Wetenschappelijk jaaroverzicht 2009 en Abstractboek Wetenschapsdag 2010

Wetenschappelijk jaaroverzicht 2009 en Abstractboek Wetenschapsdag 2010

Wetenschappelijk jaaroverzicht 2009 en Abstractboek Wetenschapsdag 2010

Leerhuis Albert Schweitzer ziekenhuis Postbus 444 3300 AK Dordrecht Tel: (078) 654 51 00 www.asz.nl Een uitgave van het Albert Schweitzer ziekenhuis

Onder redactie van: Hoofdredactie M.C.J.M. Kock C.A. van Iersel Redactie R. Manuhutu E.Y. de Kruyf-Haksteen Wetenschapscommissieleden Met dank aan alle medewerkers die de totstandkoming van deze uitgave mogelijk hebben gemaakt.

Wetenschappelijk jaaroverzicht 2009 en Abstractboek Wetenschapsdag 2010

Een uitgave van het Albert Schweitzer ziekenhuis

Oplage: 750 Cover and lay-out: Artoos Communicatiegroep b.v. Printed by: Artoos Communicatiegroep b.v. ISBN: 978-90-816089-1-6

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Inhoud Voorwoord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Samenstelling Wetenschapscommissie 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Wetenschappelijk jaaroverzicht 2009 per vakgroep: Anesthesiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Cardiologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Chirurgie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Gynaecologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Interne Geneeskunde . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Keel Neus Oorziekten . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Kindergeneeskunde. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Klinische chemie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Kwaliteit, Veiligheid en Innovatie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Longziekten . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Neurologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Nucleaire geneeskunde . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Orthopedie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Pathologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Radiologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Spoedeisende Hulp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Urologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Ziekenhuis psychiatrie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Promoties 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Verantwoording wetenschappelijk jaaroverzicht 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Abstractboek Wetenschapsdag 2010: Externe spreker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Mondelinge presentaties Wetenschapsdag 2010 Anesthesiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Chirurgie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Gynaecologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Interne geneeskunde . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Klinische Chemie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Pathologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

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Inhoud Posters Wetenschapsdag 2010 Anesthesiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Cardiologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Chirurgie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Geriatrie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Gynaecologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Neurologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Interne geneeskunde . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Klinische Chemie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Klinische Psychiatrie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Pathologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Radiologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

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Voorwoord Het laatste jaar was voor de wetenschapscommissie een jaar van veranderingen en nieuwe uitdagingen. Als eerste is het voorzitterschap van prof. T. Cleophas naar mij overgegaan. Prof. Cleophas heeft aan de wieg gestaan van de wetenschapscommissie waar hij zich uitermate sterk voor heeft ingezet, en dat nog steeds doet. Hiervoor zijn wij hem zeer erkentelijk. De wetenschapscommissie is vervolgens de weg ingeslagen van verdere professionalisering en formalisering om het wetenschappelijk klimaat in het Albert Schweitzer ziekenhuis (ASz) zo goed mogelijk te kunnen faciliteren. Er is een dagelijks bestuur ingesteld die wekelijks overleg heeft zodat met korte zetten nieuwe initiatieven werden ontplooid. Tevens heeft de wetenschapscommissie door de aanstelling van mw. C. van Iersel als beleidsadviseur nieuwe competenties binnengehaald. Het Albert Schweitzer ziekenhuis is geassocieerd lid van de vereniging Samenwerkende Topklinische opleidingsZiekenhuizen (STZ). Het ASz heeft de ambitie om de volwaardige STZ status te verwerven door te voldoen aan de toelatings- en hervisitatiecriteria in 2011. Het ASz levert niet alleen topklinsche zorg, maar huisvest ook velerlei (medische) opleidingen ondersteund door het Leerhuis. Binnen het ASz zijn diverse zelfstandige wetenschappelijke projecten actief en lopen er wetenschappelijke samenwerkingsverbanden met andere medische zorginstellingen. Door het verrichten van medisch wetenschappelijk onderzoek kunnen haar medewerkers opgeleid worden met hoge vakinhoudelijke kwaliteit en met wetenschappelijk beproeft fundament waardoor de medische zorg kan blijven verbeteren. De wetenschapscommissie heeft tot doel om arts-assistenten, co-assistenten, geneeskundige studenten, stafleden, verpleegkundigen en andere medewerkers zo goed mogelijk te faciliteren om wetenschappelijk onderzoek in het ASz te verrichten en wetenschappelijk onderzoek te bevorderen. De wetenschapscommissie is hiervoor op 1 januari 2007 opgericht. Het Leerhuis biedt hierbij ondersteuning. De Wetenschapscommissie wordt ondersteund door het Leerhuis en heeft via het Leerhuis een lijn naar de Raad van Bestuur. Verder zoekt de wetenschapscommissie draagvlak en samenwerking via de Medisch Specialisten Opleidingscommissie. Hierdoor werkt de wetenschapscommissie aan een stimulerend onderzoeksklimaat in het ASz. Een van de mijlpalen van het afgelopen jaar die de wetenschapscommissie heeft kunnen neerzetten is het stipendium ondersteund door gelden vanuit het Leerhuis. Zonder investeringen van tijd en geld kan wetenschappelijk onderzoek natuurlijk nooit goed van de grond komen. Met het stipendium (wetenschapsfonds) van het ASz kan de wetenschapscommisie haar onderzoekers financieel ondersteunen. Dit zal een flinke impuls geven aan het wetenschappelijk onderzoek in het ASz. Op de eerste inschrijfronde van de tweede helft van 2010 hebben we 5 aanvragen voor een stipendium binnengekregen. Verder wordt sinds dit jaar het uitermate fraaie wetenschappelijk tijdschrift (het WASZ) uitgegeven, met voorlopig jaarlijks 2 nummers met een oplage van 500 exemplaren. Hiermee worden medewerkers en verwijzers van het ASz op de hoogte gehouden van allerlei wetenschappelijk nieuws en activiteiten van het ASz. De wetenschapscommissie wil nog eens benadrukken dat in 2009 twee van haar AIOS’en en in 2010 ook weer twee van haar AIOS’en zijn gepromoveerd aan de Erasmus Universiteit / Erasmus MC. Bijzonder is dat ASz staflid mw. G.S. Kooi als co-promotor optrad bij de promotie van de heer C. Gerestijn.

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We hebben de volgende wetenschappelijke cursussen weten te continueren: ‘wetenschappelijk onderzoek opzetten’, ‘steekproefgrootte berekenen’, ‘statische software (SPSS) gebruiken’, ‘valideren diagnostische tests’. Deze zijn verder uitgebreid met de cursussen ‘pubmed’, ‘poster maken’ en de cursus ‘medical writing in english’ welke in november van start gaat. Bovendien blijft het wetenschappelijk spreekuur een belangrijk terugkerend succes om wetenschap zo goed mogelijk te ondersteunen. De wetenschapscommissie heeft in september het multidisciplinair onderwijs verzorgd. Hierbij werd uitvoerig ingegaan op wat noodzakelijk is om wetenschappelijk onderzoek uit te voeren; van idee naar publicatie, de nieuwe wetenswaardigheden omtrent pubmed; over regelgeving; over de METC, over tips bij presenteren; en allerminst over de ervaringen in het veld over wetenschap bedrijven in het ASz. De jaarlijkse wetenschapsdag blijft als de barometer van het wetenschappelijk klimaat in het ASz een belangrijk moment. Het blijft spannend hoeveel wetenschappelijke resultaten de enthousiaste onderzoekers hebben kunnen publiceren en presenteren op nationale en internationale congressen en in nationale en internationale vakbladen. We zijn zeer vereert dat dr. N.H.M. Renders, arts-microbioloog uit het Jeroen Bosch Ziekenhuis de wetenswaardigheden en actuele feiten over Q-koorts en de Q-koorts-poli op de wetenschapsdag presenteert. Dit jaar is de wetenschapsdag meer dan ooit het podium voor de ASz-onderzoekers, die grotendeels bestaat uit de arts-assistenten, om hun wetenschappelijke resultaten presenteren. Dat is niet alleen belangrijk voor nieuwe kennis en inzichten, maar ook voor de onderzoekers om zelf ervaring op te doen in presenteren en publiceren. Er wordt gestreden om de prijs van de ‘beste publicatie van 2009’, de prijs voor de ‘beste mondelinge presentatie’ en de prijs voor de ‘beste poster’. Ondanks dat er veel is bereikt in de afgelopen periode heeft de Wetenschapscommissie nog genoeg ambities voor de toekomst. Lopende wetenschappelijke onderzoekslijnen worden geinventariseerd en gepubliceerd op de website, zodat geïnteresseerde jonge onderzoekers meteen kunnen aanhaken bij bestaande lijnen. Dit is een win-win situatie voor zowel de geïnteresseerde onderzoeker als voor de projectleider. Dit leidt tot betere facilitatie van het wetenschappelijk onderzoek en tot een toename van wetenschappelijke output. Door deze kennis kan de patiëntenzorg worden verbeterd. Bovendien is dit belangrijk voor de arts-assistent die zijn ambities kan presenteren en voor het ASz die door toename van kennis door wetenschap de zorg van patiënten kan optimaliseren. De wetenschapscommissie benadrukt en stimuleert de noodzaak tot multidisciplinaire samenwerking op het gebied van wetenschappelijk onderzoek en publicaties. Dit bevordert de multidisciplinaire ondersteuning maar zorgt ook voor extra kwaliteit van het onderzoek. Bovendien zal deze positieve werkhouding de inzet van medewerkers versterken wat weer kan leiden tot meer wetenschappelijke output. Ik wens u een interessante en succesvolle wetenschappelijke toekomst toe.

Marc Kock Voorzitter wetenschapscommissie

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Samenstelling Wetenschapscommissie 2010 Dagelijks bestuur dr. M.C.J.M. Kock, voorzitter, radioloog dr. M-D Levin, vice-voorzitter, internist-hematoloog drs. C.A. van Iersel, beleidsadviseur

Overige leden 2010 drs. A. Bischoff, KNO arts dr. E.F.H. van Bommel, internist-nefroloog dr. R.P.M. Ceulen, dermatoloog prof. dr. A.J.M. Cleophas, internist mw. R. van Hof, medisch informatiespecialist (Bibliotheek) drs. A.D. Klaren, manager Leerhuis dr. L.F.G. Krist, anesthesiolooog dr. P.W. Plaisier, chirurg drs. J.M.M. van de Ridder, onderwijskundig adviseur Leerhuis drs. S. Rombout-de Weerd, gynaecoloog dr. C.J. Sas, kinderarts drs. N. Swarte, gynaecoloog drs. A. van der Velden, arts-assistent spoedeisende geneeskunde dr. P.J. Westenend, patholoog drs. L.J.P.M. van Woerkens, cardioloog drs. D. Zemel, neuroloog Oud leden 2009: drs. M. Tax, klinisch chemicus i.o. dr. A.W.M.M. Koopman-van Gemert, anesthesiolooog

Hoofdredactie Wetenschappelijk tijdschrift ‘WASz’ 2009 drs. M. Tax, klinisch chemicus i.o. drs. A. van der Velden, arts-assistent spoedeisende geneeskunde dr. J. Prins, klinisch chemicus

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Wetenschappelijk jaaroverzicht 2009 per vakgroep

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Anesthesiologie PubMed publicaties Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: a randomized controlled trial (DECREASE-IV). Dunkelgrun M, Boersma E, Schouten O, Koopman-van Gemert AW, van Poorten F, Bax JJ, Thomson IR, Poldermans D; Dutch Echocardiographic Cardiac Risk Evaluation. Applying Stress Echocardiography Study Group. Ann Surg. 2009 Jun, 249(6):921-6. OBJECTIVE: This study evaluated the effectiveness and safety of beta-blockers and statins for the prevention of perioperative cardiovascular events in intermediate-risk patients undergoing noncardiovascular surgery. SUMMARY BACKGROUND DATA: Beta-blockers and statins reduce perioperative cardiac events in high-risk patients undergoing vascular surgery by restoring the myocardial oxygen supply/demand balance and/or stabilizing coronary plaques. However, their effects in intermediate-risk patients remained ill-defined. METHODS: In this randomized open-label 2 x 2 factorial design trial 1066 intermediate cardiac risk patients were assigned to bisoprolol, fluvastatin, combination treatment, or control therapy before surgery (median: 34 days). Intermediate risk was defined by an estimated risk of perioperative cardiac death and myocardial infarction (MI) of 1% to 6%, using clinical data and type of surgery. Starting dose of bisoprolol was 2.5 mg daily, titrated to a perioperative heart rate of 50 to 70 beats per minute. Fluvastatin was prescribed in a fixed dose of 80 mg. The primary end point was the composite of 30-day cardiac death and MI. This study is registered in the ISRCTN registry and has the ID number ISRCTN47637497. RESULTS: Patients randomized to bisoprolol (N = 533) had a lower incidence of perioperative cardiac death and nonfatal MI than those randomized to bisoprolol-control (2.1% vs. 6.0% events; hazard ratios: 0.34; 95% confidence intervals: 0.17-0.67; P = 0.002). Patients randomized to fluvastatin experienced a lower incidence of the end point than those randomized to fluvastatin-control therapy (3.2% vs. 4.9% events; hazard ratios: 0.65; 95% confidence intervals: 0.35-1.10), but statistical significance was not reached (P = 0.17). CONCLUSION: Bisoprolol was associated with a significant reduction of 30-day cardiac death and nonfatal MI, while fluvastatin showed a trend for improved outcome.

Remifentanil-propofol analgo-sedation shortens duration of ventilation and length of ICU stay compared to a conventional regimen: a centre randomised, cross-over, open-label study in the Netherlands. Rozendaal FW, Spronk PE, Snellen FF, Schoen A, van Zanten AR, Foudraine NA, Mulder PG, Bakker J; UltiSAFE investigators. Collaborators: Polderman K, Fennema N, Jacobs CJ, Smid JC, Koopman-van Gemert A., van der Meer AD, Versluis DJ, de Jong M. Intensive Care Med. 2009 Feb, 35(2):291-8. OBJECTIVE: Compare duration of mechanical ventilation (MV), weaning time, ICU-LOS (ICU-LOS), efficacy and safety of remifentanil-based regimen with conventional sedation and analgesia. DESIGN: Centre randomised, open-label, crossover, ‘real-life’ study. SETTING: 15 Dutch hospitals. PATIENTS: Adult medical and post-surgical ICU patients with anticipated short-term (2-3 days) MV. INTERVENTIONS: Patient cohorts were randomised to remifentanil-based regimen (n = 96) with propofol as required, for a maximum of 10 days, or to conventional regimens (n = 109) of propofol,

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midazolam or lorazepam combined with fentanyl or morphine. MEASUREMENTS AND MAIN RESULTS: Outcomes were weaning time, duration of MV, ICU-LOS, sedation- and analgesia levels, intensivist/ICU nurse satisfaction, adverse events, mean arterial pressure, heart rate. Median duration of ventilation (MV) was 5.1 days with conventional treatment versus 3.9 days with remifentanil (NS). The remifentanilbased regimen reduced median weaning time by 18.9 h (P = 0.0001). Median ICU-LOS was 7.9 days versus 5.9 days, respectively (NS). However, the treatment effects on duration of MV and ICU stay were time-dependent: patients were almost twice as likely to be extubated (P = 0.018) and discharged from the ICU (P = 0.05) on day 1-3. Propofol doses were reduced by 20% (P = 0.05). Remifentanil also improved sedation-agitation scores (P < 0.0001) and intensivist/ICU nurse satisfaction (P < 0.0001). All other outcomes were comparable. CONCLUSIONS: In patients with an expected short-term duration of MV, remifentanil significantly improves sedation and agitation levels and reduces weaning time. This contributes to a shorter duration of MV and ICU-LOS.

Overige publicaties Sepsis and multi-organ failure in a patient infected with Pasteurella Multocida. Van Bruggen V, Gielen W, Ponssen H, Voss A, Keijman J. Neth J Crit Care. 2009, 13(3):139-141.

Continuously improving patient safety by a Rapid Respons System. Van Bruggen V, Barendrecht P, Geense A, van Dijk E, Achilleos M, Saris I, Meijer M, Deykers A, Verwoerdt G, Taks M, Oskam E, So R. Neth J Crit Care. 2009, 13(6):324.

Advies voor maatregelen ter voorkoming van hersenfunctiemonitoring. Koopman-van Gemert AWMM, Van den Nieuwenhuyzen MCO. De Anesthesioloog. 2009, 3:8-11.

Voordrachten Continu verbeteren van de patiëntveiligheid via een Spoed Interventie Systeem. van Bruggen V, So R. Congres Expeditie patientveiligheid. Rotterdam, november 2009.

Clinical Experience – ToMaat study. Koopman-van Gemert AWMM. International Course Donor “Train the Trainer”. Nieuwegein, januari 2009.

Beleid bij massaal bloedverlies in de (semi) acute fase. Koopman-van Gemert AWMM. NVB symposium. Ede, mei 2009.

Bloedmanagement “State of the art”. Koopman-van Gemert AWMM. Symposium. St. Maartenskliniek, Nijmegen, mei 2009.

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Management groot bloedverlies. Koopman-van Gemert AWMM. Multidisciplinaire bespreking. Albert Schweitzer ziekenhuis, Dordrecht, september 2009.

Beleid bij massaal bloedverlies. Koopman-van Gemert AWMM. NVIC symposium traumatologie en acute geneeskunde. Ede, september 2009.

Spoedprocedures bij groot bloedverlies. Koopman-van Gemert AWMM. Postgraduate symposium. Sint Augustinus ziekenhuis Antwerpen, oktober 2009.

Autotransfusie. Koopman-van Gemert AWMM. NVML symposium. Woerden, december 2009.

Posters Postoperatieve Pijn Management bij Open Liesbreuk Correcties. POPM trial. Koopman-van Gemert AWMM, Sarar M. Wetenschapsdag Albert Schweitzer ziekenhuis. Dordrecht, juni 2009.

Hospital mortality analysis in a large teaching hospital suggests need for implementation of a rapid response system. So KL. NVIC dagen. Ede, februari 2009.

The integrative Real Time Monitoring bundle: enhancing patient safety using a combination of an outcome monitoring tool and patient chart analysis on a hospital wide level. So KL. International Forum Quality & Safety in Health Care. Berlijn, maart 2009.

Dutch National Initiative for implementation of rapid response systems: “the Dutch approach”. So KL. 5th International Symposium on Rapid Response Systems and Medical Emergency Teams. Kopenhagen, mei 2009.

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Cardiologie PubMed publicaties Computed tomography unmasks a phantom tumour Baks T, Kock MCJM, Kofflard MJ. Int J Cardiol. 2009, Apr 18. [Epub ahead of print] We describe a patient with left sided congestive heart failure and a round-shaped mass on the chest X-ray. Using computed tomography, the mass is diagnosed as a phantom tumour consisting of loculated effusion in the interlobular fissure that vanishes after treatment for heart failure is initiated.

A rare coronary anomaly detected by computed tomography angiography: the left circumflex artery originating from the descending thoracic aorta. Hoogstraate SR, Kofflard MJ, Nieman K, Kock MCJM. Eur J Cardiothorac Surg. 2009 Jun, 35(6):1077. Geen abstract in PubMed.

Diastolic abnormalties as the first feature of hypertrophic cardiomyopathy in Dutch Myosin-Binding Protein C founder mutations. Michels M, Soliman OI, Kofflard MJ, Hoedemaekers YM, Dooijes D, Majoor-Krakauer D, ten Cate FJ. JACC Cardiovasc Imaging. 2009 Jan, 2(1):58-64. OBJECTIVES: To test the hypothesis that carriers of Dutch founder mutations in cardiac myosinbinding protein C (MYBPC3), without left ventricular hypertrophy (LVH) or electrocardiographic abnormalities, have diastolic dysfunction on tissue Doppler imaging (TDI), which can be used for the screening of family members in the hypertrophic cardiomyopathy (HCM) population. BACKGROUND: TDI is a more sensitive technique for the assessment of left ventricular contraction and relaxation abnormalities than is conventional echocardiography. METHODS: Echocardiographic studies including TDI were performed in genotyped hypertrophic cardiomyopathy patients (genotype-positive, G+/LVH+; n = 27), mutation carriers without LVH (G+/LVH-; n = 27), and healthy controls (n = 55). The identified mutations in MYBPC3 in the G+/LVH+ subjects were c.2864_2865delCT (12 subjects), c.2373dupG (n = 8), and p. Arg943X (n = 7). In the G+/LVH- subjects, the following mutations were identified: c.2864_2865delCT (n = 11), c.2373dupG (n = 8), and p. Arg943X (n = 8). RESULTS: Mean TDI-derived systolic and early and late diastolic mitral annular velocities were significantly lower in the G+/LVH+ subjects compared with the other groups. However, there was no difference between controls and G+/LVH- subjects. Mean TDI-derived late mitral annular diastolic velocities were significantly higher in the G+/LVH- subjects compared with controls and G+/LVH+ subjects. Using a cut-off value of mean +/- 2 SD, an abnormal late mitral annular diastolic velocity was found in 14 (51%) of G+/LVH- patients. There was no difference among the 3 different mutations. CONCLUSIONS: In contrast to earlier reports, mean mitral annular systolic velocity and early mitral annular diastolic velocity velocities were not reduced in G+/LVH- subjects, and TDI velocities were not sufficiently sensitive for determination of the affected status of an individual subject. Our findings, however, support the theory that diastolic dysfunction is a primary component of pre-clinical HCM.

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Disease penetrance and risk stratification for sudden cardiac death in asymptomatic hypertrophic cardiomyopathy mutation carriers. Michels M, Soliman OI, Phefferkorn J, Hoedemaekers YM, Kofflard MJ, Dooijes D, MajoorKrakauer D, Ten Cate FJ. Eur Heart J. 2009 Nov, 30(21):2593-8. AIMS: To investigate the outcome of cardiac evaluation and the risk stratification for sudden cardiac death (SCD) in asymptomatic hypertrophic cardiomyopathy (HCM) mutation carriers. METHODS AND RESULTS: Seventy-six HCM mutation carriers from 32 families identified by predictive DNA testing underwent cardiac evaluation including history, examination, electrocardiography, Doppler echocardiography, exercise testing, and 24 h Holter monitoring. The published diagnostic criteria for HCM in adult members of affected families were used to diagnose HCM. Thirty-three (43%) men and 43 (57%) women with a mean age of 42 years (range 16-79) were examined; in 31 (41%) HCM was diagnosed. Disease penetrance was age related and men were more often affected than women (P = 0.04). Myosin Binding Protein C (MYBPC3) mutation carriers were affected at higher age than Myosin Heavy Chain (MYH7) mutation carriers (P = 0.01). Risk factors for SCD were present in affected and unaffected carriers. CONCLUSION: Hypertrophic cardiomyopathy was diagnosed in 41% of carriers. Disease penetrance was age dependent, warranting repeated cardiologic evaluation. The MYBPC3 mutation carriers were affected at higher age than MYH7 mutation carriers. Risk factors for SCD were present in carriers with and without HCM. Follow-up studies are necessary to evaluate the effectiveness of risk stratification for SCD in this population.

