30-day mortality for patients with ruptured AAAs treated with endovascular repair or open surgery. http://repub.eur.nl/res/pub/18497/ 2009-02-01T00:00:00Z Purpose: To compare clinical success, functional capacity, and quality of life during 12 months after revascularization or supervised exercise training in patients with intermittent claudication. Materials and Methods: This study had institutional review board approval, and all patients gave written informed consent. Between September 2002 and September 2005, 151 consecutive patients who presented with symptoms of intermittent claudication were randomly assigned to undergo either endovascular revascularization (angioplasty-first approach) (n = 76) or hospital-based supervised exercise (n = 75). The outcome measures were clinical success, functional capacity, and quality of life after 6 and 12 months. Clinical success was defined as improvement in at least one category in the Rutherford scale above the pretreatment level. Significance of differences between the groups was assessed with the unpaired τ test, x2 test, or Mann-Whitney U test. To adjust outcomes for imbalances of baseline values, multi-variable regression analysis was performed. Results: Immediately after the start of treatment, patients who underwent revascularization improved more than patients who performed exercise in terms of clinical success (adjusted odds ratio [OR], 39; 99% confidence interval [CI]: 11, 131; P <.001), but this advantage was lost after 6 (adjusted OR, 0.9; 99% CI: 0.3, 2.3; P = .70) and 12 (adjusted OR, 1.1; 99% CI: 0.5, 2.8; P = .73) months. After revascularization, fewer patients showed signs of ipsilateral symptoms at 6 months compared with patients in the exercise group (adjusted OR, 0.4; 99% CI: 0.2, 0.9; P <.001), but no significant differences were demonstrated at 12 months. After both treatments, functional capacity and quality of life scores increased after 6 and 12 months, but no significant differences between the groups were demonstrated. Conclusion: After 6 and 12 months, patients with intermittent claudication benefited equally from either endovascular revascularization or supervised exercise. Improvement was, however, more immediate after revascularization. http://repub.eur.nl/res/pub/29170/ 2008-09-01T00:00:00Z Background & Aims: Budd-Chiari syndrome (BCS) is a rare and life-threatening disorder secondary to hepatic venous outflow obstruction. Small series of BCS patients indicate that transjugular intrahepatic portosystemic shunt (TIPS) may be useful. However, the influence of TIPS on patient survival and factors that predict the outcome of TIPS in BCS patients remain unknown. Methods: One hundred twenty-four consecutive BCS patients treated with TIPS in 6 European centers between July 1993 and March 2006 were followed until death, orthotopic liver transplantation (OLT), or last clinical evaluation. Results: Prior to treatment with TIPS, BCS patients had a high Model of End Stage Liver Disease and high Rotterdam BCS prognostic index (98% of patients at intermediate or high risk) indicating severity of liver dysfunction. However, 1- and 5-year OLT-free survival were 88% and 78%, respectively. In the high-risk patients, 5-year OLT-free survival was much better than that estimated by the Rotterdam BCS index (71% vs 42%, respectively). In the whole population, bilirubin, age, and international normalized ratio for prothrombin time independently predicted 1-year OLT-free survival. A prognostic score with a good discriminative capacity (area under the curve, 0.86) was developed from these variables. Seven out of 8 patients with a score >7 died or underwent transplantation vs 5 out of 114 patients with a score <7. Conclusions: Long-term outcome for patients with severe BCS treated with TIPS is excellent even in high-risk patients, suggesting that TIPS may improve survival. Furthermore, we identified a small subgroup of BCS patients with poor prognosis despite TIPS who might benefit from early OLT. http://repub.eur.nl/res/pub/14129/ 2008-01-01T00:00:00Z Aim. The aim of this study was to determine the influence of gender, age, the aneurysm diameter and comorbidity on the 30-day mortality after open repair of ruptured abdominal aortic aneurysms (AAA). Methods. Between January 1, 1993, and December 31, 2006 all consecutive patients who underwent open repair for a ruptured AAA at the tertiary care of Catharina teaching Hospital were included in this study (N=186). Patients who underwent endovascular repair of their ruptured abdominal aortic aneurysms were excluded from this study. Patient and procedure characteristics were collected and analyzed in relation to 30-day mortality. The association between age, gender, diameter of AAA and comorbidity with 30-day mortality was analyzed with χ2 are and logistic regression; a P value <0.05 was considered significant. Results. In this study there were 186 patients with ruptured AAA repair with an 30-day mortality of 36.6% (68/186). Among female patient 30-day mortality was 45.8% (11/24) compared with 35.2% (57/162) among male patients (P=0.31). Patients of 80 years and older had a 61.3% (19/31) 30-day mortality where younger patients had 33% (51/155) 30-day mortality (P=0.02). Thirty-day mortality was 47.2% (17/36) for patients with an AAA less than 65 mm compared with 34% (36/104) for patients with an AAA of 65 mm or larger (P=0.16). Multivariate analysis demonstrated age was a significant predictor of ruptured AAA repair mortality (P=0.017). Conclusion. In this study, age was the only significant risk factor of 30-day mortality after open repair in patients with ruptured AAA. http://repub.eur.nl/res/pub/11579/ 2007-09-01T00:00:00Z Objectives: The Medical Outcomes Study Short Form 36-Item Health Survey (SF-36) is the most widely used generic instrument to estimate quality of life of patients on renal replacement therapy. Purpose of this study was to summarize and compare the published literature on quality of life of hemodialysis (HD), peritoneal dialysis (PD), and renal transplant (RTx) patients. Methods: We used random-effects regression analyses to compare the SF-36 scores across treatment groups and adjusted this comparison for age and prevalence of diabetes using random-effects meta-regression analyses. Results: We found 52 articles that met the inclusion criteria, reporting quality of life of 36,582 patients. The unadjusted scores of all SF-36 health dimensions were not significantly different between HD and PD patients, but the scores of RTx patients were higher than those of dialysis patients, except for the dimensions Mental Health and Bodily Pain. Point differences between dialysis and RTx patients varied from 2 to 32. With adjustment for age and diabetes, the differences became smaller (point difference 2–22). The significance of the differences of both dialysis groups compared with RTx recipients disappeared for the dimensions Vitality and Social Functioning. The significance of the differences between HD and RTx patients disappeared on the dimensions Physical Functioning, Role Physical, and Bodily Pain. Conclusion: We conclude that dialysis patients have a lower quality of life than RTx patients, but this difference can partly be explained by differences in age and prevalence of diabetes. Keywords: hemodialysis, meta-analysis, peritoneal dialysis, quality of life, renal transplantation. http://repub.eur.nl/res/pub/13797/ 2005-06-01T00:00:00Z PURPOSE: To systematically review published data about the short- and long-term effects of exercise training and angioplasty on functional capacity and quality of life of patients with intermittent claudication. MATERIALS AND METHODS: Articles published between January 1980 and February 2003 were included if patients had intermittent claudication treated with exercise training or angioplasty and if both functional capacity and quality-of-life scores from Medical Outcomes Study 36-Item Short Form health survey were reported for at least 3 months of follow-up. Data were pooled by using a random effects model and weighted means. Pooled results were compared between the treatment groups by using the chi2 test and the Student t test (alpha = .05, two sided). RESULTS: In the analyses, five studies (202 patients) were included in the exercise group, and three studies (470 patients), in the angioplasty group. At 3 months of follow-up, the ankle-brachial index was significantly improved in the angioplasty group (mean change, 0.18; P < .01) but not in the exercise group (mean change, 0.01; P = .29). At 3 months, quality of life was significantly improved with regard to ratings of physical functioning and bodily pain in the exercise group (mean change, 18 and 10, respectively; P < .01) and physical role functioning in the angioplasty group (mean change, 30; P = .03). Mean change in ankle-brachial index significantly differed between the two treatment groups at 3 and 6 months (P < .01); mean change in quality-of-life scores did not. CONCLUSION: Improvement in quality of life was demonstrated after both exercise training and