Voordrachten Minor Elevations in Troponin I Predict Mortality in Patients With Atrial Fibrillation. van den Bos EJ, Constantinescu AA, Domburg van RT, Kofflard MM. AHA Annual Meeting 2009. Washington, april 2009. Circulation. 2009, 120:S673.

Left atrial stimulation (LAS) versus right atrial stimulation (RAS) for paroxysmal atrial fibrillation (PAF) in sick sinus syndrome (SSS). Breuls N. Atrial stimulation from the coronary sinus in PAF (ACSIPAF). ECG cursus. Ierland, 2009.

Usefulness of intra-aortic balloon pump counterpulsation in patients with cardiogenic shock from acute myocardial infarction. den Uil CA. European Society of Cardiology, Annual Congress. Barcelona, september 2009.

Percutaneous left ventricular assist devices vs. intra-aortic balloon pump counterpulsation for treatment of cardiogenic shock: a meta-analysis of controlled trials. den Uil CA. European Society of Intensive Care Medicine, Annual Congress. Wenen, oktober 2009.

Mechanical circulatory support devices improve tissue perfusion in patients with end-stage heart failure or cardiogenic shock. den Uil CA. European Society of Intensive Care Medicine, Annual Congress. Wenen, oktober 2009. 17

Cardiologie

Dose-dependent benefit of nitroglycerin on microcirculation of patients with severe heart failure. den Uil CA. European Society of Intensive Care Medicine, Annual Congress. Wenen, oktober 2009.

Posters Left atrial stimulation (LAS) versus right atrial stimulation (RAS) for paroxysmal atrial fibrillation (PAF) in sick sinus syndrome (SSS). Atrial stimulation from the coronary sinus in PAF (ACSIPAF). Breuls PNWM, Zock E, Schmidt H, Woerkens van LJ, Res J. In: EP-Europace 11(2). Berlijn, juni 2009.

Impaired microcirculation is associated with lactate level in patients with cardiogenic shock. den Uil CA. International Symposium on Intensive Care. Brussel, maart 2009.

Low-dose nitroglycerin improves microcirculation in hospitalized patients with acute heart failure. den Uil CA. European Society of Cardiology, Annual Congress. Barcelona, september 2009.

Percutaneous left ventricular assist devices vs. intra-aortic balloon pump counterpulsation for treatment of cardiogenic shock: a meta-analysis of controlled trials. den Uil CA. European Society of Intensive Care Medicine, Annual Congress. Wenen, oktober 2009.

Prognosis of patients undergoing cardiac surgery and treated with intra-aortic balloon pump counterpulsation prior to surgery: a long-term follow-up study. den Uil CA. European Society of Intensive Care Medicine, Annual Congress. Wenen, oktober 2009.

Inverse correlation between nitroglycerin induced changes in central-peripheral termperature gradient and changes in sublingual perfused capillary density in patients with cardiogenic shock or end-stage chronic heart failure. den Uil CA. European Society of Intensive Care Medicine, Annual Congress. Wenen, oktober 2009.

Do changes in noninvasive hemodynamic parameters in patients with heart failure and treated with cardiac resynchronization therapy correspond with changes in quality of life? Zock E, de Boer RP, de Boer TJM, Constantinescu AA, Breuls PNWM. Wetenschapsdag Albert Schweitzer ziekenhuis. Dordrecht, juni 2009.

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Chirurgie PubMed publicaties Distensibility of Forearm Veins in Haemodialysis Patients on Duplex Ultrasound Testing Using Three Provocation Methods. Korten E, Spronk S, Hoedt MT, de Jong GM, Tutein Nolthenius RP. Eur J Vasc Endovasc Surg. 2009, 38(3):375-380. OBJECTIVE: It is well-known that vasodilatator function is affected in patients with renal failure. We hypothesized impaired venous forearm distensibility in haemodialysis patients. The purpose of this study was to investigate which provocation method generated ‘maximal’ venous distensibility in the forearm of haemodialysis patients compared to healthy volunteers by using duplex ultrasound. DESIGN: The study group consisted of haemodialysis patients (n=30) and healthy volunteers (n=30). In each participant ultrasound measurements of the venous diameter were performed by using 3 different provocation methods. METHODS: The applied provocation methods were: 1) hydrostatic pressure, 2) venous congestion and 3) hydrostatic pressure and warmth. Significance of differences in mean diameter changes within the groups was assessed with the paired t-test. Significance of differences in mean diameter changes between the groups was compared by using multivariate regression analysis. RESULTS: In haemodialysis patients, the increase in mean diameter after the different methods was: 29% after methods 2 versus 1, 23% after methods 3 versus 2 and 59% after methods 3 versus 1. In healthy volunteers, the mean diameter increase was: 27% after methods 2 versus 1, 29% after methods 3 versus 2 and 64% after methods 3 versus 1. The greatest increase in the mean internal venous diameter among the haemodialysis patients and the healthy volunteers was after the provocation method which combined hydrostatic pressure with warmth (mean difference: 1mm, 95% CI: .57, 1.36; P<.001 and mean difference: 1.4mm, 95% CI: .88, 1.78; P<.001, respectively). After adjustment for the baseline variables, both groups demonstrated a non-significant mean diameter difference for each of the provocation methods. CONCLUSION: Hydrostatic pressure combined with warmth generates the greatest venous distensibility in the lower arm in haemodialysis patients in a sitting position and is not significantly different compared to healthy volunteers. Without the superior provocation method, venous diameters of haemodialysis patients can be assessed as false-negatives yielding that a primary radio cephalic arteriovenous fistula (RCAVF) at wrist level (the first choice) in these patients will be withheld.

Cryoplasty for occlusive disease of the femoropopliteal arteries: 1-year follow-up. Korteweg MA, van Gils M, Hoedt MT, van der Valk PH, Tutein Noltenius RP, Avontuur JA, Bronswijk-Monster KF, Elgersma OE. Cardiovasc Intervent Radiol. 2009, 32(2):221-5. Atherosclerosis of femoropopliteal arteries is an important cause of morbidity and mortality. Percutaneous transluminal angioplasty (PTA) has only limited success in treating these arteries, mainly because of the high rate of recurrent stenosis. Cryoplasty has been proposed as a technique which might improve treatment outcome. This study reports our single-center experience with cryoplasty. Thirty-two claudicants, 33 arteries, in whom conservative therapy failed, were consecutively included. Duplex ultrasound (US), angiography, and ankle-brachial index (ABI) measurement were performed before the procedure; ABI and duplex US, 2 weeks and 3, 6, and 12 months after the procedure. Patients’ symptoms were categorized according to the Rutherford classification. Lesions were classified as TASC A, B, or C according to angiographic appearance. Differences in ABI before and after the procedure were defined as significant at

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p < 0.05 by paired t-test. Patency was evaluated using duplex US by determining the peak systolic velocity ratio. Sixteen TASC A lesions, 13 TASC B lesions, and 4 TASC C lesions were included. ABI improved significantly for TASC A lesions 2 weeks and 3 months postprocedure. Patency after 2 weeks, 6 months, and 12 months was 93%, 67%, and 64% for TASC A lesions, 83%, 31%, and 31% for TASC B lesions, and 100%, 50%, and 33% for TASC C lesions, respectively. In conclusion, cryoplasty has good immediate success rates and patency rates similar to the results of conventional PTA in the literature.

Suppose a mammary carcinoma is absent from the surgical specimen. Kuipers IM, Oostenbroek RJ, Storm RK, Menke-Pluymers MB, Westenend PJ, Plaisier PW. Ned Tijdschr Geneeskd. 2009, 153:A3. In three women aged 53, 51, and 42 respectively, who were treated by breast-conserving surgery for mammary carcinoma, the cancer was not found in the surgical specimen. For both patient and treating physician it is rather worrying when there is no good explanation for the fact that a histologically proven breast cancer cannot be detected in the surgical specimen without neoadjuvant therapy having been given. It is important to revise the needle biopsies, to exclude mix up of patient materials, to totally include the resected specimen in the pathological examination and to perform addition imaging of the remaining breast, preferably with MRI. An explanation may be that biopsy has removed such an amount of tumour tissue that the remains are not found. If no flaws are apparent, adjuvant radiotherapy and further adjuvant therapy on indication suffices.

Een man met buikpijn, braken en obstipatie. Langeveld ARJ, Dinkelaar W. Ned Tijdschr Geneeskd. 2009, 153:B83 Geen abstract in PubMed.

Complications and failure of uterine artery embolisation for intractable postpartum haemorrhage. Maassen MS, Lambers MD, Tutein Nolthenius RP, van der Valk PH, Elgersma OE. BJOG. 2009, 116(1):55-61. OBJECTIVE: Primary postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality around the world. Most patients can be managed conservatively, but patients with intractable bleeding require more aggressive treatment. In these cases uterine artery embolisation (UAE) has proven to be a useful tool to control PPH. The reported success rate of UAE is over 90% with only minor complications. In this case series we studied the effectiveness and complications of UAE. DESIGN: Retrospective analysis of a case series. SETTING: Case series in a large peripheral hospital in the Netherlands. SAMPLE: Eleven patients who were treated with UAE for intractable PPH from November 2004 to February 2008. METHODS: In this paper we review the results of all patients treated with UAE for intractable PPH in our hospital and focus on the two cases with adverse outcomes. MAIN OUTCOME MEASURES: Effectiveness, causes of failure of UAE, complications. RESULTS: Nine out of eleven patients were treated successfully with UAE. One patient needed an emergency hysterectomy for intractable bleeding. In the aftermath she developed a vesicovaginal fistula (VVF). Another patient suffered a major thrombo-embolic event of the right leg, for which she underwent embolectomies and despite fasciotomy a necrotectomy.

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CONCLUSIONS: UAE is a valuable tool in managing major PPH and in most cases it can replace surgery and thus prevent sacrification of the uterus. However, due to blood supply of the uterus by one of the ovarian or aberrant arteries, UAE might fail to control the bleeding. In addition, serious complications such as a thrombo-embolic event or VVF may occur. We hereby present a case of migration of an embolus from the site of re-embolisation into the femoral artery requiring immediate intervention to prevent the loss of the lower leg. This complication demonstrates that gelatine sponge particles could migrate from the internal iliac artery into the external iliac artery.

Quantitative intra-operative assessment of peritoneal carcinomatosis – a comparison of three prognostic tools. Swellengrebel HA, Zoetmulder FA, Smeenk RM, Antonini N, Verwaal VJ. Eur J Surg Oncol. 2009 Oct, 35(10):1078-84. AIMS: Selecting patients for cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (HIPEC) remains challenging. We compared the predictive power of three intra-operative assessment tools of peritoneal involvement of colorectal cancer. METHODS: Ninety-two procedures (1999-2005) were prospectively scored using the Simplified Peritoneal Cancer Index (SPCI) and 7 Region Count. The Peritoneal Cancer Index (PCI) was retrospectively scored using the SPCI tool, operative notes and pathological reports. Endpoints were completeness of cytoreduction and overall survival. Logistic regression and Receiver Operating Characteristic (ROC) curves were applied to compare the predictive value of the three scoring systems on completeness of cytoreduction. RESULTS: After a median follow-up of 31 months, the median overall survival was 25.6 months. It decreased to 7.3 months, when cytoreduction was incomplete (p=0.001). An increased PCI, SPCI or number of regions were all associated with a decrease in probability of complete cytoreduction (p<0.05). With complete cytoreduction as outcome, the ROC areas for the PCI, SPCI and 7 Region Count were 0.92, 0.94 and 0.90, respectively (p=0.14). Using a cut-off value of 16 in the PCI system (p=0.03), 13 in the SPCI system (p=0.04) and 6 regions in the 7 Region Count (p=0.0002) the probability of complete cytoreduction decreased significantly. CONCLUSION: The PCI, SPCI and 7 Region Count are useful and equally effective prognostic tools predicting completeness of cytoreduction and associated improved survival. The 7 Region Count may be preferred due to its practical simplicity.

Overige publicaties Phyllodestumor van de mamma: een diagnostische uitdaging. Bul M, Plaisier PW, Westenend PJ, Storm RK, Oostenbroek RJ. Ned Tijdschr Heelkd. 2009, 18:100-105.

Het belang van het bespreken van anticonceptie in de oncologie. Kaijser J, Kooi GS, Berenschot HWA, Plaisier PW. Ned Tijdschr Oncologie. 2009, 6(70):5.

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Voordrachten The ileostomy: still a source of misery during creation and reversal. European Council of Enterostomal Therapy van Duijvendijk AE. 10th ECET Congress. Porto, Portugal, juni 2009.

Posters Distensibility of Forearm Veins in Haemodialysis Patients on Duplex Ultrasound Testing Using Three Provocation Methods. Korten E, Spronk S, Hoedt MT, de Jong GM, Tutein Nolthenius RP. Wetenschapsdag Albert Schweitzer ziekenhuis. Dordrecht, juni 2009.

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Gynaecologie PubMed publicaties Value of cervical cytology in diagnosing endometrial carcinoma in women with postmenopausal bleeding. Doom van HC, Opmeer BC, Kooi GS, Ewing-Graham PC, Kruitwagen RF, Mol BW. Acta Cytol. 2009 May-Jun, 53(3):277-82. OBJECTIVE: To assess the accuracy of the cervical smear in the diagnosis of endometrial cancer in women with postmenopausal bleeding, with an emphasis on the diagnostic relevance of normal endometrial cells. STUDY DESIGN: Women presenting with abnormal postmenopausal bleeding, not using hormone replacement therapy, were included prospectively. Cervical cytology was coded according to both the Papanicolaou (Pap) classification and the Dutch coding system (CISOE-A), which classifies endometrial and other cell types separately. For both classification systems, likelihood ratios (LR) for the presence of (pre) malignancy of the endometrium were calculated. RESULTS: We included 543 women with postmenopausal bleeding. A (pre) cancerous endometrial lesion was present in 64 women (11.7%). A Pap III increased the probability of (pre) malignancy (LR 3.5), whereas Pap IV and Pap V virtually proved the presence of carcinoma. The CISOE-A classification showed similar results. The presence of normal endometrial cells did not increase the probability of endometrial (pre) malignancy. CONCLUSION: Adding the results of the cervical smear to endometrial thickness could detect incidental endometrial cancers that are missed by transvaginal sonography (< 5 mm). In women with postmenopausal bleeding the presence of normal endometrial cells is not predictive of endometrial cancer.

The prediction of progression-free and overall survival in women with an advanced stage of epithelial ovarian carcinoma. Gerestein CG, Eijkemans MJ, Jong de D, Burg van der ME, Dijkgraaf RH, Kooi GS, Baalbergen A, Burger CW, Ansink AC. BJOG. 2009 Feb, 116(3):372-80. OBJECTIVE: Prognosis in women with ovarian cancer mainly depends on International Federation of Gynecology and Obstetrics stage and the ability to perform optimal cytoreductive surgery. Since ovarian cancer has a heterogeneous presentation and clinical course, predicting progression-free survival (PFS) and overall survival (OS) in the individual patient is difficult. The objective of this study was to determine predictors of PFS and OS in women with advanced stage epithelial ovarian cancer (EOC) after primary cytoreductive surgery and first-line platinum-based chemotherapy. DESIGN: Retrospective observational study. SETTING: Two teaching hospitals and one university hospital in the south-western part of the Netherlands. POPULATION: Women with advanced stage EOC. METHODS: All women who underwent primary cytoreductive surgery for advanced stage EOC followed by first-line platinum-based chemotherapy between January 1998 and October 2004 were identified. To investigate independent predictors of PFS and OS, a Cox’ proportional hazard model was used. Nomograms were generated with the identified predictive parameters. MAIN OUTCOME MEASURES: The primary outcome measure was OS and the secondary outcome measures were response and PFS. RESULTS: A total of 118 women entered the study protocol. Median PFS and OS were 15 and 44 months, respectively. Preoperative platelet count (P = 0.007), and residual disease <1 cm (P = 0.004) predicted PFS with a optimism corrected c-statistic of 0.63. Predictive parameters for OS were preoperative haemoglobin serum concentration (P = 0.012), preoperative platelet counts (P = 0.031) and residual disease <1 cm (P = 0.028) with a optimism corrected c-statistic of 0.67.

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CONCLUSION: PFS could be predicted by postoperative residual disease and preoperative platelet counts, whereas residual disease, preoperative platelet counts and preoperative haemoglobin serum concentration were predictive for OS. The proposed nomograms need to be externally validated.

Postoperative mortality after primary cytoreductive surgery for advanced stage epithelial ovarian cancer: a systematic review. Gerestein CG, Damhuis RA, Burger CW, Kooi GS. Gynecol Oncol. 2009 Sep, 114(3):523-7. OBJECTIVE: Accurate estimation of the risk of postoperative mortality (POM) is essential for the decision whether or not to perform cytoreductive surgery in a patient with advanced stage ovarian cancer. To ascertain modern reference figures, a systematic review of studies reporting POM after primary cytoreductive surgery for advanced stage epithelial ovarian cancer (EOC) was performed. MATERIALS AND METHODS: A Medline search was performed to retrieve papers on primary cytoreductive surgery for advanced stage EOC. Twenty-three papers met the inclusion criteria and were reviewed. RESULTS: According to population-based studies, POM after primary cytoreductive surgery for EOC is 3.7% on average. Single centre studies report an average rate of 2.5%. The overall mean POM is 2.8%. POM is more frequent for elderly women and after extensive procedures. Accurate information on age-specific and procedure-specific rates could not be obtained. CONCLUSION: POM rates after surgery for EOC are satisfactorily low. There is a clear need for reliable reference figures for mortality after debulking surgery in the elderly.

Causes of postoperative mortality after surgery for ovarian cancer. Gerestein CG, Damhuis RA, de Vries M, Reedijk A, Burger CW, Kooi GS. Eur J Cancer. 2009 Nov, 45(16):2799-803. Residual disease after cytoreductive surgery is an important prognostic factor in patients with advanced stage epithelial ovarian cancer (EOC). Aggressive surgical procedures necessary to achieve maximal cytoreduction are inevitably associated with postoperative morbidity and mortality. To determine causes of postoperative mortality (POM) after surgery for EOC all postoperative deaths in the southwestern part of the Netherlands over a 17-year period were identified and analysed by reviewing medical notes. Between 1989 and 2005, 2434 patients underwent cytoreductive surgery for EOC. Sixty-seven patients (3.1%) died within 30 days after surgery. Postoperative mortality increased with age from 1.5% (26/1765) for the age group 20-69 to 6.6% (32/486) for the age group 70-79 and 9.8% (18/183) for patients aged 80 years or older. Pulmonary failure (18%) and surgical site infection (15%) were the most common causes of death. Only a quarter of deaths resulted from surgical site complications. Our results suggest that causes of postoperative mortality after surgery for EOC are very heterogeneous. Given the impact of general complications, progress in preoperative risk assessment, preoperative preparation and postoperative care seem essential to reduce the occurrence of fatal complications.

Prediction of residual disease after primary cytoreductive surgery for advancedstage ovarian cancer: accuracy of clinical judgment. Gerestein CG, van der Spek DW, Eijkemans MJ, Bakker J, Kooi GS, Burger CW. Int J Gynecol Cancer. 2009 Dec, 19(9):1511-5.

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OBJECTIVES: Treatment of patients with an advanced-stage epithelial ovarian cancer (EOC) is based on cytoreductive surgery and platinum-based chemotherapy. Amount of residual disease after primary cytoreductive surgery is an important prognostic factor. The objectives of the present study were to evaluate the accuracy and reproducibility of preoperative clinical judgment of residual disease after primary cytoreductive surgery and to compare the predictive performance of the offhand assessment to the predictive performance of prediction models. MATERIALS AND METHODS: Fifteen observers (5 gynecologic oncologists, 5 gynecologists, and 5 senior residents) were offered preoperative data of 20 patients with advanced-stage EOC who underwent primary cytoreductive surgery. The observers were asked to predict residual disease after cytoreductive surgery (1 cm). Their estimation was compared with the performance of 2 prediction models. RESULTS: Overall, suboptimal cytoreduction was predicted with a sensitivity of 50% and a specificity of 56%. The intraclass correlation coefficient was 0.27. chi(2) Test showed no significant difference in prediction of suboptimal cytoreduction between the different subgroups and prediction models. CONCLUSIONS: Clinical judgment of residual disease after primary cytoreductive surgery in patients with advanced-stage EOC shows limited accuracy. Given the poor interobserver reproducibility, prediction models could attribute to uniform treatment decisions and improve counseling.

Complications and failure of uterine artery embolisation for intractable postpartum haemorrhage. Maassen MS, Lambers MD, Tutein Nolthenius RP, van der Valk PH, Elgersma OE. BJOG. 2009, 116(1):55-61. OBJECTIVE: Primary postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality around the world. Most patients can be managed conservatively, but patients with intractable bleeding require more aggressive treatment. In these cases uterine artery embolisation (UAE) has proven to be a useful tool to control PPH. The reported success rate of UAE is over 90% with only minor complications. In this case series we studied the effectiveness and complications of UAE. DESIGN: Retrospective analysis of a case series. SETTING: Case series in a large peripheral hospital in the Netherlands. SAMPLE: Eleven patients who were treated with UAE for intractable PPH from November 2004 to February 2008. METHODS: In this paper we review the results of all patients treated with UAE for intractable PPH in our hospital and focus on the two cases with adverse outcomes. MAIN OUTCOME MEASURES: Effectiveness, causes of failure of UAE, complications. RESULTS: Nine out of eleven patients were treated successfully with UAE. One patient needed an emergency hysterectomy for intractable bleeding. In the aftermath she developed a vesicovaginal fistula (VVF). Another patient suffered a major thrombo-embolic event of the right leg, for which she underwent embolectomies and despite fasciotomy a necrotectomy. CONCLUSIONS: UAE is a valuable tool in managing major PPH and in most cases it can replace surgery and thus prevent sacrification of the uterus. However, due to blood supply of the uterus by one of the ovarian or aberrant arteries, UAE might fail to control the bleeding. In addition, serious complications such as a thrombo-embolic event or VVF may occur. We hereby present a case of migration of an embolus from the site of re-embolisation into the femoral artery requiring immediate intervention to prevent the loss of the lower leg. This complication demonstrates that gelatine sponge particles could migrate from the internal iliac artery into the external iliac artery.

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Een focale leverafwijking na een normaal verlopen zwangerschap. Vermeulen HG, Kooi GS, Lesterhuis W. Ned Tijdschr Geneeskd. 2009, 153(21):1030-3. Two months after a normal pregnancy, a 27-year-old woman presented with a focal liver lesion, which was first interpreted on CT as ‘multiple liver cell adenomas’. 2 months later, it turned out to be a metastasis of a choriocarcinoma. This rare neoplasm will often be omitted from the differential diagnosis of liver lesions found during or after pregnancy. However, it is important not to miss this diagnosis since choriocarcinoma metastasis can be successfully treated. Therefore, it is advisable when focal liver lesions are found in women of child-bearing age also to measure human chorionic gonadotropin (hCG) serum concentration.

Overige publicaties Het belang van het bespreken van anticonceptie in de oncologie. Kaijser J, Kooi GS, Berenschot HWA, Plaisier PW. Ned Tijdschr v Oncologie. 2009, 6(70):5.

Rubriek ingezonden. Fertiliteitspreservatie bij vrouwen met kanker. Kaijser J, Kooi GS, Levin MD. Ned Tijdschr Geneeskd. 2009. Reply on: Fertility preservation in female oncology patients. Jenninga E, Kroep JR, Hilders CG, Louwé LA, Verburg HJ, Nortier JW. Ned Tijdschr Geneeskd. 2008 Nov 8, 152(45):2437-41.

Voordrachten Een oudere vrouw met ovariumcarcinoom en dan? Kooi GS. IKR symposium vulvacarcinoom en de oudere gynaecologische patiënt. Rotterdam, januari 2009.

Oude onderwerpen in een nieuw jasje; de meerwaarde van opleiden voor de omgeving. Kooi GS. Obstetrie bijeenkomst. Rotterdam, januari 2009.

Traject AIOS gynaecologie: wat gaat goed en wat kan beter?. Kooi GS. Symposium Effectieve feedback wat is dat? Albert Schweitzer ziekenhuis Dordrecht, januari 2009.

Gynaecologische oncologie. Kooi GS. Transmuraal huisartsen scholing. Leopold, Oostenrijk, januari 2009.

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Regionale implementatietraining portfolio gynaecologie. Kooi GS. STZ bijeenkomst CBOG opleidingsinitiatieven boekje met 4 ASz projecten. Amersfoort, februari 2009.

Opleiden in de dagelijkse praktijk. Kooi GS. Landelijke SEH congres. Utrecht, maart 2009.

Gynaecologische oncologie. Kooi GS. Transmuraal huisartsen scholing. Koudekerken, april 2009.

Vaginaal bloedverlies en dan? Hellendoorn I, Kooi GS. Regionale SEH onderwijsdag. Albert Schweitzer ziekenhuis Dordrecht, september 2009.

Gynecologische oncologie. Kooi GS. Albeda collega gastdocentschap. Rotterdam, oktober 2009.

De opleidingsetalage, Wat is ‘t en wat moeten we ermee? Kooi GS. Erasmus MC. Rotterdam, december 2009.

Heupdysplasie en stuitligging. de waarde van versie van stuit naar hoofdligging. Lambeek AF, Hellendoorn I, Brouwers EMJJ, Akerboom BMC, Lambers MDA, Papatsonis DNM, Lunshof MS, Vos LD, Kooi GS. NVOG gynecongres. Utrecht, juni 2009.

Prediction of 30-day morbidity after primary cytoreductive surgery for advanced stage ovarian cancer. Nieuwenhuyzen- Boer de GM, Gerestein CG, Eykemans MJ, Burger CW, Kooi GS. Wetenschapsdag Albert Schweitzer ziekenhuis. Dordrecht, juni 2009.

Posters T.I.P. training implementation Portfolio in Gynaecology and Obstetrics. Dirksen-Tombe de GJM, Dullemond RC, Kate ten-Booij MJ, Kooi GS, Lagro GP, Swaluw van der AMG, Zanting A. AMEE Conference. Malaga, Spanje, augustus 2009. Educ Med. 2009, 12(suppl 2).

Gewichtig over afvallen. Dool van den GC, Veen van L. 2e nationale congres preconceptiezorg. Nieuwegein, september 2009.

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Nomogram for suboptimal cytoreduction at primary surgery for advanced stage ovarian cancer. Gerestein CG, Eijkemans MJ, Bakker J, Elgersma OE, Kooi GS, Burger CW. ESGO 16th International Meeting. Belgrado, Servië, oktober 2009.

Prediction of 30-day morbidity after primary cytoreductive surgery for advanced stage ovarian cancer. Gerestein CG, Nieuwenhuyzen-de Boer GM, Eijkemans MJ, Burger CW, Kooi GS. ESGO 16th International Meeting. Belgrado, Servië, Oktober 2009.

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Interne Geneeskunde PubMed publicaties Accuracy assessments of quantitative diagnostic tests for clinical research. Atiqi R, van Iersel C, Cleophas TJ. Int J Clin Pharmacol Ther. 2009 Mar, 47(3):153-8. BACKGROUND: Clinical research is impossible without accurate diagnostic tests. The methods for assessing accuracy of quantitative diagnostic tests are not routinely used by the scientific community. OBJECTIVE AND METHODS: To review the advantages and disadvantages of methods that could be used for that purpose. Using real data examples we review seven possible methods. RESULTS AND CONCLUSIONS: Simple linear regression testing the presence of a significant correlation between the new test data (x-axis data) and the control test data (y-axis data) is not accurate for testing the validity of a novel quantitative diagnostic test. Accurate methods using linear regression include the following. First, from y = a + b x, test the hypothesis that b is statistically significantly larger than zero, than test the hypothesis that b = 1.000 and a = 0.000. Second, if “the b = 1.000 and a = 0.000 hypothesis” cannot be confirmed, then use as criterion for validation a squared correlation-coefficient r2 or intraclass correlation of > 95%, or a relative residual variance of < 5%. If the new test is validated this way, then the predicted control-test-values are calculated from the equation y = a + bx. The above three methods assume uncertainty of the new test data, but not of the control test data. Deming regression, PassingBablok regression, paired Student’s t-tests, and Altman-Bland plots assume uncertainty of both the new test and the control test. This is rarely a condition for validation, and carries the risk of unneeded loss of sensitivity of testing. However, if the control test is not the gold standard test and it is decided to account the uncertainty of the control test, then Passing-Bablok regression is the only method that adjusts for non-normal data as frequently observed in practice.

Meta-analysis of recent studies on patients admitted to hospital due to adverse drug effects. Atiqi R, Cleophas TJ, Van Bommel E, Zwinderman AH. Int J Clin Pharmacol Ther. 2009 Sep, 47(9):549-55. The use of drugs has expanded during the previous decade. However, earlier studies on patients admitted for adverse drugs effects (ADEs) have been heterogeneous. The objectives of this study were to assess the number of recent admissions to hospital due to ADEs and to assess the degree of heterogeneity in recent studies. Prospective studies published in the past decade were therefore pooled and compared with the pooled results from earlier studies. The pooled overall percentage in recent studies (n = 20) was 5.4% (5.0 - 5.8) and this did not significantly differ from that in the earlier studies (n = 21, pooled percentage 4.7%, 3.1 - 6.2). The studies were clinically very heterogeneous with percentages of ADEs between 3.4 and 33.2%. The nature of the patient group could be held largely responsible for the clinical heterogeneity observed.

Methods for analyzing cardiovascular studies with repeated measures. Cleophas TJ, Zwinderman AH. Neth Heart J. 2009, 17:429-34. Background. Repeated measurements in a single subject are generally more similar than unrepeated measurements in different subjects. Unrepeated analyses of repeated data cause

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underestimation of the treatment effects.Objective. To review methods adequate for the analysis of cardiovascular studies with repeated measures.Results. (1) For between-subjects comparisons, summary measures and random-effects mixedlinear models are possible. Examples of summary measures include the area under the curve of drug time-concentration and time-efficacy curves, maximal values, mean values, and changes from baseline. A problem is that precision is lost because averages, rather than individual data, are applied. Random-effects mixed-linear models, available in SPSS statistical software and other software programmes, provide better precision for that purpose. (2) For within-subjects comparisons, repeated-measures ANOVAs are available in SPSS and other software programmes. Subgroup factors such as gender differences and age class can be included.Discussion. For non-Gaussian data, Wilcoxon’s and Friedman’s tests are available, for binary data McNemar’s tests can be used in case of two repeated observations. No standard methods are available for repeated binary measures with more than two observations. The purpose of this review was not to present a complete report but, rather, to underline that ample efforts should be made to account for the special nature of repeated measures.

Meta-analyses of diagnostic studies. Cleophas TJ, Zwinderman AH. Clin Chem Lab Med. 2009, 47(11):1351-1354. BACKGROUND: Diagnostic reviews often include the sensitivity/specificity results of individual studies. A problem occurs when these data are pooled because the correlation between sensitivity and specificity is generally strongly negative, causing overestimation of the pooled results. The diagnostic odds ratio (DOR), defined as the odds of true positives vs. that of false positives, may avoid this problem. The aim of the study was to review the advantages and limitations of the DORs. METHODS: A systematic review of 44 previously published diagnostic studies was used as an example. RESULTS: DORs can be readily implemented in diagnostic research. Advantages include: (1) they adjust for the negative and curvilinear correlations between sensitivities and specificities, (2) they take account of the heterogeneity between studies with respect to the different thresholds chosen by the investigators in the original studies, and (3) it is easy to extend the model with covariates representing between-study differences in design. Limitations include: 1) the outcome parameter is a summary estimate of both sensitivity and specificity, and 2) the magnitude of the studies included is not taken into account. CONCLUSIONS: Reported sensitivities and specificities of different studies assessing similar diagnostic tests are not only negatively correlated, but also negatively correlated in a curvilinear manner. It is appropriate to take this negative curvilinear correlation into account in the data pooling of such meta-analyses. The DORs can be applied for that purpose.

Idiopathic retroperitoneal fibrosis: prospective evaluation of incidence and clinicoradiologic presentation. Bommel van EFH, Jansen I, Hendriksz TR, Aarnoudse AL. Medicine (Baltimore). 2009 Jul, 88(4):193-201. Retroperitoneal fibrosis (RPF) is a rare disorder of unknown etiology. Its incidence is unknown, and the insidious and nonspecific nature of symptoms may contribute to considerable diagnostic delay. We conducted the current study to assess the incidence and clinicoradiologic characteristics of idiopathic RPF. For this, we evaluated prospectively 53 consecutive patients with a diagnosis of idiopathic RPF at our tertiary care referral center from April 1998 through January

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2008.Calculated annual incidence of RPF was 1.3/100,000 inhabitants. Mean age was 64 +/- 11.1 (SD) yr; male-female ratio was 3.3:1.0. Median duration of symptoms was 6.0 mo (IQR 3.0-12.0). Abdominal, flank, and/or back pain and discomfort were the major symptoms, with visual analogue scale scores of 49 +/- 27.2 mm and 43 +/- 29.4 mm for pain and discomfort, respectively. Female patients had higher erythrocyte sedimentation rate (ESR), higher white blood cell count, and lower hemoglobin content than male patients at presentation. Computed tomography-documented maximal mass thickness amounted to 35 +/- 16.6 mm; craniocaudal length amounted to 137 +/- 48.8 mm. RPF mass extension up to or above the level of the renal vessels was noted in 3 patients (6%). Six patients (11%) presented with atypical RPF localization and/or bulky mass. Localized lymphadenopathy adjacent to the RPF mass was observed frequently (25%). Patients with hydronephrosis (56%) presented earlier than patients without hydronephrosis, with higher creatinine and greater mass thickness but similar pain severity. Patients were typically at high cardiovascular risk with increased-often aneurysmal-infrarenal aortic diameter (25.0 mm, IQR 22.0-30.0). RPF mass distribution was similar in patients with or without aneurysmal dilation. Occupational asbestos exposure (20%) and asbestos-related pleural changes (17%) were frequent among males. Previous or concurrent chronic inflammatory disease and/or autoimmune disease was noted in 8 patients (15%). Multivariate analysis revealed an independent association of ESR values with severity of pain and discomfort. Smoking was independently associated with infrarenal aortic diameter.In summary, annual RPF incidence is higher than previously assumed. Age at diagnosis and male-female ratio seem to have changed over time. RPF typically affects patients at high cardiovascular risk, including increased aortic diameter. Clinical presentation is influenced by sex, severity of inflammation and presence of hydronephrosis. Prolonged asbestos exposure and asbestos-related pleural changes were frequent among males. Localized lymphadenopathy adjacent to the RPF mass occurs frequently and should not confuse RPF diagnosis.

Factors that predict response of patients with hepatitis B e antigen-positive chronic hepatitis B to peginterferon-alfa. Buster EH, Hansen BE, Lau GK, Piratvisuth T, Zeuzem S, Steyerberg EW, Janssen HL. Gastroenterology. 2009 Dec, 137(6):2002-9. BACKGROUND & AIMS: Therapy with pegylated interferon (PEG-IFN)-alfa results in sustained response in a minority of patients with chronic hepatitis B virus (HBV) infection and has considerable side effects. We analyzed data from the 2 largest global trials of hepatitis B e antigen (HBeAg)-positive patients with chronic hepatitis B to determine which are most likely to respond to PEG-IFN-alfa therapy. METHODS: The study included 542 patients treated with PEG-IFN-alfa2a (180 microg/wk, 48 wk) and 266 patients treated with PEG-IFN-alfa-2b (100 microg/wk, 52 wk). Eighty-seven patients were excluded, leaving 721 patients for analysis. A sustained response was defined as HBeAg loss and HBV-DNA level less than 2.0 x 10(3) IU/mL 6 months after treatment. Logistic regression analysis was used to identify predictors of sustained response and a multivariable model was constructed. RESULTS: HBV genotype, high levels of alanine aminotransferase (ALT; >or=2 x upper limit of normal), low levels of HBV DNA (<2.0 x 10(8) IU/mL), female sex, older age, and absence of previous IFN therapy predicted a sustained response. Genotype A patients with high ALT and/or low HBV-DNA levels had a high predicted probability (>30%) of a sustained response. The strongest predictors of response were a high level of ALT in genotype B patients and a low level of HBV DNA in genotype C patients. Genotype D patients had a low chance of sustained response, irrespective of ALT or HBV-DNA levels. CONCLUSIONS: The best candidates for a sustained response to PEG-IFN-alfa are genotype A patients with high levels of ALT or low

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levels of HBV DNA, and genotypes B and C patients who have both high levels of ALT and low HBV DNA. Genotype D patients have a low chance of sustained response.

Early HBeAg loss during peginterferon alpha-2b therapy predicts HBsAg loss: results of a long-term follow-up study in chronic hepatitis B patients. Buster EH, Flink HJ, Simsek H, Heathcote EJ, Sharmila S, Kitis GE, Gerken G, Buti M, de Vries RA, Verhey E, Hansen BE, Janssen HL. Am J Gastroenterol. 2009 Oct, 104(10):2449-57. OBJECTIVES: Treatment with pegylated interferon (PEG-IFN) alpha-2b results in hepatitis B e antigen (HBeAg) loss in 36% of patients at 6 months post treatment. The aim of this study was to determine whether a long-term response to PEG-IFN is dependent on the timing of HBeAg loss. METHODS: A total of 91 patients treated with PEG-IFN alpha-2b alone (100 microg per week) and 81 patients treated with PEG-IFN alpha-2b and lamivudine (100 mg/day) for 52 weeks were enrolled in this study. Patients were initially followed up at 4-week intervals and had one additional long-term follow-up (LTFU) visit (mean: 3.03+/-0.77 years 26 weeks post treatment). RESULTS: Of the 172 patients included, 78 patients (46%) did not have loss of HBeAg, 47 (27%) lost HBeAg within 32 weeks, and 47 patients (27%) had loss of HBeAg after week 32. At LTFU, patients with HBeAg loss< or =32 weeks had hepatitis B virus DNA of <400 copies/ml significantly more often than did those who lost HBeAg after week 32 (47 vs. 21%, respectively; P=0.009). Hepatitis B surface antigen (HBsAg) negativity was also observed significantly more often in patients with early HBeAg loss (36 vs. 4%, respectively, P<0.001). Early HBeAg loss tended to occur more often in patients treated with PEG-IFN and lamivudine combination therapy than in those treated with PEG-IFN alone (35 vs. 21%; P=0.10), as did HBsAg loss (15 vs. 8%; P=0.14). CONCLUSIONS: Early PEG-IFN-induced HBeAg loss results in a high likelihood of HBsAg loss and may be associated with more profound viral suppression during the first 32 weeks of therapy in patients treated with lamivudine combinations.

Life style interventions in the management of hypertension, a survey based on the opinion of 105 practitioners. Elhani S, Cleophas TJ, Atiqi R. Neth Heart J. 2009 Jan, 17(1):9-12. BACKGROUND: Lifestyle interventions in the management of hypertension were beneficial in published studies. OBJECTIVE: To evaluate (1) which lifestyle recommendations are given by physicians and to what extent the possibility of drug-induced hypertension is addressed; (2) to study the characteristics of the physicians who more often perform lifestyle interventions. METHODS: General practitioners in the area of Dordrecht were asked whether or not they included lifestyle advice in the management of their patients’ hypertension. RESULTS: Of the 176 physicians invited, 105 consented to take part. Measures to reduce body weight, stopping smoking, and physical exercise advice were given by 94, 92, and 92% of the physicians, respectively. Advice on psychological relaxation and reducing liquorice (Dutch: drop) intake was only given by 23 and 32%. Rural physicians were more active: they more often recommended quitting smoking (p<0.02), reducing weight (p<0.02), and participating in sporting activities (p<0.02). And so were older physicians: they more often recommended starting low-calorie diets (p<0.05), stopping liquorice consumption (p<0.04) and emphasised drug compliance (p<0.02). Increased blood pressure as a side effect of concomitant medications, other than nonsteroidal anti-inflammatory drugs and oral contraceptives, was virtually never addressed. CONCLUSIONS: (1) Advice to reduce body weight, stop smoking, and

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increase physical exercise are the only lifestyle recommendations routinely given, (2) rural physicians and older physicians were more active in giving non-drug treatments, (3) increased blood pressure as a side effect of medications was virtually never addressed.

Comments on the EASL practice guidelines for the management of chronic hepatitis B: controversies in interferon-based therapy. Janssen HL, Buster EH. J Hepatol. 2009 Jul, 51(1):224-6. Geen abstract in PubMed.

Improved prognosis of patients with primary biliary cirrhosis that have a biochemical response to ursodeoxycholic acid. Kuiper EM, Hansen BE, de Vries RA, den Ouden-Muller JW, van Ditzhuijsen TJ, Haagsma EB, Houben MH, Witteman BJ, van Erpecum KJ, van Buuren HR. Gastroenterology. 2009 Apr, 136(4):1281-7. BACKGROUND & AIMS: Ursodeoxycholic acid (UDCA) improves laboratory liver test results in patients with primary biliary cirrhosis (PBC). Few studies have assessed the prognostic significance of biochemical data collected following UDCA treatment. We performed a prospective multicenter study of patients with PBC treated with UDCA to compare prognosis with biochemical response. METHODS: PBC was classified as early (pretreatment bilirubin and albumin levels normal), moderately advanced (one level abnormal), or advanced (both levels abnormal). Biochemical response was defined as proposed by Pares (decrease in alkaline phosphatase [ALP] level>40% of baseline level or normal level), Corpechot (ALP level<3-fold the upper limit of normal [ULN], aspartate aminotransferase level<2-fold the ULN, bilirubin level<1-fold the ULN), and our group (Rotterdam; normalization of abnormal bilirubin and/or albumin levels). RESULTS: The study included 375 patients, and median follow-up time was 9.7 (range, 1.0-17.3) years. The prognosis for early PBC was comparable with that of the Dutch population and better than predicted by the Mayo risk score. Survival of responders was better than that of nonresponders, according to Corpechot and Rotterdam criteria (P<.001). Prognosis of early PBC was comparable for responders and nonresponders; prognosis of responders was significantly better in those with (moderately) advanced disease. CONCLUSIONS: Prognosis for UDCA-treated patients with early PBC is comparable to that of the general population. Survival of those with advanced PBC with biochemical response to UDCA is significantly better than for nonresponders. Thus, UDCA may be of benefit irrespective of the stage of disease. Prognostic information, based on bilirubin and albumin levels, is superior to that provided by ALP levels.

The Dutch EPS Registry: increasing the knowledge of encapsulating peritoneal sclerosis. Korte MR, Boeschoten EW, Betjes MG. Neth J Med. 2009 Sep, 67(8):359-62. Encapsulating peritoneal sclerosis (EPS) is a rare condition characterised by fibrotic thickening of the visceral peritoneum, leading to encapsulating of the intestines with partial or total intestinal obstruction. EPS is a serious complication of peritoneal dialysis (PD) with high morbidity and a mortality exceeding 50%. At present, there is uncertainty concerning the incidence and the risk factors involved in the development of EPS. To address these questions a nationwide registry has been initiated. The primary

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goals of the registry are to record the incidence of EPS and investigate the association of different variables, such as PD duration, medication, dialysis solutions and kidney transplantation with EPS. The registry will improve the knowledge of EPS and will serve to develop guidelines and necessary management strategies. From the registry different research activities can be initiated. A major challenge lies in the establishment of criteria that allow a timely diagnosis of EPS. At present, there are no diagnostic tools that can accurately detect EPS at an early stage. For this reason, besides patients with proven EPS, the clinical suspicion of EPS will be a sufficient criterion for inclusion in the registry. This nationwide EPS registry is currently enrolling patients.

A rare cause of large liver cysts. Moons LG, Wolfhagen FH, Beukers R, de Man RA, van Leenders GJ, van Buuren HR. Am J Gastroenterol. 2009 Apr, 104(4):1056-8. Geen abstract in PubMed.

Acute interstitial nephritis during rifampicin therapy can be a paradoxical response: a case report. Meulen van der J, Jong de GTM, Westenend PJ. Cases J. 2009, 2:6643. An 18-year-old Ethiopian woman presented with debilitating back pain and high fever. X-ray examinations showed diffuse pulmonary tuberculosis and a psoas abscess. After starting rifampicin, isoniazid, ethambutol and pyrazinamide, acute interstitial nephritis developed that spontaneously recovered. According to Harrison’s Online rifampicin should have been causative, but the spontaneous recovery excluded that possibility. The clinical course fit the diagnosis of a paradoxical response, for which recently risk factors have been described. Thus, a paradoxical response should be added to the list of causes of interstitial nephritis in tuberculosis patients and in such cases rifampicin could be continued.

Een focale leverafwijking na een normaal verlopen zwangerschap. Vermeulen HG, Kooi S, Lesterhuis W. Ned Tijdschr Geneeskd. 2009, 153:B325. Two months after a normal pregnancy, a 27-year-old woman presented with a focal liver lesion, which was first interpreted on CT as ‘multiple liver cell adenomas’. 2 months later, it turned out to be a metastasis of a choriocarcinoma. This rare neoplasm will often be omitted from the differential diagnosis of liver lesions found during or after pregnancy. However, it is important not to miss this diagnosis since choriocarcinoma metastasis can be successfully treated. Therefore, it is advisable when focal liver lesions are found in women of child-bearing age also to measure human chorionic gonadotropin (hCG) serum concentration.

Hypocalcaemia as presenting symptom of velocardiofacial syndrome. van Vliet EI, van Ouwerkerk BM. Neth J Med. 2009 Mar, 67(3):105-6.