angioplasty, whereas functional capacity showed significant improvement after angioplasty. The ankle-brachial index significantly differed between the two treatment groups at 3 and 6 months, whereas the quality-of-life scores did not. http://repub.eur.nl/res/pub/9763/ 2001-01-01T00:00:00Z PURPOSE: To perform a meta-analysis of long-term results of balloon dilation and stent implantation in the treatment of femoropopliteal arterial disease. MATERIALS AND METHODS: The English-language literature was searched for studies published between 1993 and 2000. Inclusion criteria for articles were presentation of long-term primary patency rates, standard errors (explicitly reported or derivable), and baseline characteristics of the study population. Two reviewers independently extracted data, and discrepancies were resolved by consensus. Primary patency rates were combined by using a technique that allows adjustment for differences across study populations. Analyses were adjusted for lesion type and clinical indication. RESULTS: Nineteen studies met the inclusion criteria, representing 923 balloon dilations and 473 stent implantations. Combined 3-year patency rates after balloon dilation were 61% (standard error, 2.2%) for stenoses and claudication, 48% (standard error, 3.3%) for occlusions and claudication, 43% (standard error, 4.1%) for stenoses and critical ischemia, and 30% (standard error, 3.7%) for occlusions and critical ischemia. The 3-year patency rates after stent implantation were 63%-66% (standard error, 4.1%) and were independent of clinical indication and lesion type. Funnel plots demonstrated an asymmetric distribution of the data points associated with stent studies. CONCLUSION: Balloon dilation and stent implantation for claudication and stenosis yield similar long-term patency rates. For more severe femoropopliteal disease, the results of stent implantation seem more favorable. Publication bias could not be ruled out. http://repub.eur.nl/res/pub/9407/ 2000-01-01T00:00:00Z PURPOSE: To perform a meta-analysis of renal arterial stent placement in comparison with renal percutaneous transluminal angioplasty (PTA) in patients with renal arterial stenosis. MATERIALS AND METHODS: Studies dealing with renal arterial stent placement (14 articles; 678 patients) and renal PTA (10 articles; 644 patients) published up to August 1998 were selected. A random-effects model was used to pool the data. RESULTS: Renal arterial stent placement proved highly successful, with an initial adequate performance in 98% and major complications in 11%. The overall cure rate for hypertension was 20%, whereas hypertension was improved in 49%. Renal function improved in 30% and stabilized in 38% of patients. The restenosis rate at follow-up of 6-29 months was 17%. Stent placement had a higher technical success rate and a lower restenosis rate than did renal PTA (98% vs 77% and 17% vs 26%, respectively; P <.001). The complication rate was not different between the two treatments. The cure rate for hypertension was higher and the improvement rate for renal function was lower after stent placement than after renal PTA (20% vs 10% and 30% vs 38%, respectively; P <.001). CONCLUSION: Renal arterial stent placement is technically superior and clinically comparable to renal PTA alone. http://repub.eur.nl/res/pub/9122/ 1999-01-01T00:00:00Z BACKGROUND: To assess the quality of life in patients with iliac artery occlusive disease, we compared primary stent placement versus primary angioplasty followed by selective stent placement in a multicenter randomized controlled trial. METHODS AND RESULTS: Quality-of-life assessments were completed by 254 patients in a telephone interview. Assessment measures consisted of the RAND 36-Item Health Survey 1.0, time tradeoff, standard gamble, rating scale, health utilities index, and EuroQol-5D. The interviews were performed before treatment and after 1, 3, 12, and 24 months. When the 2 treatments were compared, no significant difference was observed (P>0.05). All measurements showed a significant improvement in the quality of life after treatment (P<0.05). The RAND 36-Item Health Survey measures physical functioning, role limitations caused by physical problems, and bodily pain and the EuroQol-5D were the most sensitive to the impact of revascularization. CONCLUSIONS: Health-related quality of life improves equally after primary stent placement and primary angioplasty with selective stent placement in the treatment of intermittent claudication caused by iliac artery occlusive disease.