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Hypocalcaemia due to hypoparathyroidism is a rare finding in adults. The coexistence of cardiac abnormalities may be suggestive of a hereditary syndrome. We describe a case of velocardiofacial syndrome in a woman without a family history of this disorder. The hypocalcaemia was treated with calcium and vitamin D supplementation.

Overige publicaties Veel moeite, weinig effect. Zorgpaden verbeteren diagnostiek en behandeling niet. Atiqi R, Cleophas TJ, Niemeijer MG, Cleophas G. Medisch Contact. 2009, 37:1532-3.

Khat abuse in Yemen, a population -based survey. Basunaid S, van Dongen M, Cleophas TJ. Epub. Informaworld 2009.

Announcement: Ten years European College of Pharmaceutical Medicine: 4th Edition of its textbook “Statistics Applied to Clinical Trials”. Cleophas TJ. Int J Clin Pharmacol Ther. 2009, 47(4):287-288.

Behandeling van Hypertensie met Combinatietherapie door middel van Olmesartan en Amlodipine (Sevikar). Heijmen MG, Cleophas ATM. Cardio Actueel. 2009, 14(12):1-6.

Het belang van het bespreken van anticonceptie in de oncologie. Kaijser J, Kooi GS, Berenschot HWA, Plaisier PW. Ned Tijdschr Oncologie. 2009, 6(2):70-75.

‘Goed verzorgd, beter gevoel’ stimuleert zelfvertrouwen van kankerpatiënten. Van de Lagemaat J, van Iersel CA. IKR bulletin. 2009 April, 33:17-19.

Cardiovascular research: decision analysis using binary partitioning. Lesterhuis WH, Cleophas TJ. Perfusion. 2009, 22:88-91.

Cardiovascular research: propensity scores and propensity score matching. Levin M-D, Cleophas TJ. Perfusion. 2009, 22:190-193.

Heart Failure and Mortality in Diabetes, pooled Analysis of 30,197 Subjects. Masoor K, Cleophas TJ. Journal of Cardiac Failure. 2009, 15:305-9.

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Combination Therapy with Olmesartan and Amlodipine in the Treatment of Hypertension. Niemeijer MG, Cleophas TJ. Pharmaceuticals. 2009, 2:125-133.

Incident-analyse in de gezondheidszorg en de wetenschappelijke methode. Ponsen H, Cleophas TJ. Medisch Contact. 2009, 64:1109-11.

Primaire myelofibrose, voorbij Janus. Slot S, Schilthuizen C, P. Boekhorst te P, Commandeur S, Sonneveld S, Huijgens P, Levin MD, Zweegman S. Ned Tijdschr Hematologie. 2009, 6(8): 300-309.

Viscerale Leishmaniasis na 2 weken vakantie in Aragon (Zuid-Spanje). Tax M, Brouwer J, Cleophas TJ, van Gelder W. Ned Tijdschr Infectieziekten. 2009, 4:243 en 247-8.

Verpleegkundig spreekuur bij hormonale therapie. Van Zandbergen A, van Iersel CA. Oncologica. 2009, 26(2):26-29.

Boek Statistics Applied to Clinical Trials. Cleophas TJ, Zwinderman AH, Cleophas TF, Cleophas EP. 4th ed. Springer; 2009. ISBN 9781402095221.

Hoofdstuk in boek Op welke leeftijd kan een statine worden gestopt? Cleophas TJ. In: Eussen SR, De Vries JH, Stalenhoef AE, Van Dis I, Smeldt AH, Strang AC, Cleophas TJ, Gevers JA, Trip MD, Van Puijenbroek EP (editors). Vademecum Permanente Nascholing, de Meest Gestelde Vragen over: Cholesterol. Houten: Bohn Stafleu van Loghum; 2009. ISBN 9789031375073.

Voordrachten MPS-onderwijs arts-assistenten. Berenschot H. Dordrecht, maart 2009.

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Lymfoom-roadshow HOVON. Berenschot H. Dordrecht, april 2009.

Endoscopische technieken bij ijzergebreksanemie. Beukers R. 1e Albert Schweitzer Anemie Symposium. Dordrecht, oktober 2009.

Micro-albuminurie: een cardiovasculaire risicofactor? Bommel van EFH. Cardiovasculair symposium. NH Hotel Rotterdam, september 2009.

Extracorporele therapie bij intoxicaties. Bommel van EFH. Landelijke studiedag fellows aandachtsgebied Nefrologie. Jaarbeurs congres centrum Utrecht, september 2009.

Continue dialyse technieken: niet-renale indicaties Bommel van EFH. Landelijke studiedag fellows aandachtsgebied Nefrologie. Jaarbeurs congres centrum Utrecht, september 2009.

Hypertension trials and new aspects of hypertension management. Brugts JJ. Cardiovasculair Onderzoeks Instituut. Erasmus Universiteit Rotterdam, 2009.

Impaired outcome of ACE-inhibitors according to genetic variation in the renin-angiotensin system. Brugts JJ. Cardiovasculair Onderzoeks Instituut. Erasmus Universiteit Rotterdam, 2009.

Genetic determinants of treatment effect of ACE-inhibitors in patients with stable coronary artery disease. Brugts JJ. 58th Annual Scientific Session. American College of Cardiology 2009. Orlando, Florida, USA. Young Investigator Award. J Am Coll Cardiol. 2009.

Genetic factors related to decreased outcome with ACE-inhibitor therapy in patient with stable CAD. Brugts JJ. State of the Art session “Pharmacogenetics, the new frontier of hypertension trials”. European Society of Cardiology congress 2009. Barcelona, Spain, august 2009. Best abstract. Eur Heart J. 2009.

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ACE-inhibitors in cardiovascular disease: what about blood pressure and genetics? Brugts JJ. Cardiology and Vascular Medicine Update and Perspective 2009. European Society of Cardiology Congess. Congress center de Doelen, Rotterdam, 2009.

Individualized ACE-inhibitor therapy in stable coronary artery disease. Brugts JJ. Nederlandse Vereniging voor Cardiologie 2009 “onderzoeksprijs General Cardiology”. Amsterdam. Neth Heart J. 2009.

Genetic factors related to blood pressure and blood pressure response to ACEinhibitor therapy in patient with stable CAD. Brugts JJ. European Society of Cardiology congress 2009. Barcelona, Spain, august 2009. Eur Heart J. 2009.

Meer zicht op peritoneale sclerose. Korte MR. Nederlandse Nefrologie Dagen. Veldhoven, april 2009.

Early Diagnostic Markers for encapsulating peritoneal sclerosis: a case - control study. Korte MR. Nederlandse Nefrologie Dagen. Veldhoven, april 2009.

A case of Idiopathic Adulthood Ductopenia. Lesterhuis W. Voorjaarsvergadering Nederlandse Vereniging Voor Gastroeneterologie. Veldhoven, maart 2009.

Diabetes mellitus. Van Ouwerkerk BM. Regionale huisartsennascholing Diabetes. Dordrecht, december 2009.

Geen B-cellen, maar wel koorts. Schilthuizen C, Berenschot HWA, Levin MD. Regionale Hematologie Avond. Rhoon, oktober 2009.

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Posters Tamoxifen reduces mortality of encapsulating peritoneal sclerosis; results of the Dutch Multicentre EPS Study. Betjes MGH, Sampimon D, Lingsma H, Fieren M, Weimar W, Korte MR. American Society of Nephrology. San Diego, 2009. J Am Soc Nephrol. 2009, (Abstract issue):553816

Risk factors associated with Increased Incidence of Encapsulating Peritoneal Sclerosis in a Controlled Multicenter Study. Betjes MGH, Fieren M, Sampimon D, Lingsma H, Weimar W, Korte MR. American Society of Nephrology. San Diego, 2009. J Am Soc Nephrol. 2009, (Abstract issue):553776.

Zelfstandig spreekuur oncologieverpleegkundigen. Blaak G, van Iersel C, van Zandbergen A. Oncologiedagen voor verpleegkundigen: Voortgang & Variatie. Utrecht, november 2009.

A practical-oriented research on the recognition of depression in people with diabetes. Boshoven HEMV, Lemstra A, Luteijn M, Ouwerkerk van BM, Polet J. Wetenschapsdag Albert Schweitzer ziekenhuis. Dordrecht, juni 2009.

Identification of Patients with Impaired Outcome on ACE-inhibitor therapy. Brugts JJ, Isaacs A, Boersma E, Witteman JCM, Maat de MPM, Danser AHJ, Duijn van C, Uitterlinden A, Remme W, Ceconi C, Fox K, Bertrand M, Ferrari R, Simoons ML. European Society of Cardiology congress 2009. Barcelona, Spain, august 2009. Eur Heart J. 2009, 30:1039-1108.

Genetic determinants of blood pressure and blood pressure response to ACEinhibitor therapy in patients with stable coroanry artery disease. Brugts JJ, Isaacs A, Boersma E, Witteman JCM, Maat de MPM, Duijn van C, Uitterlinden A, Remme W, Ceconi C, Fox K, Bertrand M, Ferrari R, Simoons ML, Danser AHJ. European Society of Cardiology congress 2009. Barcelona, Spain, august 2009. Eur Heart J. 2009, 30:1039-1108.

The use of statins in primary prevention. Brugts JJ, Yetgin T, Hoeks S, Gotto A, Knopp R, Nakamura H, Westendorp R, Craen de A, Shepherd J, Ridker P, Domburg van R, Deckers JW. European Society of Cardiology congress 2009. Barcelona, Spain, august 2009. Eur Heart J. 2009, 30:1039-1108.

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The benefits of HMG-CoA reducatse inhibitors in patients without established cardiovascular disease with cardiovascular risk factors: metaanalysis of randomized trials. Brugts JJ, Yetgin T, Hoeks S, Gotto A, Knopp R, Nakamura H, Westendorp R, Craen de A, Shepherd J, Ridker P, Domburg van R, Deckers JW. NVVC congres 2009. Amsterdam, oktober 2009. Neth Heart J. 2009.

Tailored-therapy of ACE-inhibitors in stable coronary artery disease. Brugts JJ, Maat de M, Boersma E, Uitterlinden AG, Duijn van C, Witteman JCM, Danser AHJ, Simoons ML. NVVC congres 2009. Amsterdam, oktober 2009. Neth Heart J. 2009.

Dialysis markers prior to EPS. Sampimon DE, Korte MR, Lopes Barreto D,Vlijm A, Struijk DG, Krediet RT. Annual Dialysis Conference. Houston, USA, maart 2009.

Early Diagnostic Markers for encapsulating peritoneal sclerosis: a case - control study. Sampimon DE, Korte MR, Lopes Barreto D, Vlijm A, Waart de R, Struijk DG, Krediet RT. World Congress Nephrology. Milaan, mei 2009

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Keel Neus Oorziekten PubMed publicaties Implementation of neonatal screening for hearing impairment: influence on pediatric otitis media surgery in The Netherlands. Lok W, Chenault MN, Anteunis LJ. Int J Pediatr Otorhinolaryngol. 2009 Aug, 73(8):1090-4. OBJECTIVE: Screening for hearing impairment in the Netherlands took place at the age of 9 months for many years but was recently moved to the neonatal period. Since otitis media has its highest prevalence at the age of 9 months, it might be that screening for hearing impairment at this age is linked to treatment of otitis media. We were interested in what the impact would be on the number of children treated with ventilation tubes or adenoidectomy when they were no longer screened at the age of 9 months. METHODS: National birth rates, data regarding screening for hearing impairment at the age of 9 months and at the neonatal period, as well as data regarding adenoidectomy and tube placement were used to study treatment of otitis media in children aged 0-2 years in the Netherlands. RESULTS: The percentage of children treated with ventilation tubes after implementation of neonatal screening for hearing impairment did not decline (OR 1.1981.112), and more children were treated at a younger age. The number of children treated with adenoidectomy did however decline (OR 0.724-0.890). CONCLUSION: There seems to be an association between the implementation of neonatal screening for hearing impairment and the treatment of otitis media. During the whole studied period there was a slight but statistical significant increase in the odds for tube placement in all children aged 0-23 months. After implementation of the neonatal screen there was a distinct increase in the number of children aged 6-11 months treated with tubes. In the same period a statistical significant decline in the odds of undergoing adenoidectomy was observed.

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Kindergeneeskunde PubMed publicaties Nine patients with a microdeletion 15Q11.2 between breakpoints 1 and 2 of Prader-Willi critical region, possibly associated with behavioural disturbances. Doornbos M, Sikkema- Raddatz B, Ruijvenkamp CA, Dijkhuizen T, Bijlsma EK, Gijsbers AC, Hilhorst- Hofstee Y, Hordijk R, Verbruggen KT, Kerstjens- Frederikse WS, van Essen T, Kok K, van Silfhout AT, Breuning M, van Ravenswaaij- Arts CM. Eur J Med Genet. 2009, 52(2-3):108-15. Behavioural differences have been described in patients with type I deletions (between breakpoints 1 and 3 (BP1-BP3)) or type II deletions (between breakpoints 2 and 3) of the 15q11.2 Prader-Willi/Angelman region. The larger type I deletions appear to coincide with more severe behavioural problems (autism, ADHD, obsessive-compulsive disorder). The non-imprinted chromosomal segment between breakpoints 1 and 2 involves four highly conserved genes, TUBGCP5, NIPA1, NIPA2, and CYFIP1; the latter three are widely expressed in the central nervous system, while TUBGCP5 is expressed in the subthalamic nuclei. These genes might explain the more severe behavioural problems seen in type I deletions. We describe nine cases with a microdeletion at 15q11.2 between BP1-BP2, thus having a haploinsufficiency for TUBGCP5, NIPA1, NIPA2, and CYFIP1 without Prader-Willi/Angelman syndrome. The clinical significance of a pure BP1-BP2 microdeletion has been debated, however, our patients shared several clinical features, including delayed motor and speech development, dysmorphisms and behavioural problems (ADHD, autism, obsessive-compulsive behaviour). Although the deletion often appeared to be inherited from a normal or mildly affected parent, it was de novo in two cases and we did not find it in 350 healthy unrelated controls. Our results suggest a pathogenic nature for the BP1-BP2 microdeletion and, although there obviously is an incomplete penetrance, they support the existence of a novel microdeletion syndrome in 15q11.2.

Diagnostic image. A gril with cramp and tingling of the hands. Harnisch E, Sas TC. Ned Tijdschr Geneesk. 2009, 153:B411. Geen abstract in PubMed.

Phenotypic variance in childhood coeliac disease and the HLA-DQ/DR dose effect. Vermeulen BA, Hogen Esch CE, Yuksel Z, Koning F, Verduijn W, Doxiadis II, Schreuder GM, Mearin ML. Scand J Gastroenterol. 2009, 44(1):40-5. OBJECTIVE: Coeliac disease (CD) is associated with HLA-DQ2 and DQ8. The clinical picture is variable and certain human leucocyte antigen (HLA) DQ/DR combinations have a higher relative risk (RR) for CD than others. Moreover, the HLA-DQ gene-dose effect has an impact on the strength of the gluten-specific T-cell response and thus may correlate with clinical presentation and severity of CD. The aim of this study was to determine the correlation between HLA-DQ/DR-based genotypes and the variation in phenotypes of the disease. MATERIAL AND METHODS: A total of 113 non-related Caucasian children clinically diagnosed with CD during the period 1980-2003 with a known HLA type were included in the study. Patients were divided into four categories according to amount of disease expression predisposing to HLA-DQ2 or HLA-DQ8 molecules and the known RR of their HLA-DR/DQ type for CD: high (DR3DQ2 homozygous and DR3DQ2/DR7DQ2), substantial

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(DR3DQ2/DR5DQ7 and DR5DQ7/DR7DQ2), moderate (DR3DQ2-DR4DQ8 and DR3DQ2/DR*DQ*) and low (DR7DQ2/DR*DQ*, DR4DQ8- DR*DQ* and DR*DQ*- DR*DQ*). The clinical data and HLA genotypes of these patients were compared. RESULTS: The 113 children were diagnosed with CD at a mean age of 4.6 years and boys were significantly older than girls when diagnosed (p=0.01). RR for having CD was highest for the high HLA-risk group (RR 8.1). With the exception of a greater frequency of abdominal distension and fewer non-gastrointestinal symptoms in the substantial HLA-risk group, there were no significant differences in clinical characteristics or degree of severity of the small-bowel histological findings between the children in the different HLA-risk groups. CONCLUSION: No correlation was found between disease severity and a double HLA-DQ2 gene dose.

Overige publicaties Multilocus methylation analyses in a large cohort of 11p15-related foetal growth disorders (Russell Silver and Beckwith Wiedermann syndromes) reveals simultaneous loss of methylation at paternal and maternal imprinted loci. Azzi S, Rossignol S, Steunou V, Sas TC, Thibaud N, Danton F, Le Jule M, Heinrichs C, Cabrol S, Gicquel C, Le Bouc Y, Netchine I. Hum Mol Genet. 2009 Dec 15, 18(24):4724-33.

Voordrachten Maximizing Growth in Children with Growth Hormone Deficiency (GHD) and NonGHD Short Stature. Sas TC, Ridder de MA, Wit JM, Rotteveel J, Oostdijk W, Reeser M, Otten BJ, Muinck de SM, Keizer-Schrama Horm. Satelite symposium LWPES / ESPE annual meeting 2009. New York, USA, september 2009. 72(Suppl.3):375.

Growth hormone treatment in Turner syndrome: 20 years Dutch dose response. Sas TC, Bannink EMN, Muinck Keizer de –Schrama SMPF. Eastern Europe Meeting. Kopenhagen, Denemarken, oktober 2009.

Posters Adult height in children with growth hormone deficiency: a randomized controlled GH dose response trial. Sas TC, Ridder de MA, Wit JM, Rotteveel J, Oostdijk W, Reeser M, Otten BJ, Muinck de SM, Keizer-Schrama Horm. Satelite symposium LWPES / ESPE annual meeting 2009. New York, USA, september 2009. 72(Suppl.3):375.

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Klinische chemie PubMed publicaties Automated quantification of cellular traffic in living cells. Broeke JH, Ge H, Dijkstra IM, Cemgil AT, Riedl JA, Cornelisse LN, Toonen RF, Verhage M, Fitzgerald WJ. J Neurosci Methods. 2009, 178(2):378-84. Cellular traffic is a central aspect of cell function in health and disease. It is highly dynamic, and can be investigated at increasingly finer temporal and spatial resolution due to new imaging techniques and probes. Manual tracking of these data is labor-intensive and observer-biased and existing automation is only semi-automatic and requires near-perfect object detection and high-contrast images. Here, we describe a novel automated technique for quantifying cellular traffic. Using local intrinsic information from adjacent images in a sequence and a model for object characteristics, our approach detects and tracks multiple objects in living cells via Multiple Hypothesis Tracking and handles several confounds (merge/split, birth/death, and clutters), as reliable as expert observers. By replacing the related component (e.g. using a different appearance model) the method can be easily adapted for quantitative analysis of other biological samples.

Overige publicaties Onverwachte problemen bij de vitamine B12 bepaling. Fouraux MA, Verheijen FM, de Kluis M, Klein-Gunnewiek JMT. Tijdschr van de Belgische Vereniging van Laboratorium Technologen. 2009, (36):33-37.

Provtagning, analys, diagnos och behandling. van Gelder W. Jaarverslag 2008. Cellavision AB, Zweden 2008.

Digital Morphology: a proven concept in the modern laboratory Riedl JA. Ned Tijdschr Klin Chem Labgeneesk. 2009, 34:60-103.

Images 200; Hematogenous metastasis of lung carcinoma. Riedl JA. Online publication. http://www.bloodmed.com. Okt 2009.

Vitamine B12 bepaling: probleem opgelost! van Rossum AP, Verheijen FM, KleinGunnewiek JMT, Castel A, Fouraux MA. Ned Tijdschr Klin Chem Labgeneesk. 2009, 34:251-254.

Uw diagnose? Tax GHM, van Gelder W, Cleophas AJM. Tijdschr voor infectieziekten. 2009, 4(6):243.

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Hoofdstuk in boek Erytrocyten, leukocyten en trombocyten. van Gelder W, Engbers-Buijtenhuijs P. In: ten Boekel, E, de Boer BA. Klinische Chemie en Hematologie voor analisten. deel 1. Arnhem: Syntax Media; 2009.

Voordrachten ABO-incompatibele transfusies. Berendes P. Symposium Sanquin Bloedbank ZWN. Rotterdam, 2009.

Laboratoriumtesten bij anemie. Berendes P. PAGAS symposium. Dordrecht, Asz, 2009.

Digitale microscopie. van Gelder W. 3rd Dutch Hematology congress. Papendal, januari 2009.

Digitale beeldanalyse en –herkenning: het morfologisch bloedonderzoek van de 21ste eeuw. van Gelder W. NVML Vakbeurs Techniek en Diagnostiek. Utrecht, maart 2009.

“Digitale microscopie: de toekomst” Workshop hemocytometrie. van Gelder W. Abott. Woudschoten, april 2009.

Looking form the far side – Cellavision DM96 and the concept of telehaematology for teaching and diagnosis. van Gelder W. Sysmex symposium. Istanbul, Turkije, mei 2009.

Digital morphology in haematology. van Gelder W. The combined congres of The society of medical laboratory technologists of South Africa, Federation of South African Societies of Pathology and South African Society of Clinical Cytology. Durban, september 2009.

2 lezingen voor hematologen en laboratoriumspecialisten van locale ziekenhuizen. van Gelder W. Durban en Johannesburg, september 2009.

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Concept of digital morphology and the current applications on the DM96. van Gelder W. Nationale hematologie congres. Tchechoslowakije, Brno, november 2009.

Bloedcelmorfologie. van Gelder W. Symposium sectie Hematologie van de SKML (Stichting Kwaliteitsbewaking Medische Laboratoria). Amsterdam, december 2009.

Anemie Verheijen FM. 1e Albert Schweitzer Anemie Symposium. Dordrecht, oktober 2009.

Posters Digital morphology: a proven concept in the modern laboratory. Riedl JA, Dinkelaar RB, van Gelder W. Voorjaarscongres NVKC. Veldhoven, april 2009.

Automated morphological analysis of cells in body fluids by the digital microscopy system DM96. Riedl JA. Voorjaarscongres NVKC. Veldhoven, april 2009.

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Kwaliteit, Veiligheid en Innovatie PubMed publicaties The cost-effectiveness of 18FDG-PET in selecting patients with suspicion of recurrent laryngeal carcinoma after radiotherapy for direct laryngoscopy. Hooren van ACG, Brouwer J, Bree de R, Hoekstra OS, C. Leemans CR. Uyl-Groot de CA. Eur Arch Otorhinolaryngol. 2009, 266:1441-1448. The aim of this study was to estimate the cost-effectiveness of (18)FDG-PET in the selection for direct laryngoscopy in patients with suspicion of recurrent laryngeal carcinoma after radiotherapy. The direct medical costs of 30 patients with suspicion of a recurrence were calculated from the first visit where suspicion was raised until one year after. A conventional strategy, in which all these patients underwent direct laryngoscopy, was compared to an (18)FDG-PET strategy in which only patients with a positive or equivocal (18)FDG-PET underwent direct laryngoscopy. A sensitivity analysis was performed to examine the influence of the type of camera and ‘setting’. The mean costs of an (18)FDG-PET strategy were 399 euros less than a direct laryngoscopy strategy. The type of camera and setting had no influence. In patients with suspicion for recurrent laryngeal carcinoma after radiotherapy, (18)FDG-PET seems to be effective and less costly in selecting patients for direct laryngoscopy.

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Longziekten PubMed publicaties Exhaled breath profiling enables discrimination of chronic obstructive pulmonary disease and asthma. Fens N, Zwinderman AH, van der Schee MP, de Nijs SB, Dijkers E, Roldaan AC, Cheung D, Bel EH, Sterk PJ. Am J Respir Crit Care Med. 2009 Dec 1, 180(11):1076-82. RATIONALE: Chronic obstructive pulmonary disease (COPD) and asthma can exhibit overlapping clinical features. Exhaled air contains volatile organic compounds (VOCs) that may qualify as noninvasive biomarkers. VOC profiles can be assessed using integrative analysis by electronic nose, resulting in exhaled molecular fingerprints (breathprints).OBJECTIVES: We hypothesized that breathprints by electronic nose can discriminate patients with COPD and asthma. METHODS: Ninety subjects participated in a cross-sectional study: 30 patients with COPD (age, 61.6 +/- 9.3 years; FEV(1), 1.72 +/- 0.69 L), 20 patients with asthma (age, 35.4 +/- 15.1 years; FEV(1) 3.32 +/0.86 L), 20 nonsmoking control subjects (age, 56.7 +/- 9.3 years; FEV(1), 3.44 +/- 0.76 L), and 20 smoking control subjects (age, 56.1 +/- 5.9 years; FEV(1), 3.58 +/- 0.78). After 5 minutes of tidal breathing through an inspiratory VOC filter, an expiratory vital capacity was collected in a Tedlar bag and sampled by electronic nose. Breathprints were analyzed by discriminant analysis on principal component reduction resulting in cross-validated accuracy values (accuracy). Repeatability and reproducibility were assessed by measuring samples in duplicate by two devices. MEASUREMENTS AND MAIN RESULTS: Breathprints from patients with asthma were separated from patients with COPD (accuracy 96%; P < 0.001), from nonsmoking control subjects (accuracy, 95%; P < 0.001), and from smoking control subjects (accuracy, 92.5%; P < 0.001). Exhaled breath profiles of patients with COPD partially overlapped with those of asymptomatic smokers (accuracy, 66%; P = 0.006). Measurements were repeatable and reproducible. CONCLUSIONS: Molecular profiling of exhaled air can distinguish patients with COPD and asthma and control subjects. Our data demonstrate a potential of electronic noses in the differential diagnosis of obstructive airway diseases and in the risk assessment in asymptomatic smokers.

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Neurologie Boek Hoofdpijn - feiten en casuïstiek. Carbaat PAT. Houten: Prelum Uitgevers; 2009. ISBN 9789085620617

Hoofdstuk in boek Hoofdstuk 15: Hoofdpijn, Hoofdstuk 37: De primaire hoofdpijnsoorten. Carbaat PAT. In: Bindels PJE,Vermeulen M. Het neurologie formularium. Houten: Bohn Stafleu van Lochum; 2009. ISBN 9789031355419

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Nucleaire geneeskunde Posters Clinical value of 18F-FDG PET in the diagnostic and therapeutic evaluation of retroperitoneal fibrosis: short term results of a prospective study. Jansen I, Hendriksz TR, Han SH, van Bommel EFH. European Radiology. Wenen, maart 2009. ECR book of abstracts. 2009, 19(1):S316 (B-749).

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Orthopedie PubMed publicaties No positive effect of autologous platelet gel after total knee arthroplasty. Peerbooms JC, de Wolf GS, Colaris JW, Bruijn DJ, Verhaar JA. Acta Orthop. 2009 Oct, 80(5):557-62. BACKGROUND AND PURPOSE: Activated platelets release a cocktail of growth factors, some of which are thought to stimulate repair. We investigated whether the use of autologous platelet gel (PG) in total knee arthroplasty (TKA) would improve wound healing and knee function, and reduce blood loss and the use of analgesics. PATIENTS AND METHODS: 102 patients undergoing TKA were randomly assigned to a PG group (n = 50) or to a control (C) group (n = 52). The primary analysis was based on 73 participants (PG: 32; C: 41) with comparison of postoperative wound scores, VAS, WOMAC, knee function, use of analgesics, and the pre- and postoperative hemoglobin values after a follow-up of 3 months. 29 participants were excluded due to insufficient data. RESULTS: The characteristics of the protocol-compliant patients were similar to those of the patients who were excluded. Analysis was per protocol and focused on the remaining 73 patients. At baseline and after 3 months of follow-up, there were no statistically significant differences between both groups regarding age, height, weight, sex, side of operation, platelet count, hemoglobin values, severity of complaints (WOMAC), and level of pain. INTERPRETATION: In our patients undergoing TKA, application of PG to the wound site did not promote wound healing. Also, we found that PG had no effect on pain, knee function, or hemoglobin values.

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Pathologie PubMed publicaties Suppose a mammary carcinoma is absent from the surgical specimen. Kuipers IM, Oostenbroek RJ, Storm RK, Menke-Pluymers MB, Westenend PJ, Plaisier PW. Ned Tijdschr Geneeskd. 2009, 153:A3. In three women aged 53, 51, and 42 respectively, who were treated by breast-conserving surgery for mammary carcinoma, the cancer was not found in the surgical specimen. For both patient and treating physician it is rather worrying when there is no good explanation for the fact that a histologically proven breast cancer cannot be detected in the surgical specimen without neoadjuvant therapy having been given. It is important to revise the needle biopsies, to exclude mix up of patient materials, to totally include the resected specimen in the pathological examination and to perform addition imaging of the remaining breast, preferably with MRI. An explanation may be that biopsy has removed such an amount of tumour tissue that the remains are not found. If no flaws are apparent, adjuvant radiotherapy and further adjuvant therapy on indication suffices.

Chromosome 3 intratumor heterogeneity in uveal melanoma. Mensink HW, Vaarwater J, Kilic E, Naus NC, Mooy N, Luyten G et al. Invest Ophthalmol Vis Sci. 2009, 50(2):500-504. PURPOSE: To investigate the presence of focal or diffuse heterogeneity of monosomy 3 in uveal melanoma, by using fluorescence in situ hybridization (FISH). METHODS: Direct interphase FISH in a series of 151 uveal melanomas revealed 82 tumors with loss of chromosome 3. Tumors with monosomy 3 were suspected to be heterogeneous if there were low percentages of monosomy 3, triploid clones, inconsistencies between FISH on centromere 3 and the long arm of chromosome 3, or discrepancies between fine-needle-aspiration biopsies (FNABs) and the main tumor. These tumors (n=16), all choroidal melanomas, were selected and analyzed for intratumor heterogeneity by using FISH on paraffin-embedded tissue sections. RESULTS: Different sections of each tumor were evaluated with FISH: 6 tumors showed monosomy 3 in the same percentage throughout the tumor, and 10 showed multiple clones with different percentages of monosomy 3. However, these tumors did not show focal heterogeneity with respect to chromosome 3 status, and differences in monosomy 3 distribution between the base and apex of the tumor could not be identified. CONCLUSIONS: Although a small number of uveal melanomas show heterogeneity for chromosome 3, it does not affect survival. In the presence of triploid clones, the loss of chromosome 3 is more difficult to interpret. In general, tumor biopsies in uveal melanoma provide an accurate prediction of the patient’s prognosis.

Acute interstitial nephritis during rifampicin therapy can be a paradoxical response: a case report. Meulen van der J, Jong de GTM, Westenend PJ. Cases J. 2009, 2:6643. An 18-year-old Ethiopian woman presented with debilitating back pain and high fever. X-ray examinations showed diffuse pulmonary tuberculosis and a psoas abscess. After starting rifampicin, isoniazid, ethambutol and pyrazinamide, acute interstitial nephritis developed that spontaneously recovered. According to Harrison’s Online rifampicin should have been causative, but the spontaneous recovery excluded that possibility. The clinical course fit the diagnosis of a paradoxical response, for which recently risk factors have been described. Thus, a paradoxical

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response should be added to the list of causes of interstitial nephritis in tuberculosis patients and in such cases rifampicin could be continued.

Introduction of epithelial cells in the flap-graft interface during descemet stripping automated endothelial keratoplasty. Saelens IE, Bartels MC, Van RG, Dinjens WN, Mooy CM. Arch Ophthalmol. 2009, 127(7):936-937. Geen abstract in PubMed.

Overige publicaties Phyllodestumor van de mamma: een diagnostische uitdaging. Bul M, Plaisier PW, Westenend PJ, Storm RK, Oostenbroek RJ. Ned Tijdschr Heelkd. 2009, 18:100-105.

Posters Evaluation of an internally controlled semi-quantitative real-time PCR for detection of Pneumocystis jiroveci in paraffin-embedded clinical samples. Zee van der A, Hermans M, Kroonen R, Breugelmans AJ, Mooij CM, Westenend PJ. European Meating on Molecular Diagnostics. Scheveningen, oktober 2009.

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Radiologie PubMed publicaties Computed tomography unmasks a phantom tumour Baks T, Kock MCJM, Kofflard MJ. Int J Cardiol. 2009, Apr 18. [Epub ahead of print] We describe a patient with left sided congestive heart failure and a round-shaped mass on the chest X-ray. Using computed tomography, the mass is diagnosed as a phantom tumour consisting of loculated effusion in the interlobular fissure that vanishes after treatment for heart failure is initiated.

Idiopathic retroperitoneal fibrosis: prospective evaluation of incidence and clinicoradiologic presentation. Bommel van EFH, Jansen I, Hendriksz TR, Aarnoudse AL. Medicine (Baltimore). 2009 Jul, 88(4):193-201. Retroperitoneal fibrosis (RPF) is a rare disorder of unknown etiology. Its incidence is unknown, and the insidious and nonspecific nature of symptoms may contribute to considerable diagnostic delay. We conducted the current study to assess the incidence and clinicoradiologic characteristics of idiopathic RPF. For this, we evaluated prospectively 53 consecutive patients with a diagnosis of idiopathic RPF at our tertiary care referral center from April 1998 through January 2008.Calculated annual incidence of RPF was 1.3/100,000 inhabitants. Mean age was 64 +/- 11.1 (SD) yr; male-female ratio was 3.3:1.0. Median duration of symptoms was 6.0 mo (IQR 3.0-12.0). Abdominal, flank, and/or back pain and discomfort were the major symptoms, with visual analogue scale scores of 49 +/- 27.2 mm and 43 +/29.4 mm for pain and discomfort, respectively. Female patients had higher erythrocyte sedimentation rate (ESR), higher white blood cell count, and lower hemoglobin content than male patients at presentation. Computed tomography-documented maximal mass thickness amounted to 35 +/- 16.6 mm; craniocaudal length amounted to 137 +/- 48.8 mm. RPF mass extension up to or above the level of the renal vessels was noted in 3 patients (6%). Six patients (11%) presented with atypical RPF localization and/or bulky mass. Localized lymphadenopathy adjacent to the RPF mass was observed frequently (25%). Patients with hydronephrosis (56%) presented earlier than patients without hydronephrosis, with higher creatinine and greater mass thickness but similar pain severity. Patients were typically at high cardiovascular risk with increased-often aneurysmal-infrarenal aortic diameter (25.0 mm, IQR 22.0-30.0). RPF mass distribution was similar in patients with or without aneurysmal dilation. Occupational asbestos exposure (20%) and asbestos-related pleural changes (17%) were frequent among males. Previous or concurrent chronic inflammatory disease and/or autoimmune disease was noted in 8 patients (15%). Multivariate analysis revealed an independent association of ESR values with severity of pain and discomfort. Smoking was independently associated with infrarenal aortic diameter. In summary, annual RPF incidence is higher than previously assumed. Age at diagnosis and malefemale ratio seem to have changed over time. RPF typically affects patients at high cardiovascular risk, including increased aortic diameter. Clinical presentation is influenced by sex, severity of inflammation and presence of hydronephrosis. Prolonged asbestos exposure and asbestos-related pleural changes were frequent among males. Localized lymphadenopathy adjacent to the RPF mass occurs frequently and should not confuse RPF diagnosis.

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A rare coronary anomaly detected by computed tomography angiography: the left circumflex artery originating from the descending thoracic aorta. Hoogstraate SR, Kofflard MJ, Nieman K, Kock MCJM. Eur J Cardiothorac Surg. 2009 Jun, 35(6):1077. Geen abstract in PubMed.

Cryoplasty for occlusive disease of the femoropopliteal arteries: 1-year follow-up. Korteweg MA, van Gils M, Hoedt MT, van der Valk PH, Tutein Noltenius RP, Avontuur JA, Bronswijk-Monster KF, Elgersma OE. Cardiovasc Intervent Radiol. 2009, 32(2):221-5. Atherosclerosis of femoropopliteal arteries is an important cause of morbidity and mortality. Percutaneous transluminal angioplasty (PTA) has only limited success in treating these arteries, mainly because of the high rate of recurrent stenosis. Cryoplasty has been proposed as a technique which might improve treatment outcome. This study reports our single-center experience with cryoplasty. Thirty-two claudicants, 33 arteries, in whom conservative therapy failed, were consecutively included. Duplex ultrasound (US), angiography, and ankle-brachial index (ABI) measurement were performed before the procedure; ABI and duplex US, 2 weeks and 3, 6, and 12 months after the procedure. Patients’ symptoms were categorized according to the Rutherford classification. Lesions were classified as TASC A, B, or C according to angiographic appearance. Differences in ABI before and after the procedure were defined as significant at p < 0.05 by paired t-test. Patency was evaluated using duplex US by determining the peak systolic velocity ratio. Sixteen TASC A lesions, 13 TASC B lesions, and 4 TASC C lesions were included. ABI improved significantly for TASC A lesions 2 weeks and 3 months postprocedure. Patency after 2 weeks, 6 months, and 12 months was 93%, 67%, and 64% for TASC A lesions, 83%, 31%, and 31% for TASC B lesions, and 100%, 50%, and 33% for TASC C lesions, respectively. In conclusion, cryoplasty has good immediate success rates and patency rates similar to the results of conventional PTA in the literature.

Suppose a mammary carcinoma is absent from the surgical specimen. Kuipers IM, Oostenbroek RJ, Storm RK, Menke-Pluymers MB, Westenend PJ, Plaisier PW. Ned Tijdschr Geneeskd. 2009, 153:A3. In three women aged 53, 51, and 42 respectively, who were treated by breast-conserving surgery for mammary carcinoma, the cancer was not found in the surgical specimen. For both patient and treating physician it is rather worrying when there is no good explanation for the fact that a histologically proven breast cancer cannot be detected in the surgical specimen without neoadjuvant therapy having been given. It is important to revise the needle biopsies, to exclude mix up of patient materials, to totally include the resected specimen in the pathological examination and to perform addition imaging of the remaining breast, preferably with MRI. An explanation may be that biopsy has removed such an amount of tumour tissue that the remains are not found. If no flaws are apparent, adjuvant radiotherapy and further adjuvant therapy on indication suffices.

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Een man met buikpijn, braken en obstipatie. Langeveld ARJ, Dinkelaar W. Ned Tijdschr Geneeskd. 2009, 153:B83

Complications and failure of uterine artery embolisation for intractable postpartum haemorrhage. Maassen MS, Lambers MD, Tutein Nolthenius RP, van der Valk PH, Elgersma OE. BJOG. 2009, 116(1):55-61. OBJECTIVE: Primary postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality around the world. Most patients can be managed conservatively, but patients with intractable bleeding require more aggressive treatment. In these cases uterine artery embolisation (UAE) has proven to be a useful tool to control PPH. The reported success rate of UAE is over 90% with only minor complications. In this case series we studied the effectiveness and complications of UAE. DESIGN: Retrospective analysis of a case series. SETTING: Case series in a large peripheral hospital in the Netherlands. SAMPLE: Eleven patients who were treated with UAE for intractable PPH from November 2004 to February 2008. METHODS: In this paper we review the results of all patients treated with UAE for intractable PPH in our hospital and focus on the two cases with adverse outcomes. MAIN OUTCOME MEASURES: Effectiveness, causes of failure of UAE, complications. RESULTS: Nine out of eleven patients were treated successfully with UAE. One patient needed an emergency hysterectomy for intractable bleeding. In the aftermath she developed a vesicovaginal fistula (VVF). Another patient suffered a major thrombo-embolic event of the right leg, for which she underwent embolectomies and despite fasciotomy a necrotectomy. CONCLUSIONS: UAE is a valuable tool in managing major PPH and in most cases it can replace surgery and thus prevent sacrification of the uterus. However, due to blood supply of the uterus by one of the ovarian or aberrant arteries, UAE might fail to control the bleeding. In addition, serious complications such as a thrombo-embolic event or VVF may occur. We hereby present a case of migration of an embolus from the site of re-embolisation into the femoral artery requiring immediate intervention to prevent the loss of the lower leg. This complication demonstrates that gelatine sponge particles could migrate from the internal iliac artery into the external iliac artery.

Incremental value of arterial and equilibrium phase compared to hepatic venous phase CT in the preoperative staging of colorectal liver metastases: An evaluation with different reference standards. Wicherts DA, de Haas RJ, van Kesself CS, Bisschops RH, Takahara T, van Hillegersberg R, Bipat S, Rinkes IH, van Leeuwen MS. Eur J Radiol. 2009 Aug 18. [Epub ahead of print] PURPOSE: To evaluate the incremental value of arterial and equilibrium phase compared to hepatic venous phase multidetector row CT (MDCT) in the preoperative staging of colorectal liver metastases (CLM) and to determine the influence of the reference standard. MATERIALS AND METHODS: Fifty-three consecutive CLM patients underwent 16 detector row CT in hepatic arterial, venous, and equilibrium phase before surgery between March 2003 and January 2007. Detected lesions were characterized by three independent radiologists. The reference standard consisted of intraoperative palpation and ultrasound of the liver, and histopathological examination of the resected specimen. Additionally, data of follow-up CT was added. Statistical analysis was performed

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on a per-lesion basis. RESULTS: According to the reference standard 251 lesions were present, of which 203 (81%) were malignant (mean size: 29.4+/-22.5mm), and 41 (16%) were benign (mean size: 8.3+/-7.7mm). Sensitivity rates for CLM were comparable between triphasic and hepatic venous phase CT (P>0.05). Sensitivity for the detection of CLM lowered from 60-77% to 52-68% when follow-up CT was added to the reference standard. CONCLUSION: Arterial and equilibrium phase CT have no incremental value compared to hepatic venous phase MDCT in the detection of CLM. Sensitivity rates are, however, influenced by the type of reference standard used.

Overige publicaties Phyllodes tumor van de mamma: een diagnostische uitdaging. Bul M, Plaisier PW, Westenend PJ, Storm RK, Oostenbroek RJ. Ned Tijdschr Heelkd. 2009, 18:100-5.

Mediastinaal teratoom als oorzaak van oorzaak van persisterende hoestklachten. Dickhoff C, Polat F, Elgersma OEH, Schütte PR. Ned Tijdschr Heelkd. 2009, 18(3).

Stel dat het mammacarcinoom ontbreekt in het resectiepreparaat. Kuipers IMT, Oostenbroek RJ, Storm RK, Menke-Pluymers MBE, Westenend PJ, Plaisier PW. Ned Tijdschr Geneeskd. 2009, 44:2150-2156.

Het radioactieve jodiumzaadje. Plaisier PW, Storm RK, Han Ho S. MemoRad. 2009, 14(3):16.

Only MR can safely exclude patients from arthroscopy. Vincken PW, ter Braak BP, van Erkel AR, Bloem RM, van Luijt PA, Coene LN, de Lange S, Bloem JL. Skeletal Radiol. 2009 Oct, 38(10):977-82.

Voordrachten Is routinematige screening op heupdysplasie met behulp van echografie geïndiceerd bij kinderen geboren in hoofdligging na versie van een stuitligging? Cremers SEH. Radiologendagen. Rotterdam, september 2009.

Is routine screening for hipdysplasia with ultrasound indicated in infants born after successful external cephalic version of a breech position? Cremers SEH. ECR. Wenen, maart 2009.

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Vertebroplastieken. Interventie: materialen, technieken en indicaties. Elgersma O. Regionaal onderwijs Radiologie OOR. Dordrecht, november 2009.

Stenotisch lijden van AFS. Interventie: materialen, technieken en indicaties. Elgersma O. Regionaal onderwijs Radiologie OOR. Dordrecht, november 2009.

Skelet: Tumoren bot en weke delen. Hendriksz T, Ter Braak A. Regionaal onderwijs Radiologie OOR. Dordrecht, november 2009.

Gal- en urinewegen. Interventie: materialen, technieken en indicaties. Ophof P. Regionaal onderwijs Radiologie OOR. Dordrecht, november 2009.

Radiologische puncties. Interventie: materialen, technieken en indicaties. Ophof P. Regionaal onderwijs Radiologie OOR. Dordrecht, november 2009.

Assessment of image quality of the right ventricle in three different postgadolinium IR sequences in patients suspected of ARVC. Plaisier AS. Radiologendagen. Rotterdam, september 2009.

Visceral fat volume and its association with mesenteric panniculitis. van Putte-Katier N, Elgersma OE, Hendriksz TR. Radiologendagen. Rotterdam, september 2009.

Vasculaire interventie. Interventie: materialen, technieken en indicaties. Van der Valk P. Regionaal onderwijs Radiologie OOR. Dordrecht, november 2009.

Posters MR Evaluation of Urethral Diverticula and Differential Diagnosis in Female Patients with Chronic Lower Urinary Tract Symptoms. Dwarkasing RS, Dinkelaar W, Hop WCJ, Dohle GR, Krestin GP. RSNA. Chicago, december 2009.

Nomogram for suboptimal cytoreduction at primary surgery for advanced stage ovarian cancer. Gerestein CG, Eijkemans MJ, Bakker J, Elgersma OE, Kooi GS, Burger CW. ESGO 16 Meeting. Belgrado, Servië, oktober 2009.

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Clinical value of 18F-FDG PET in the diagnostic and therapeutic evaluation of retroperitoneal fibrosis: short term results of a prospective study. Jansen I, Hendriksz TR, Han SH, van Bommel EFH. European Radiology. Wenen, maart 2009. ECR book of abstracts. 2009, 19(1):S316(B-749).

Assessment of image quality of the right ventricle in three different postgadolinium IR sequences in patients suspected of ARVC. Plaisier AS. European Congress of Radiology. Wenen, maart 2010.

Assessment of image quality of the right ventricle in three different postgadolinium IR sequences in patients suspected of ARVC. Plaisier AS. EuroCMR09 meeting organised by the Working Group on Cardiovascular Magnetic Resonance of the European Society of Cardiology. Athene, Griekenland, mei 2009.

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Spoedeisende Hulp PubMed publicaties Pain management in emergency departments: a review of present protocols in The Netherlands. Gaakeer MI, Lieshout van JM, Bierens JJLM. Eur J Emerg Med. 2009 Oct 8. [Epub ahead of print] This descriptive study presents availability and content of acute pain protocols in emergency departments (EDs) in The Netherlands. Current acute pain protocols were collected and an a priori list of questions was used for analysis. Findings were compared with current international standards. Sixty-six of the 108 EDs responded. Fifty-six percent of the protocols did not address adults and 35% did not address children. Protocols were rather conservative and showed poor multidisciplinary approach. Seventy-three percent required a diagnosis before pain relief. Six percent did not include opioids, 36% did not allow intravenous opioids and only 49% allowed direct administration of opioids in severe pain. Pain measurement was included in 55% and in only 5% a target score was defined. Nonpharmacological approaches were mentioned in 6%. Acute pain protocols are lacking in many EDs. Most protocols did not apply current standards. We exposed an area with space for leadership.

Overige publicaties Wervelimmobilisatie: zin of onzin? Bevelander T, van Gent A. Critical Care. 2009, 4(24-27).

Management of severe sepsis and septic shock in the emergency department: current practice in the Netherlands. Gaakeer MI, Lieshout van JM, Hugelmeyer CD, Zanten van ARH. Netherlands Journal of Critical Care. Juni 2009, 13(3):128-131.

Reactie op ‘Doen wat je kan’ (Themanummer pijn, nr. 12). Gaakeer MI, Lieshout van JM, Bierens JJLM. Ned Tijdschr Geneeskd. 2009, 153:B330.

Voordrachten Expeditie patientveiligheid, Pak sepsis gericht aan! Gaakeer MI. Congres Expeditie Patiëntveiligheid VMS van Nederlandse Vereniging van Ziekenhuisapothekers. Rotterdam, november 2009.

Management van acute pijn op Spoedeisende hulp afdelingen in Nederland: een overzicht van bestaande protocollen. Gaakeer MI, Lieshout van JM, Bierens JJLM. Traumadagen NVvT. Amsterdam, november 2009.

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Analgesie & Procedurele Sedatie op de SEH. Gaakeer MI. 5e Landelijke Thema-Avond Spoedeisende Geneeskunde Albert Schweitzer ziekenhuis. Dordrecht, maart 2009.

Thema’s: Bewustzijnstoornissen, Traumatologie bovenste extremiteiten, Airwaymanagement. Gaakeer MI. Faculty docent STARtclass, SBOH. Bilthoven, september 2009.

Fractuurbehandeling op de SEH. Gaakeer MI. 6e Landelijke Thema-Avond Spoedeisende Geneeskunde. Albert Schweitzer ziekenhuis. Dordrecht, oktober 2009.

Thema’s: Bewustzijnstoornissen, Traumatologie bovenste extremiteiten, Airwaymanagement. Gaakeer MI. Faculty docent STARtclass, SBOH. Bilthoven, december 2009.

Procedural Sedation and Analgesia in an Emergency Medicine Department in the Netherlands. Zwets ED, Gaakeer MI, Veugelers R, Houser CM, Bierens JJLM. Third Dutch North Sea Emergency Medicine Congress NVSHA. Egmond aan Zee, juni 2009.

Posters A boy with a painful inguinal mass. Gaakeer MI. Third Dutch North Sea Emergency Medicine Congress NVSHA. Egmond aan Zee, juni 2009.

Management of severe sepsis and septic shock in the emergency department: a survey of current practice in emergency departments in the Netherlands. Gaakeer MI, JM Lieshout van JM, Tjan D, Zanten van A. Landelijke themaconferentie ‘Voorkomen van lijnsepsis en behandeling van ernstige sepsis’ SSC & VMS. Ede, maart 2009.

Procedural Sedation and Analgesia in an Emergency Medicine Department in the Netherlands. Zwets ED, Gaakeer MI, Veugelers R, Houser CM, BIerens JJLM. 5th Mediterranean Emergency Medicine Conference EuSEM. Valencia, september 2009.

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Urologie Pubmed publicaties Short-term outcomes of the prospective multicentre ‘Prostate Cancer Research International: Active Surveillance’ study. van den Bergh RC, Vasarainen H, van der Poel HG, Vis-Maters JJ, Rietbergen JB, Pickles T, Cornel EB, Valdagni R, Jaspars JJ, van der Hoeven J, Staerman F, Oomens EH, Rannikko A, Roemeling S, Steyerberg EW, Roobol MJ, Schröder FH, Bangma CH. BJU Int. 2010 Apr, 105(7):956-62. Epub 2009 Oct 8. OBJECTIVE: To evaluate the short-term outcomes of the prospective international Prostate Cancer Research International: Active Surveillance (‘PRIAS’) study (Dutch Trial Register NTR1718), as active surveillance (AS) for early prostate cancer might provide a partial solution to the current overtreatment dilemma in this disease. PATIENTS AND METHODS: The first 500 (of >950) participants with asymptomatic T1c/T2 prostate cancer, with a prostate-specific antigen (PSA) level of < or =10.0 ng/mL, a PSA density of <0.2 ng/mL/mL, a Gleason score of < or =3 + 3 = 6, and one or two positive biopsy cores, were analysed. The follow-up protocol consisted of frequent PSA measurements, digital rectal examinations, and standard repeat biopsies (the first after 1 year). The primary outcome is survival free of active therapy; the secondary endpoints are reasons for stopping AS, findings in 1-year repeat biopsies, and outcomes after radical prostatectomy (RP). RESULTS: Patients were included between December 2006 and July 2008. The median (25-75th percentile) follow-up after diagnosis was 1.02 (0.6-1.5) years. The 2-year survival rate free from active therapy was 73%. Of the 82 men who changed to active therapy during the follow-up, 68 (83%) did so based on the protocol. Of the 261 repeat biopsies available for analysis, 90 (34%) showed no cancer, while 57 (22%) showed a Gleason score of >6 or more than two positive biopsy cores. There was a relatively unfavourable PSA doubling time of 0-10 years in 53% (102/194) and 62% (33/53) of men with favourable and unfavourable re-biopsy results, respectively. After RP, four of 24 (17%) men had T3 disease and 12 (50%) had a Gleason score of >6. CONCLUSION: AS seems feasible, but mortality outcomes are unknown. A strict follow-up protocol including standard 1-year repeat biopsies resulted in a quarter of men stopping AS after 2 years.

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Ziekenhuis psychiatrie Posters Disordered mood: A practical-orientated research on the recognition of depression in people with diabetes. Boshoven HEMV, Lemstra A., Luteijn M, Ouwerkerk van BM. 12 th Annual Meeting of the European Association for Consultation-Liaison Psychiatry and Psychosomatics (EACLPP). In: Journal of Psychosomatic Research. New York: Elsevier; 2009, 66(6), p551.

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Promoties 2009 Chronic hepatitis B: Individualized Antiviral Therapy. Buster EHCJ. Erasmus Universiteit Rotterdam, 23 oktober 2009. ISBN: 9789085595694

The Microcirculation in Severe Heart Failure and Cardiogenic Shock den Uil CA. Erasmus University Rotterdam, 25 november 2009. ISBN: 9789085595908.

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Verantwoording wetenschappelijk jaaroverzicht 2009 Deze bundel is op de volgende wijze samengesteld. Belangrijk inclusie criterium voor de publicaties (inclusief (hoofdstukken uit) boeken) is: • (co) auteur moet tijdens een aanzienlijk deel van de werkzaamheden werkzaam zijn (geweest) in het Albert Schweitzer ziekenhuis ten tijde van dataverzameling, dataverwerking of opschrijven van de resultaten. Indien het artikel van de (co)auteur gepubliceerd wordt tijdens de aanstellingsperiode in het Albert Schweitzer ziekenhuis, maar de feitelijke werkzaamheden reeds onder een andere aanstelling zijn verricht, kunnen de artikelen niet in het Wetenschappelijk jaaroverzicht van het Albert Schweitzer ziekenhuis worden opgenomen. • De digitale publicaties voorafgaand aan de geprinte versie (Epub ahead of print) van 2009 zijn zoveel als mogelijk meegenomen in het jaaroverzicht 2009. Belangrijk inclusie criterium voor de voordrachten en posterpresentaties zijn: • het betreft een wetenschappelijke presentatie of klinische expert presentatie op geaccrediteerde congressen, symposia en opleidingen buiten normaal curriculum. • en (co) auteur moet ten tijde van de voordracht werkzaam zijn (geweest) in het Albert Schweitzer ziekenhuis

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Abstractboek Wetenschapsdag 2010

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Externe spreker Identificatie en classificatie van chronische Q-koorts patiënten. Dr. N.H.M. Renders Arts-microbioloog, Jeroen Bosch ziekenhuis

Sinds 2007 is er een Q-koorts epidemie in Nederland. Momenteel zijn 3958 patiënten met acute Q-koorts gediagnosticeerd waarvan ruim 2000 infecties in regionaal medisch microbiologisch laboratorium van het Jeroen Bosch Ziekenhuis zijn vastgesteld. Het aantal patiënten dat een chronische Q-koorts infectie ontwikkelt varieert in de literatuur van 1 tot 5%. Op basis van de gevallen die in 2007 t/m heden zijn gemeld zouden er 40 tot 200 patiënten met chronische Q-koorts te verwachten zijn. Volgens de literatuur verloopt bij 60% van de mensen de ziekte symptomatisch en bij deze categorie patiënten zou de kans op ontwikkelen van chronisch Q-koorts kleiner zijn. Waarschijnlijk zal het aantal chronische Q koorts patiënten hoger liggen omdat er een onbekend aantal niet gediagnosticeerde patiënten is. Na acute Q-koorts worden de patiënten serologisch vervolgd op maand 3, 6 en 12. In 2008 zagen we de eerste patiënten met zeer hoge IgG titers. (Vanaf 2009 was de PCR voor diagnostiek beschikbaar) Er is een multidisciplinair team gevormd die deze patiënten gezamenlijk bespreken en een Q koorts poli geopend. Het multidisciplinair team heeft een diagnostisch algoritme gemaakt en een richtlijn voor de behandeling van chronische Q-koorts patiënten opgesteld. Er zijn 3 categorieën gemaakt om chronische Q-koorts patiënten in te delen. Groep 1: patiënten met klinische verdenking op chronische Q-koorts en serologie passend bij chron Q. Groep 2: patienten met serologie passend bij chronische Q, PCR negatief, klinisch geen klachten. Groep 3: patiënten met risicofactoren op het ontwikkelen op chron Q, deze groep kwam in aanmerking voor profylaxe. Tijdens de presentatie wordt de identificatie en classificatie van chronische Q-koorts patiënten toegelicht.

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Mondelinge presentaties Wetenschapsdag 2010

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Anesthesiologie Does implementing a Rapid Response System decrease the number of in-hospital cardiac arrests on the general wards? V. van Bruggen1, P. Barendregt1, A. Geense1, E. van Dijk1, M. Achilleos1, M. Meijer1, A. Deijkers2, G. Verwoerd2, M. Taks3, E. Oskam4, R. So1,3. 1

Afdeling Intensive Care, Albert Schweitzer ziekenhuis. Afdeling Chirurgie, Albert Schweitzer ziekenhuis. 3 Afdeling KV&I, Albert Schweitzer ziekenhuis. 4 Afdeling Spoedeisende hulp, Albert Schweitzer ziekenhuis. 2

Background / Achtergrond Resulting from the Dutch VMS Safety Program ‘Prevent injury, work safely’ we recently started to implement a Rapid Response System (RRS) on both clinical locations of our hospital: Dordwijk and Zwijndrecht.The RRS consists of: a “warning signs” pocket card, a Rapid Response Team (RRT) and an evaluation system. The purpose of the RRS is to recognize and treat the patients with clinical warning signs early on the ward to reduce preventable hospital-wide “avoidable injury”.

Objective / Doel Our aim was to investigate whether implementation a RRS can decrease the number of in-hospital cardiac arrests (CA) on the general wards.

Methods / Methoden Data regarding the RRT calls and the in-hospital CA were collected from May,1 2008 until April,30 2009 (total: 260 calls). We were interested in: the number of RRT calls and the total in-hospital cardiac arrests on the general wards.

Results / Resultaten Number RRT calls per 1000 discharged patients (Dordwijk): 0 (2007) 1,2 (2008) 3,2 (2009); Number RRT calls per 1000 discharged patients (Zwijndrecht): 0 (2007) 6,4 (2008) 11,8 (2009); Number in-hospital CA per 1000 discharged patients (Dordwijk): 1,4 (2007) 1,2 (2008) 1,4 (2009); Number in-hospital CA per 1000 discharged patients (Zwijndrecht): 2,6 (2007) 1,3 (2008) 0,6 (2009).

Conclusion / Conclusie Implementation of a RRS can decrease the number of in-hospital CA dramatically. Possible succesfactors include: timely activation of the Rapid Response System, degree of implementation of the Rapid Response System and timely agree restrictive measurements on the general ward.

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Chirurgie De resultaten van heupchirurgie opgeworpen als nieuwe prestatie-indicator T.S.C. Jakma1, S. Vijfhuize1, R.J. Oostenbroek1, B.J. Punt1. 1

Afdeling Chirurgie, Albert Schweitzer ziekenhuis.

Background / Achtergrond Met 15.000 heupfracturen per jaar vormt de heupchirurgie een belangrijk onderdeel van de dagelijkse chirurgische praktijk. Momenteel is een vigerende kwaliteitsindicator het percentage heupfracturen dat binnen 24 uur wordt geopereerd. Zonder te willen afdingen op het belang om deze fracturen zo snel mogelijk “weg te opereren”, lijkt ons het resultaat minstens even belangrijk voor deze kwetsbare patiëntengroep.

Objective / Doel Om de kwaliteit van eigen handelen te toetsen werd een retrospectief onderzoek verricht naar de resultaten van alle geopereerde heupfracturen van medio 2005 tot 2007 met als uitkomstmaten het aantal re-interventies en de overleving na 1 jaar.

Methods / Methoden Alle geopereerde heupfracturen in de periode medio 2005 – 2007 werden geïncludeerd. Het aantal re-interventies op de operatiekamer, variërend van het uitruimen van een hematoom tot vervangen van het eerder gekozen implantaat (kophalsprothese, gecannuleerde schroeven, DHS, Y-nagel of PFN) werd gescoord. Tevens werd de datum van overlijden tot 1 jaar na de initiële operatie geregistreerd. Vanaf medio 2005 werden via het ZIS operatietijden geregistreerd. Zo werd berekend of patiënten binnen 24 uur na presentatie op de SEH geopereerd werden. Op basis hiervan werden patiënten in twee groepen verdeeld. In de subgroep die niet binnen 24 uur geopereerd was, werd onderscheid gemaakt tussen patiëntgerelateerde en logistiekgerelateerde factoren die het delay bepaalden.

Results / Resultaten Er werden 379 patiënten geopereerd, waarvan 226 (60%) binnen 24 uur na presentatie op de SEH. Met betrekking tot de mortaliteit gaf dit een absoluut risico reductie van 1.7% (95% CI: -0.060 – 0.099). De in-hospital-mortaliteit betrof in de respectievelijke groepen 7.1 en 6.5%. In relatie tot het aantal re-interventies gaf opereren binnen 24 uur een absoluut risico reductie van -3.2% (95% CI: -0.094 – 0.035). Beide uitkomsten zijn dus niet significant. In het grootste deel van de operaties die later dan 24 uur na presentatie op de SEH plaatsvonden, ging het om uitstel op basis van patiëntgerelateerde factoren. In 77% hiervan betrof het uitstel op advies van een ander specialisme tijdens de pre-operatieve screeningsfase.

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Conclusion / Conclusie Het percentage re-interventies en de mortaliteit binnen één jaar na heupchirurgie is aanzienlijk. In vergelijking met de literatuur zijn onze resultaten echter niet ongunstig. In onze studiegroep lijkt het opereren binnen 24 uur na presentatie met een heupfractuur op de SEH geen betere uitkomst te verzorgen op de eindpunten 1-jaars mortaliteit en re-interventies binnen één jaar. Op het eindpunt re-interventies binnen één jaar is er zelfs een trend die slechtere uitkomsten voor de groep geopereerd binnen 24 uur laat zien. Een patiëntgerelateerd delay lijkt dus geoorloofd. Mogelijk dat het aantal re-interventies binnen één jaar een goede nieuwe prestatie-indicator is voor heupfractuurchirurgie. Met uitbreiding van onze dataset en verdere analyse hiervan hopen we hier in de nabije toekomst een gefundeerde uitspraak over te kunnen doen.

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Fistelvorming bij diverticulitis: uitkomsten van chirurgische therapie R.M. Smeenk1, W.L.E.M. Hesp1. 1

Afdeling Chirurgie, Albert Schweitzer ziekenhuis.

Background / Achtergrond Patiënten met diverticulitis presenteren zich in enkele gevallen met een fistel naar de blaas, vagina of huid. Behandeling van dit ziektebeeld bestaat uit resectie van het zieke colon en de fistel, met of zonder primaire anastomose en/of deviërend ileostoma.

Objective / Doel Doel van deze studie is om de uitkomst van de chirurgische therapie voor fistelende diverticulitis te evalueren.

Methods / Methoden Een retrospectieve analyse werd uitgevoerd van patiënten die geopereerd werden voor diverticulitis van januari 2004 tot en met December 2009. Patiënten met een colovesicale, colovaginale of enterocutane/enteroenterale fistel werden geïncludeerd voor verdere analyse.

Results / Resultaten In 6 jaar tijd ondergingen 214 patiënten een operatie voor diverticulitis. Het betrof een fistelende diverticulitis in 39 van de gevallen (18%), waarvan 19 mannen. De gemiddelde leeftijd was 69 jaar (38-90). Er was sprake van een colovesicale, colovaginale of enterocutane/enteroenterale fistel in respectievelijk 31, 4 en 4 gevallen. Een (recto)sigmoidresectie werd verricht in 28 patiënten, waarvan 10 een deviërend ileostoma kregen. De overige 11 patiënten ondergingen ene Hartmann procedure. De postoperatieve morbiditeit en mortaliteit bedroeg respectievelijk 48% en 13%. Naadlekkage trad op in 6 van de 18 patiënten (33%) met een primaire anastomose zonder stoma. Herstel van continuïteit vond plaats in 16 van de 21 patiënten (76%) met een gemiddelde duur na initiële operatie van 5.6 maanden (2-10).

Conclusion / Conclusie Bijna 1 op de 5 patiënten die geopereerd worden voor diverticulitis heeft een fistel en dan met name naar de blaas. Resectie van het zieke colon met primaire anastomose heeft de voorkeur, maar het lijkt verstandig om in die gevallen wel een deviërend stoma aan te leggen dat binnen aanzienbare tijd weer opgeheven kan worden.

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Gynaecologie Treatment of female SUI with a transobturator device: are there differences between inside-out and outside-in techniques after thorough multidisciplinary analysis and physiotherapy? C. Bakker1, J.H.N. Schram1, R. Potjer2, C.J.A. Hogewoning1. 1 2

Afdeling Gynaecologie/Regionaal Bekkenbodem Centrum, Albert Schweitzer ziekenhuis. Afdeling Urologie/Regionaal Bekkenbodem Centrum, Albert Schweitzer ziekenhuis.

Submitted: Int Journal of Urogynecology

Background / Achtergrond In our Regional pelvic floor centre two transobturator techniques for the surgical treatment of stress urinary incontinence (SUI) are in use since more then 5 years. The clinical impression was that the outside-in technique (TOT, Intramesh Softlift®,Cousin) gave more complications and less results concerning stress incontinence then inside-out (TVT-O®, Johnson&Johnson).

Objective / Doel The aim of this study is to compare the results and complications of the two transobturator techniques used in our centre.

Methods / Methoden Multidisciplinary analysis of urinary incontinent patients started in our centre in January 2007. After analysis treatment of SUI patients always starts with physiotherapy for three months at least. When still incontinent after this period surgery is proposed. This retrospective study includes 74 randomised patients who received a TVT-O or TOT transobturator suburethral tape from April 2007 till June 2008. The incidence of complications and the presence of stress urinary incontinence are studied one year after urethral suspension by clinical examination, urodynamics and validated questionnaires (Dutch pelvic floor questionnaire and PISQ). Data were analyzed using the Chi-square test and Fisher’s exact test.

Results / Resultaten Complications occurred in seven out of 74 patients. Five of them underwent a repeat urethral suspension after removal of the first tape. Complications were mainly displacement of the tape and residual SUI. No significant differences were found between the results of TVT-O and TOT. (92,85% and 89,6% respectively) The multidisciplinary approach did not influence the results significantly.

Conclusion / Conclusie Clinical impression is not always a wise guide in choosing a surgical technique. After thorough multidisciplinary analysis and physiotherapy only a minority of patients needs surgery and when needed, no differences in complication rates and cure rates are being shown in our clinic between inside-out and outside-in transobturator tapes.

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Feedback door arts-assistenten: een perceptieonderzoek G.M. Nieuwenhuyzen-de Boer1, J.M.M. van de Ridder2. 1

Afdeling Gynaecologie, Albert Schweitzer ziekenhuis. Leerhuis, Albert Schweitzer ziekenhuis.

2

Background / Achtergrond Evaluatieve opmerkingen door A(N)IOS in het ziekenhuis worden tussen de werkzaamheden door gegeven. Daardoor is weinig zicht op de inhoud van deze opmerkingen, aan wie ze gegeven worden, hoe vaak ze gegeven worden en of daadwerkelijk sprake is van feedback.

Objective / Doel Uit de medisch-onderwijskundige literatuur is veel bekend over de beleving van feedback onder coassistenten, maar weinig bekend over het feedbackgedrag van A(N)IOS. Dit onderzoek heeft als doel percepties van A(N)IOS ten aanzien van hun feedbackgedrag te exploreren.

Methods / Methoden Om de onderzoeksvragen te beantwoorden is een zelfevaluatie vragenlijst opgesteld. Voorafgaand aan een verplichte feedbacktraining, hebben alle deelnemende A(N)IOS uit het Albert Schweitzer ziekenhuis in Dordrecht een vragenlijst ingevuld. De vragen zijn gesteld over a) wat de arts inhoudelijk verstaat onder feedback; b) aan wie feedback gegeven wordt; c) in welke frequentie feedback gegeven wordt; d) op welke competenties feedback gegeven wordt. De data zijn geanalyseerd door de frequenties te bepalen.

Results / Resultaten 67 A(N)IOS beantwoordden de vragenlijst, waarvan 72% AIOS (n=48). 83% (n=54) van de A(N) IOS geeft aan dat feedback specifieke informatie bevat, 94% (n=60) geeft feedback met de intentie de prestatie van de ander te verbeteren en 35% (n=22) geeft aan dat feedback gaat over een vergelijking tussen standaard en performance. A(N)IOS geven feedback aan coassistenten (79%; n=50), aan collega A(N)IOS (70%; n=46) en aan de opleiders (25%; n=16). Ze doen dit respectievelijk gemiddeld 7 (SD=10), 4 (SD=7) en 1 (SD=1) keer per maand. A(N)IOS geven het meest feedback op de competentie medisch handelen (84%; n=64) en het minst op maatschappelijk handelen (31%; n=24).

Conclusion / Conclusie Bij A(N)IOS blijkt dat de intentie tot feedback geven aanwezig is. De inhoud richt zich meest op de competentie medisch handelen. A(N)IOS geven frequenter feedback aan personen lager in de hiërarchie. Maar de kennis over de manier waarop feedback gegeven wordt ontbreekt soms. Vervolgonderzoek wordt verricht naar het effect van een training op de inhoud en frequentie van feedback geven.

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Interne geneeskunde Video capsule endoscopy in the albert schweitzer hospital: indications, results and consequences A. Bharos1, I. Konings1, Y. Elderson1, J. van Dieren1. 1

Afdeling Interne geneeskunce, MDL, Albert Schweitzer ziekenhuis.

Background / Achtergrond When routine endoscopy and other imaging techniques fail to reveal an abnormality, Video Capsule Endoscopy (VCE) can be used as a diagnostic procedure in patients with Obscure Gastro Intestinal Bleeding (OGIB) or suspicion on small bowel diseases. OGIB consists of occult obscure gastrointestinal bleeding (occult-OGIB), associated with iron deficiency anemia (IDA), and overt obscure gastrointestinal bleeding (overt-OGIB).

Objective / Doel The aim of this retrospective study was to determine the indications, findings and clinical consequences of VCE.

Methods / Methoden Seventy-five VCE procedures in 73 patients were performed in the Albert Schweitzer Hospital, The Netherlands, between 2009-2010, all pre-evaluated by a nurse endoscopist. 46 procedures were evaluated by gastroenterologist. A database was created containing indications, detection/ completion rates and clinical consequences for these 46 VCE procedures in 43 patients.

Results / Resultaten Indications for VCE were IDA (69.6%), overt-OGIB (17.4%), Crohn’s disease (10.9%) and other (2.2%). A definite or probable positive finding was found in 56.6% of all indications. For OGIB this was 55.0% (46.9% in IDA and 87.5% in overt-OGIB), for Crohn’s disease 60% and for others 100%. Angiodysplasia was identified as most common cause (42,5%) in OGIB (40,6% in IDA, 50% in overt-OGIB) followed by inflammatory defects in 20% (15,6% in IDA and 37,5% in overt-OGIB). In 89.1% of all cases, the capsule reached the colon before the battery died. No capsule-retention occurred. Evaluating the clinical consequences of VCE, only 25% of all patients (n=11) did undergo subsequent diagnostic or therapeutic procedures. In patients with OGIB (n=38) this was 26,3% (n=10), of which 6 patients underwent a double balloon enteroscopy, 1 a push enteroscopy and 3 patients repeated gastro- or colonoscopy. Twenty-seven patients with OGIB continued or started with iron treatment or erythropoietin therapy.

Conclusion / Conclusie The most common indications for VCE in our study were IDA and overt-OGIB, with a total detection rate of 56.6% in all cases, 55.0% in OGIB-cases and 60% for Crohn’s disease. In only 25% of all patients the VCE results led to clinical consequences such as subsequent diagnostic or therapeutic procedures. We found a reasonably high detection rate, similar to rates described in recent literature, however, often without clinical consequences. In most OGIB patients VCE did not change the obvious therapeutic approach and iron supplementation was continued or started. Therefore, the clinical importance of VCE findings can be questioned.

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Kanker en werk – taak voor de oncologieverpleegkundige A. van Zandbergen1, S.J. Tamminga2, J. van de Lagemaat-Korver1, C. van Iersel3, G.S. Kooi4, J.J.E.M. Kitzen5, P.W. Plaisier6, J.H.A.M. Verbeek2, A.G.E.M. de Boer2, M.H.W. Frings-Dresen2. 1

Dagbehandeling Oncologie, Albert Schweitzer ziekenhuis. Coronel Instituut voor Arbeid en Gezondheid, AMC. 3 Afdeling KV&I, Albert Schweitzer ziekenhuis. 4 Afdeling gynaecologie, Albert Schweitzer ziekenhuis. 5 Afdeling interne geneeskunde, Albert Schweitzer ziekenhuis. 6 Afdeling chirurgie, Albert Schweitzer ziekenhuis. 2

Background / Achtergrond De overlevingskansen van kanker zijn in de afgelopen jaren gestegen. Voor veel patiënten die kanker hebben overleefd is kanker een chronische ziekte geworden die leidt tot slechtere algemene gezondheid in vergelijking met de algemene populatie. De ziekte en de behandeling kunnen invloed hebben op veel aspecten van kwaliteit van leven waaronder behoud van werk en terugkeer naar werk. Uit onderzoek is gebleken dat terugkeer naar werk belangrijk is voor kankerpatiënten; het hebben van werk draagt bij aan hogere kwaliteit van leven, minder financiële problemen en geeft structuur en zingeving. Uit onderzoek blijkt ook dat niet alle kankerpatiënten, die voor de diagnose werkten, het werk hervatten. Bovendien ervaren kankerpatiënten beperkingen in het werk.

Objective / Doel Om de negatieve gevolgen voor kankerpatiënten te reduceren is begeleiding bij werkhervatting ontwikkeld om duurzame werkhervatting te bevorderen.

Methods / Methoden De onderzoekspopulatie bestaat uit kankerpatiënten die met curatieve intentie behandeld worden en die betaald werk hebben. Patiënten worden gerandomiseerd naar een controlegroep en ontvangen de gebruikelijke zorg, of naar een interventiegroep en ontvangen de begeleiding bij werkhervatting. De begeleiding bij werkhervatting bestaat uit maximaal 4 gesprekken met de oncologieverpleegkundige over werkhervatting, het versturen van twee brieven aan de bedrijfsarts met medische informatie en een driegesprek met de patiënt, bedrijfsarts en de leidinggevende om een terugkeer naar werk plan op te stellen. Begeleiding bij werkhervatting wordt zoveel mogelijk uitgevoerd als onderdeel van het al bestaande verpleegkundig spreekuur.

Results / Resultaten Het onderzoek wordt uitgevoerd in verschillende ziekenhuizen in Nederland, te weten: Albert Schweitzer ziekenhuis (ASz), AMC, Reinier de Graaf Groep (RdGG), NKI-AvL, Flevoziekenhuis en Sint Lucas Andreas ziekenhuis (SLAZ). Op het moment nemen 80 patiënten deel aan het onderzoek. De instroom van patiënten zal lopen tot en met december 2010. De eerste resultaten worden eind 2011 verwacht. De bewustwording van het belang van werk voor kankerpatiënten en het kunnen bieden van handvatten in het omgaan met werkhervatting, wordt door de oncologieverpleegkundigen die de gesprekken voeren als zeer waardevol ervaren.

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Conclusion / Conclusie Begeleiding bij werkhervatting is een veel belovende methode om kankerpatiënten in het proces van werkhervatting te begeleiden. Bij deze begeleiding staat de samenwerking tussen het ziekenhuis en de bedrijfsarts centraal.

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Klinische Chemie Digital Morphology: a proven concept in the modern laboratory J.A. Riedl1, W. van Gelder1. 1

Geïntegreerd Klinisch Chemisch Laboratorium, Albert Schweitzer ziekenhuis.

J Clin Pathol 2010, in press

Background / Achtergrond A few years ago, a new digital microscope system (DM96, Cellavision, Sweden) was introduced. We extensively tested this system in classifying all major peripheral white blood cell categories. Based on our findings and those of previous eval¬uations of the DM96, we decided to put the DM96 into practice in our centre location. Currently, our digital microscope system is fully integrated in the routine haematology workflow for more than 2 years. A routine 200 cell differential takes circa 2 minutes, including post-classification and reporting to the LIS. Our daily workload of peripheral blood smears is processed by a single laboratory technician. The manual review rate decreased from 19% (before introduction of digital morphology) to currently less than 0.5% of all samples. Recently, a new software module was developed enabling the DM96 to also analyse cytospin slides of spinal fluid and other body fluid samples (e.g. abdominal and pleural fluid). The system automatically recognizes neutrophils, lymphocytes, macrophages, eosinophils, smudge cells and arte¬facts and classifies all other cells in the category “other”.

Objective / Doel Is automated morphological analysis of body fluids by the DM96 possible?

Methods / Methoden Body fluid samples were analysed on the DM96 and manually by a laboratory technician.

Results / Resultaten A study in 116 samples demonstrates an overall pre-classification accuracy of 90% in spinal fluid and 86.4% in other body fluids. Post-classification correlation coefficients with manual review results for spinal fluid sample analyses are between 0.97 and 0.99 and between 0.89 and 0.99 for other body fluids. The within run variation is less than 6% for all cell categories (< 4% excluding macrophages).

Conclusion / Conclusie The DM96 has proven to be reliable and efficient, contributing to overall quality improvement in morphological analysis of peripheral blood and other body fluid samples.

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Pathologie MRI of the breast for optimal selection of patients with a preoperative diagnosis of ductal carcinoma in situ for a sentinel node biopsy procedure. A study proposal. P.J. Westenend1, A. ter Braak2, P. Plaisier3. 1

Pathologisch Anatomisch Laboratorium, Dordrecht. Afdeling Radiologie, Albert Schweitzer ziekenhuis. 3 Afdeling Chirurgie, Albert Schweitzer ziekenhuis. 2

Background / Achtergrond Since the implementation of mammographic breast cancer screening the incidence of DCIS has risen dramatically. A further increase is projected as a consequence of the introduction of digital mammography in the screening population, as was recently done in the Netherlands. In a portion of patients, a diagnosis of DCIS on a CNB may represent a DCIS and invasive ductal carcinoma (IDC) on an excision, a sampling problem known in the literature as the ‘underestimate rate.’ The presence of IDC warrants a sentinel node biopsy procedure in these patients. Decision trees have been developed to identify those patients with only DCIS on CNB with a high risk of IDC in the excision specimen and these patients are offered a SNP.However, these criteria are imperfect and a considerable number of patients have a SNP while not having a IDC on excision and others do not have a SNP yet an IDC is found in their excision specimen. Therefore, optimization of patient selection is needed to better allocate available resources and give more relevant preoperative information to patients.

Objective / Doel While not being a very sensitive method in the detection of DCIS, MRI of the breast is proven to be a sensitive method for detecting invasive carcinoma. Therefore, our hypothesis is that MRI of the breast will be an aid in improving patient selection for SNP.

Methods / Methoden In this study patients will have the usual diagnostic procedure for a breast lesion consisting of physical breast examination, digital mammography and ultrasound examination of the breast and if necessary also of the axilla. Patients with a high suspicion of DCIS will have an additional MRI.

Results / Resultaten Preliminary results of a retrospective study in 267 patients will be discussed.

Conclusion / Conclusie The study is supported by a grant from Pink Ribbon.

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Anesthesiologie Subcutaneous stimulation as add-on therapy to spinal cord stimulation for treatment of leg pain and/or lower back pain. T.E. Hamm-Faber1, I. Gültuna1. 1

Pijnbehandelcentrum, Albert Schweitzer ziekenhuis.

Background / Achtergrond Failed Back Surgery Syndrome (FBSS) is a clinical entity consisting of leg and /or back pain due to radicular nerve damage after surgery. The effectiveness of spinal cord stimulation (SCS) in the pain management of patients with FBSS has been proven. In most patients leg pain is predominant, however, a percentage also suffer significantly from back pain. Currently back pain is considered to be entirely part of the radicular neuropathic pain component of FBSS. However, in many patients SCS alone is insufficient to cover both leg and lower back pain. Recently reports indicate the benefit of adding subcutaneous stimulation (SubQ) to treat low back pain.

Objective / Doel Our objective was to demonstrate the efficacy of SubQ as add-on therapy in FBSS patients with chronic refractory pain for whom SCS is unsuccesful for treating low-back pain.

Methods / Methoden FBSS patients with chronic leg and/or low-back pain where conventional therapies had failed underwent implantation of a combination of SCS (8-contact Octad lead) and/or SubQ (4-contact Quad-Plus lead(s)). Initially leads were placed in the epidural space for SCS for a trial of stimulation to assess response on suppression of leg and low-back pain. Where SCS alone was unsufficient in treating lower back pain, leads were placed superficially in the subcutaneous tissue of the lower back, directly in the region of maximum pain. A permanent system was implanted if patients reported greater than 50% pain relief during the trial. Pain intensity for leg and lower back pain was scored seperately, using VAS (scale 0-100). Pain and Quebec Back Pain Disability Scale (QBPDS) after 6 months treatment were compared to pain and QBPDS at baseline. Data are presented as mean ± SD.

Results / Resultaten Eleven FBSS patients, 5 male and 6 female (age: 51.4 ± 8.0 y), in whom SCS alone was unsufficient in treating lower back pain, were included in the study. In nine cases, SubQ was used in combination with SCS to treat chronic lower back and lower extremity pain. In two cases only SubQ was used to treat lower back pain. SCS significantly reduced leg pain after 6 months (VASbl: 49.8 ± 24.5 vs VAS6m: 28.0 ± 13.4; p<0.01, n=9). SubQ stimulation significantly reduced lower back pain after 6 months (VASbl: 61.7 ± 13.1 vs VAS6m: 33.3 ± 11.3; p<0.01, n=11). Overall pain medication was reduced by around 70%. QBPDS did not improve (61.3 ± 14.5 to 49.5 ± 16.2; p=0.06, n=11). Furthermore, we could observe that patients return to work (n=2). Adverse events were SubQ-lead dislocation (n=1), local pain at connector (n=1), and unsufficient low-back pain reduction (n=1).

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Conclusion / Conclusie Subcutaneous stimulation should be considered for the treatment of chronic lower back pain in patients with FBSS for who SCS alone is unsufficient in treating lower back pain, as it has a good influence on lower-back pain and is safe.

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Optimaal Bloed Management bij Electieve Orthopedische Chirurgie: de eerste resultaten van de Transfusie Op Maat studie A.W.M.M. Koopman-van Gemert1, G. Kuijpers2. 1

Afdeling Anesthesiologie, Albert Schweitzer ziekenhuis. Namens de andere ToMaat-onderzoekers: C. So-Osman, J. van Hilten, T.Jansen-Werkhoven, R. Brand en A. Brand (LUMC leiden), E.Kluyver en R.Poll (Slotervaartziekenhuis Amsterdam), R. Onstenk (Groene Hart ziekenhuis, Gouda).

2

Background / Achtergrond Toepassing van bloedtransfusiebesparende technieken tijdens orthopedische chirurgie wordt vaak toegepast. Echter de effectiviteit van besparing van bloedproducten is erg uiteenlopend en varieert van 20-80% reductie van allogene bloedproducten. Tegelijkertijd heeft het hanteren van een stringentere transfusietrigger zijn intrede gedaan. De vraag rijst of toepassing van bloedtransfusiebesparende technieken dan nog evenveel bloedproducten bespaart.

Objective / Doel Onderzocht is of het gebruik van Erytropoietine (EPO), cell saver (CS) of postoperatieve wonddrainage bij patiënten die een heup- of knievervangende operatie ondergaan, leidt tot reductie van allogene bloedproducten, indien dit gecombineerd wordt met een restrictief transfusiebeleid.

Methods / Methoden Een prospectieve, dubbel gerandomiseerde, multicenter studie is gestart. Patiënten > 18 jaar, werden gestratificeerd aan de hand van het preoperative Hb-level. Stratum I = Hb < 8,2 mmol/l; Deze patiënten werden eerst gerandomiseerd voor wel of geen Epo. Stratum II = Hb > 8,2 mmol/l. Deze patiënten kregen geen Epo. Beide strata werden gerandomiseerd voor 3 mogelijkheden: A: cell saver per- en postoperatief; D: postoperatief ongewassen drainbloedreïnfusie of geen van deze methoden. Om een 75% reductie van allogene bloedtransfusies (BT) door Epo, en om een 30% reductie door autologe transfusies aan te tonen, was een sample grootte van 2250 patiënten nodig.

Results / Resultaten Van 2004 tot 2009 werden 2579 patiënten geïncludeerd, waarvan 1128 uit het ASz. n=1457 ondergingen een THP-operatie, n=979 een TKP-operatie en 7% een revisie heup/knieoperatie. In totaal ontving 11,6% een BT, gemiddeld 0,3 eenheid. Epo reduceerde het aantal BT met 43% (OR = 0.57; p=0.10) evenals het aantal getransfundeerde patiënten (67% reductie; OR = 0.33; p=<0.001). Reïnfusie van autoloog bloed reduceerde niet het aantal BT of getransfundeerde patiënten, behalve bij patiënten met een hoger uitgangs-Hb. Dan daalde het aantal getransfundeerde patiënten van significant van 9 naar 6,6% (OR = 0,7). Trombotische complicaties in de Epo-groep kwamen in 1,8% voor, in de niet-Epo-groep in 1,1% (p=0.32)

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Conclusion / Conclusie Een restrictief transfusiebeleid levert een belangrijke bijdrage aan het verlagen van het aantal bloedtransfusies. Epo-therapie in de orthopedie is veilig en verlaagt het risico van de patiënt op een bloedtransfusie. Toepassing van de cell saver of postoperatieve wonddrainage verminderde in geringe mate de kans op een bloedtransfusie alleen in de patiënten met een hoog uitgangs-Hb.

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Een alternatieve methode voor herstel van Cardiac Resynchronisatie Therapie (CRT) J.Th. Schmidt1, P.R. Schütte2, M. Vrolijk-de Mos3, A.W.M.M. Koopman-v. Gemert3, A.G. de Vries4. 1

Pacemaker techniek, Albert Schweitzer ziekenhuis. Afdeling chirurgie, Albert Schweitzer ziekenhuis. 3 Afdeling Anesthesiologie, Albert Schweitzer ziekenhuis. 4 Afdeling Cardiologie, Albert Schweitzer ziekenhuis. 2

Background / Achtergrond De incidentie van een pacemakerdraadbreuk (lead) is 1-4% en vaak het gevolg van entrapment van de lead tussen de clavicula en de eerste rib. Met name bij veelvuldige bewegingen van de arm ontstaat frictie en beschadiging. Een percutane lead vervanging is een risicovolle ingreep vanwege verkleving in het endocard/vaatwand. Indien de flow in de vene dit toelaat wordt een nieuwe lead geïntroduceerd en de defecte lead geïsoleerd. Met name wanneer het een linker ventrikel lead betreft dit gecompliceerd vanwege de ligging via de sinus coronarius in de postero-laterale tak.

Objective / Doel Een 75 jarige man met een uitgebreide voorgeschiedenis van coronair lijden en ernstig hartfalen op basis van een ischemische cardiomyopathie werd sinds jaren behandeld met een biventriculaire pacemaker. In juni had hij ernstige decompensatio cordis ten gevolge van een breuk in de linker ventrikel lead. Gekozen werd om onder algehele anesthesie de leadbreuk locaal te herstellen.

Methods / Methoden Ondanks preoperatieve behandeling met i.v. diuretica en inotropica. bleef de hemodynamische conditie van patiënt zeer slecht met ernstige dyspnoe en forward failure. Tijdens de ingreep werd patiënt ingeleid met minimale doseringen anesthetica teneinde cardiale depressie te minimaliseren. Continue bloeddrukmeting vond plaats via een canule in de arteria radialis. Hemodynamische ondersteuning met noradrenaline was noodzakelijk. De pacemakerpocket werd geopend en de leads vervolgd richting subclavia. De leadbreuk kon vlot worden geïdentificeerd op de rand van de vena subclavia en werd na 1 cm terugtrekken gefixeerd met een zijde ligatuur. Vervolgens werd de isolatielaag 5 mm ter hoogte van de breuk verwijderd en het draadgedeelte tussen de pacemakerdevice en de breuk vervangen door een repair-Lead (IS1). Het testen van de herstelde lead toonde een goede stimulatie drempel en leadimpedantie. Controle van de pacemaker toonde iets verhoogde drempelwaarde voor LV pacing ten opzichte van voorheen, maar verder een goede functie.

Results / Resultaten Direct na herstel van de leadbreuk en daarmee van de contractie synchronisatie van de linker ventrikel was een bloeddrukstijging waarneembaar en kon de noradrenaline worden gestaakt. Na ontwaken uit de anesthesie voelde patiënt zich direct minder dyspnoïsch dan pre-operatief. Bij nacontrole drie dagen later waren de tekenen van forward failure verminderd (bloeddruk van

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Anesthesiologie

120/80 mmHg) en was er een sterke subjectieve verbetering.

Conclusion / Conclusie Het gebruik van een repair-kit-lead om een defecte (unipolaire) linker ventrikeldraad van een biventriculaire pacemaker te herstellen is een unieke mogelijkheid om een gecompliceerde procedure (leadextractie en plaatsing nieuwe lead) bij een patiënt met een eindstadium hartfalen te vermijden en zijn synchronisatietherapie te hestellen. In deze casus is de procedure zonder complicaties verlopen en heeft dit geleid tot een directe substantiële verbetering van de cardiale conditie van de patiënt.

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Cardiologie Left atrial stimulation (LAS) compared with right atrial stimualtion (RAS)in de the treatment of sich sinus syndrome (SSS) and paroxysmal atrial fibrillation (PAF). Does it matter? N. Breuls1, E. Zock1, E. van de Bos1, L. van Woerkens1 1

Afdeling Cardiologie, Albert Schweitzer ziekenhuis.

Background / Achtergrond Patients with SSS frequently suffer from PAF. Most of the atrial arrhythmias originate in the left atrium. Overdrive suppression has been shown to effective in the prevention of atrial triggers for PAF. Biatrial pacing is more effective in suppression of PAF, possibly by suppression left atrial trigger activity.

Objective / Doel Efiicacy of left atrial stmulation for the supression of atrial arrthymias in the Sick sinus sybdrome

Methods / Methoden Patients were randomly assigned for Left atrial stimulation LAS (26) or right atrial stimulation RAS (36) for the treatment of symptomatic SSS and PAF for a total follow-up of 3 years. LAS was performed by active lead fixation (Medtronic 3830) in the proximal or distal part of the coronary sinus (CS). RAS was done using active fixation in the right atrial appendage. The leads were connected to conventional dual chamber pacemakers. For evaluation, quality of life test score (QOLTS), Visual Analog Score (VAS) on a scale of 1 to 10, pacemaker follow-up measurements(PFUM), including holterfuncion and clinical adverse events (CAE) were used. Time window for evaluation of 6 mnts after implantation. Statistical analysis was performed using student T-tests.

Results / Resultaten During pacing the LA were significantly higher then during pacing the RA. Sensing was comparable. Mean procedure times was prolonged in the LA group, when compared with the RA-group, but still within very acceptable limits.

Conclusion / Conclusie In this relative small randomized study, LAS is superior in suppressing PAF and is superior in terms of QOL in the SSS and PAF, when compared to conventional atrial pacing in the RA.

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Chirurgie Performance indicators for lung cancer surgery in the netherlands P.W. Plaisier1, R.A.M. Damhuis2. 1

Surgery, Albert Schweitzer Hospital, Dordrecht/NL. Department of Cancer registry and research, Rotterdam Cancer Centre, Rotterdam/NL.

2

Background/ Objective Quality assessment has been introduced to improve the standards of care, to guide contracting by health insurance agencies and to account health expenses to the public. Apart from the ESTS Database, several registries have been developed to provide information on the process and outcomes of lung cancer surgery. To assess potential variation in results between hospitals in the Netherlands, we retrieved data from the National Cancer Registry.

Methods / Methoden For this study, we used information on age, gender, tumour type, type of surgery and hospital for patients diagnosed with non-small cell lung cancer in 2007. Results were tabulated for resection rate, 30-day postoperative mortality, complication rate and pneumonectomy proportion. Results are projected using so-called funnel plots in which the results for individual hospitals are plotted against volume. Statistical control limits were calculated using a binomial approximation. Postoperative mortality was subsequently analysed using case-mix correction.

Results / Resultaten The study comprised 8455 patients of whom 1792 (21%) were treated by resection in 77 hospitals. The serious complication rate was 7%, postoperative mortality 3% and pneumonectomy proportion 14%. There was considerable variation between hospitals but valid comparison between hospitals was not possible since control limits suggest that monitoring has limited resolution for series smaller than 100 while in the Netherlands, still 20% of patients are operated in hospitals performing less than 20 lung cancer resections per year.

Conclusion / Conclusie Results for the Netherlands are similar to those from other large registries. Quality assessment may not be practicable for small-volume hospitals and the volume-outcome question needs to be settled in multi-hospital analyses.

94

Geriatrie Less is more. Development and validation of a score to assess risk of adverse drug reactions among in-hospital patients 65 years or older. The gerontonet ADR Risk score G. Onder1, M. Petrovic2, B. Tangiifuran3, M.C. Meinardi4, W.P. Markito-Notenboom4, A. Somers5, C. Rajkumar3, R. Bernabei1, T.J.M. van der Cammen4. 1

Afdeling Geriatrie, Policlinico A.Gemelli, Catholic University of the sacred heart, Rome, Italy. Afdeling Geriatrie/Gerontologie, Iniversiteitsziekenhuis Gent. 3 Afdeling Interne, Brighton and Sussex medical school, Brighton. 4 Afdeling Geriatrie, Erasmus medisch centrum, Rotterdam. 5 Ziekenhuisapotheek, Universiteitsziekenhuis Gent. 2

Arch intern med. 2010, 170:1142-8

Background / Achtergrond In western countries, drugrelated ilnesses are an important medical problem, resulting in 3% to 5% of all hospital admissions, accounting for 5% to 10% of inhospital costs, and being associated with a substantial increase in morbidity and mortality. Older patients are particularly vulnerable to drug-relared ilness because they are usually on multiple drug regimens, which expose them to the risk of drug interactions, and because age is associated with changes in pharmacokinetics and pharmacodynamics. Therefore, based on these considerations, the objective of this study was to develop and validate a practical, efficient and simple method of identifying patients who are at increased risk of an ADR in a population of in-hospital older adults.

Objective / Doel The aim of the present study was to develop and validate a method of identifying elderly patients who are at increased risk for an adverse drug reaction(ADR).

Methods / Methoden Data from the gruppo Italiano di Farmacoepidemiologia nell Anziano(Italian Group if Pharmacoepidemiologyin the Elderly)GIFA were used to develop an ADR risk score. Variables associated with ADRs were identified by stepwise logistic regression analysis and used to compute the ADR risk score. The ADR risk score was then validated in sample of older adultsbwho were admitted to 4 university hospitals in Europe(validation study).

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Geriatrie

Results / Resultaten Of 5936 patients (mean SD age 78.0(7.2) years) in the GIFA sample, 383 (6.5%) experienced an ADR. The number of drugs and history of an ADR were the strongest predictors of ADRs, followed by heart failure, liver disease, presence of 4 or more conditions, and renal failure. These variables were use to compute the ADR risk score. The area under the receiver operating characteristic curve, which assesses the ability of the risk score to predict theADRs was 0.71(95% confidence interval, 0.68-0.73). Overall,483 patients entered the validation study (mean SD age, 80.3(7.6) years), and 56(11.6%) experienced an ADR. The area under the receiver operator characteristic curve in this sample was 0.70(95% confidence interval 0.63-0.78).

Conclusion / Conclusie This study proposs a practical and simple method of identifying patients who are at an increased risk of an ADR. This approach may be useful in clinical practice as a tool to identify patients at risk of an ADR and in research to target a population that can benefit from inteventions aimed to reduce drug-related illness.

96

Gynaecologie Male circumcision associated with a lower prevalence of colposcopy-detected, human papillomavirus-associated penile lesions among Kenyan men D. Backes1, C.J.A. Hogewoning2, J. Smith3, M.C.G. Bleeker4. 1

Dept of Epidemiology, Gillings School of Global Public Health North Carolina. Dept of Gynecology and Obstetrics, Albert Schweitzer ziekenhuis. 3 Dept of Epidemiology Gillings School of Global Public health, University of North Carolina. 4 Afdeling Klinische pathologie, VUMC Amsterdam. 2

Submitted: Journal of Infectious diseases

Background / Achtergrond De stuitligging komt voor bij 3 – 4 % bij alle a terme zwangeren. Met een uitwendige versie van stuit naar hoofdligging wordt beoogd het aantal stuitliggingen durante partu te verminderen. Daarmee verminder je het aantal complicaties van de vaginale stuitbevalling en het aantal sectio caesera in verband met de stuitligging.

Objective / Doel Inventarisatie van de uitkomsten van een uitwendige versie bij zwangeren met een kind in stuitligging in een perifeer opleidingsziekenhuis.

Methods / Methoden Het betreft een retrospectieve statusonderzoek. De onderzoekspopulatie bestaat uit alle vrouwen met een foetus in stuitligging met een eenlingzwangerschap en een amenorroe van > 34 weken, bij wie in het Albert Schweitzer Ziekenhuis tussen 1 januari 2006 tot en met 31 december 2008 een poging tot uitwendige versie naar hoofdligging is verricht (N=420). Zij zijn verwezen uit de eerste lijn of afkomstig uit de eigen patiënten populatie. De volgende parameters werden vastgelegd en geanalyseerd: maternale leeftijd, gewicht, lengte, body mass index, graviditeit, pariteit, amenorroe tijdens de versie, resultaat van versie. Daarnaast ook de partusgegevens zoals: amenorroe van de partus, ligging bij de partus, partus modus, geslacht, kindsgewicht, Apgarscore na vijf minuten en neonatale complicatie.

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Gynaecologie

Results / Resultaten In totaal zijn er 225 (53%) versies geslaagd. 19 patiënten niet in hoofdligging bevallen en van 2 hebben we geen partusgegevens. Er zijn 195 versies niet geslaagd. Bij 8 patiënten is er toch sprake was van een spontane versie naar hoofdligging. Er zijn 2 zwangeren geweest die binnen 24 uur na een versiepoging bevallen zijn, dit was niet vanwege foetale nood. In tegenstelling tot de bevindingen in de literatuur wordt de slagingskans van de versie in onze populatie niet statistisch significant beïnvloed door BMI en de ligging van de placenta. Uit de data blijkt dat de slagingskans van de versie groter is bij mulitpara zwangeren en een amenorroe onder 38 weken. In totaal zijn er 206 vrouwen bevallen van een kind in stuitligging na uitwendige versie. Bij 153 (74%) vrouwen is een sectio caesarea verricht. Daadwerkelijk zijn er 212 bevallen van een kind in hoofdligging. Bij 13 patiënten na een geslaagde versie is er een secundaire sectio verricht, dit is 6.1%,

Conclusion / Conclusie In het Albert Schweitzer ziekenhuis is het slagingspercentage van de uitwendige versie is 53 %. Het verrichten van een uitwendige versie geeft een vermindering van het aantal sectio caeserea. Na een geslaagde versie is het sectio percentage 6.1 % terwijl dit bij een niet geslaagde versie 74 % bedraagt. De belangrijkste motivatie voor het verrichten van een uitwendige versie is de reductie van de kans op een sectio caesarea. Uit verdere analyse moet blijken of een uitwendige versie ook invloed heeft op de kosten van de verloskundigen zorg en neonatale morbiditeit.

98

Gynaecologie

Uitwendige versie bij stuitligging in het Albert Schweitzer ziekenhuis Dordrecht I. Hellendoorn1, B. Engeltjes2, M. D. A. Lambers3. 1

Afdeling Gynaecologie, Maasstad ziekenhuis. Afdeling Obstetrie, Albert Schweitzer ziekenhuis. 3 Afdeling Gynaecologie, Albert Schweitzer ziekenhuis. 2

Background / Achtergrond De stuitligging komt voor bij 3 – 4 % bij alle a terme zwangeren. Met een uitwendige versie van stuit naar hoofdligging wordt beoogd het aantal stuitliggingen durante partu te verminderen. Daarmee verminder je het aantal complicaties van de vaginale stuitbevalling en het aantal sectio caesera in verband met de stuitligging.

Objective / Doel Inventarisatie van de uitkomsten van een uitwendige versie bij zwangeren met een kind in stuitligging in een perifeer opleidingsziekenhuis.

Methods / Methoden Het betreft een retrospectieve statusonderzoek. De onderzoekspopulatie bestaat uit alle vrouwen met een foetus in stuitligging met een eenlingzwangerschap en amenorroe van > 34 weken, welke in het Albert Schweitzer Ziekenhuis te Dordrecht tussen 2006 tot en met 2008 een poging tot uitwendige versie naar hoofdligging is verricht (N=420). Zij zijn verwezen uit de eerste lijn of afkomstig uit de eigen patiënten populatie. De volgende parameters werden vastgelegd en geanalyseerd: maternale leeftijd, gewicht, lengte, body mass index, graviditeit, pariteit, amenorroe tijdens de versie, resultaat van versie. Daarnaast ook de partusgegevens zoals: amenorroe van de partus, ligging bij de partus, partus modus, geslacht, kindsgewicht, Apgarscore na vijf minuten en neonatale complicatie.

Results / Resultaten In totaal zijn er 225 (53%) versies geslaagd, hiervan zijn 19 patiënten niet in hoofdligging bevallen en van 2 hebben we geen partusgegevens. Er zijn 195 versies niet geslaagd, waarbij bij 8 patiënten er toch nog sprake was van een spontane versie naar hoofdligging. Er zijn 2 zwangeren geweest die binnen 24 uur na een versiepoging bevallen zijn, dit was niet vanwege foetale nood. In tegenstelling tot de bekende literatuur wordt de slagingskans van de versie in onze populatie niet statistische significant beïnvloedt door BMI en de ligging van de placenta. Uit de data blijkt dat slagingskans voor de versie groter is bij mulitpara zwangeren en een amenorroe onder 38 weken.

Conclusion / Conclusie In het Albert Schweitzer ziekenhuis is het slagingspercentage 53 %, dit is goed in vergelijking met het landelijk gemiddelde. Het verrichten van een uitwendige versie geeft een vermindering van het aantal sectio caeserea. Na een geslaagde versie is het sectio percentage 6.1 % terwijl dit bij een niet geslaagde versie 74 % bedraagt.

99

Gynaecologie

Suburethral tapes: erosion, malfunction and a save way to solve them C.J.A. Hogewoning1, C.R.C. Hogewoning2. 1

Afdeling Gynaecologie/ Regionaal Bekkenbodem Centrum, Albert Schweitzer ziekenhuis. Faculteit geneeskunde, Leiden University Medical Center.

2

Submitted: Int Journal of Urogynecology

Background / Achtergrond The rate of late (>6 months) complications of suburethral tapes is low. They consist mainly of erosions and malfunction. It is not clear whether different types of tape or of operative techniques like transobturator or retropubic give the same late complications.

Objective / Doel In this study we present 32 patients who underwent a standardized repair of partial removal of their tape and placement of a collagen strip (Pelvilace®) in one time. In this way we hoped to repair the complications in the most comfortable way.

Methods / Methoden In this prospective intention to treat study we present 32 patients with late complications, mainly erosion and/or malfunction because of displacement of the tape. The tapes involved were TOT (Intramesh Soft Lift® ,Cousin Biotech), Uretex-TO® (Bard), TVT-O®, and TVT® (both Gynecare, Johnson&Johnson). We describe the exact complication, sort of tape, surgical repair and post-operative course, urodynamics with urethral closing pressure before and at least 6 months after repair and cystoscopic findings. All patients were evaluated with clinical validated questionnaires(Dutch pelvic floor society and PISQ) before and 6 months after repair. Most patients were sent to us from the wider region because of our expertise.

Results / Resultaten Of 32 women 17 were without complaints and continent after 6 months(53%).15 women had no complaints regarding erosion or dyspareunia but 10 were only partially continent, and 5 women were as incontinent as before or worse. 9 women underwent after 6 months a new urethral suspension (retropubic, classic TVT) and were continent afterwards. The other 6 women accepted the situation as it was.

Conclusion / Conclusie Surgical repair of late complications of the treatment of SUI with polypropylene tapes should be centralized and standardized. Under these conditions the prognosis is good.

100

Gynaecologie

Protocol anti-D in de praktijk T.D. Kieviet-van Immerzeel1, W. Jumia1, B. Akerboom1. 1

Afdeling Gynaecologie, Albert Schweitzer ziekenhuis.

Background / Achtergrond Sinds de invoering van de post partum profylaxe in 1969 met 1000 IE anti-D-immunoglobuline aan rhesus negatieve vrouwen die bevallen zijn van een rhesus-D-positief kind, is de prevalentie van rhesus immunisatie in de zwangerschap sterk gedaald. Inmiddels is uit onderzoek gebleken dat bij bepaalde risicogroepen er niet 1000 IE maar 2000 IE anti-D-immunoglobuline toegediend dienen te worden. Om zo effectief mogelijk de adequate dosering profylaxe toe te dienen is in ons ziekenhuis een protocol opgezet. Het protocol houdt in dat alle rhesus negatieve vrouwen met een rhesus positief kind postpartum 1000 IE anti-D krijgen toegediend ( tot< 48 uur). Als er rondom de partus sprake is geweest van een manuele placenta verwijdering, een meerling, een sectio caesarea of fundusexpressie krijgen deze vrouwen postpartum 2000 IE anti-D immunoglobuline toegediend. De registratie vindt drievoudig plaatst namelijk allereerst in het systeem voor landelijke verloskundige registratie (LVR) genaamd MOSOS P, vervolgens wordt het door de afdelingsarts in het electronisch voorschrijfsysteem (EVS) van het ziekenhuis ingevoerd. Tenslotte maakt de verpleegkundige die het middel toedient een notitie in een eigen registratiemap, welke primair bedoeld is in verband met registratie voor het RIVM.

Objective / Doel Het doel van dit onderzoek is om te kijken hoe effectief dit protocol word nageleefd en eventueel een verbeter traject uit te zetten.

Methods / Methoden Wij hebben alle partussen van rhesus negatieve moeders geincludeerd die in het jaar 2009 zijn bevallen van een rhesus positief kind. Vervolgens is er bekeken of deze patiënten volgens het protocol binnen 48 uur postpartum een gift anti-D-immunoglobuline toegediend hebben gekregen. Ook is er gekeken of zij in een risicogroep vielen en dus in aanmerking kwamen voor een dubbele dosis anti-D immunoglobuline. Tenslotte werd onderzocht wat er geregistreerd is over de werkelijke toediening van het medicijn in de drie bovengenoemde systemen ( Mosos P, EVS, Anti-D registratie map).

Results / Resultaten Er waren in 2009 in totaal 174 vrouwen die in aanmerking kwamen voor post partum anti-D profylaxe. Hiervan behoorden er 33 tot een risicogroep. In totaal heeft 88% postpartum anti-D-immunoglobuline toegediend gekregen. Van de overige 12 % is in het EPD, Mosos P, EVS en Anti-D registratie map niet terug te vinden of zij anti-D hebben gehad. Van de risico patiënten heeft 67% inderdaad een dubbele dosis anti-D gehad. De overige een derde van de patiënten die een dubbele dosis zouden moeten krijgen hebben geen of 1000IE anti-D-immunoglobuline gehad. Van alle patiënten die anti-D zouden moeten krijgen stond dit in 34% van de gevallen in het EVS. In het anti-D registratie map was de registratie graad hoger: 88%. Van alle 174 patiënten is 26.4% volledig en volgens protocol geregistreerd .

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Gynaecologie

Conclusion / Conclusie Het anti-D protocol van het ASZ wordt lang niet altijd nageleefd en de registratie is vaak onvolledig. Wat het meest opvalt is dat 12% van de vrouwen die postpartum minimaal 1 ampul anti-D zouden moeten krijgen dit niet hebben gehad. Een mogelijke oorzaak voor dit probleem is dat registratie van Anti-D in het ziekenhuis gebeurt in 3 verschillende systemen door 3 verschillende disciplines. Slechts 26.4% van de patiënten is volledig en volgens protocol geregistreerd Met name de registratiegraad in het EVS is erg laag. Het blijkt dat aan de toevoer van het middel door de apotheek verbonden is aan de verpleegkundige registratiemap en niet aan het EVS. Deze handeling vervalt hiermee tot een formaliteit. Het toedienen van 2000 IE anti-D-immunoglobuline in plaats van 1000 IE anti-D-immunoglobuline werd bij de risicogroepen manuele placenta verwijdering of fundusexpressie vaak verzuimd. Het is aan te raden de registratie van Anti-D toediening te vereenvoudigen om te waarborgen dat meer patiënte de adequate behandeling krijgen. Het is van belang dat alle leerling-verpleegkundigen, nieuwe zaalartsen en nieuwe gynaecologen worden gewezen op het anti-D protocol en het belang van juiste toediening en registratie. Eventueel kan een flow chart bijdragen aan verheldering van het protocol en met hulp van klinische lessen kan het inzicht in de procedure vergroot worden.

102

Gynaecologie

Effectiever omgaan met telefonische consulten A. Muller-Schoonens1, B. Engeltjes1, G.S. Kooi1. 1

Polikliniek Gynaecologie, Albert Schweitzer ziekenhuis.

Background / Achtergrond Tijdens het spreekuur kunnen patiënten die een telefonische afspraak hebben om 12.00 uur en om 16.00 uur [telefonisch] contact opnemen voor uitslagen of specifieke vragen. Hierdoor kunnen ‘telefoonpieken’ ontstaan. Zeker bij meerdere spreekuren tegelijk. Door het observeren en signaleren van dit probleem, in de praktijk, actief op zoek naar een effectievere methode om hier mee om te gaan. Dit item is gebruikt voor het maken van de Meesterproef ter afsluiting van de opleiding voor doktersassistente [28 mei 2010].

Objective / Doel Hoe kan er worden bereikt dat de patiënt die een telefonische afspraak heeft. op de afgesproken tijd, direct te woord wordt gestaan en de juiste informatie krijgt.

Methods / Methoden Inventariseren hoe andere poliklinieken [zowel intern als extern het ASZ] hier in de praktijk mee omgaan. Hierbij zijn het actief betrekken van de directe collegae en de gynaecologen van de Maatschap Gynaecologie een belangrijke factor om tot een effectievere verbetering in de praktijk te komen. Een effectievere methode die ook zeker juridisch moet worden ondersteund.

Results / Resultaten De inventarisatie heeft er toe geleid dat per 1 juli 2010 de patiënten gebeld gaan worden. Hierdoor worden de ‘telefoonpieken’ voorkomen. En kan er meer aandacht geschonken worden aan de patiënt aan de balie.

Conclusion / Conclusie Doordat het uitgangspunt met betrekking tot de telefonische consulten van een andere kant wordt belicht, wordt de patiënt klantvriendelijker geholpen. Er wordt service gerichter gewerkt waarbij de privacy van de patiënt meer kan worden gewaarborgd.

103

Gynaecologie

Repair of pelvic organ prolapse using mesh and IVS tunnelers: results and complication M. Noorlander1, M. van der Gaast2, J.H.N. Schram3, C.J.A. Hogewoning3. 1

Afdeling Gynaecologie, Albert Schweitzer ziekenhuis. Afdeling Gynaecologie, Erasmus MC Rotterdam. 3 Afdeling Gynaecologie/ Regionaal Bekkenbodem Centrum, Albert Schweitzer ziekenhuis. 2

Submitted: Int Journal of Urogynecology

Background / Achtergrond Pelvic organ prolapse is a highly prevalent condition for which approximately one in nine women undergoes surgery in time. No consensus exists on the optimal surgical management of pelvic organ prolapse. Because of high recurrence rates in classic prolapse surgery, the use of mesh materials is steeply rising. In our clinic meshes are used most of the times (>85%) for the treatment of recurrent prolapse, for more then 5 years.

Objective / Doel In this prospective intention to treat study our objective was to evaluate the results of transvaginal repair of pelvic organ prolapse using meshes, placed with IVS® (Covidien) tunnelers. In this study we used two meshes, the older, normal weight Surgipro® mesh and the new, light weight Parietene light® mesh separately (both Covidien).

Methods / Methoden In this prospective cohort 115 patients who underwent surgery using these mesh materials were extensively documented and interviewed preoperative and postoperative.

Results / Resultaten Our main finding is a cure rate at the follow up of one year ranging from 96,7% till 100% and a significant improvement in the quality of life score.

Conclusion / Conclusie In skilled hands vaginal prolapse surgery using mesh materials is a safe way of surgical repair with a relatively low complication rate, good results, subjectively (quality of life) and objectively (anatomical) and with a low recurrence rate. In this study we also demonstrated no difference between results of normal weight mesh and light weight mesh.

104

Neurologie Prehospital barriers in acute stroke care in the region of Dordrecht, the Netherlands. E. Zock1, R.P. Kleyweg1. 1

Afdeling Neurologie, Albert Schweitzer ziekenhuis.

Background / Achtergrond Thrombolytic therapy has to be given within 4,5 hours after ischemic stroke. Within the concept ‘time is brain’, the faster trombolysis starts, the more effective it is. In the Netherlands only 5 to 7% of the stroke patients receive trombolysis, while 25% can be reached under the most ideal circumstances. Many barriers can delay fast trombolytic therapy.

Objective / Doel To assess which prehospital barriers delay thrombolytic therapy in patients after ischemic stroke in the region of Dordrecht in the Netherlands.

Methods / Methoden Observational research will be executed from May till October 2010. Patients after ischemic stroke as well as patients after hemorrhagic stroke will be included. Insight in prehospital barriers will be reached by a questionnaire consisting of nineteen open and closed questions. Descriptive statistics will be used for data-analysis.

Results / Resultaten Collecting data has not been completed yet and will be finished in October 2010. Patient characteristics (age, gender, history of stroke), percentage of thrombolytic therapy, first reaction to the signs and knowledge of patient and family about signs associated with stroke will be presented.

Conclusion / Conclusie The first data are analysed and suggest that: most patients do not call for help in the first hour and a large part isn’t aware of symptoms associated with stroke. The expectation is that interventions should be developed to attain more awareness of the symptoms associated with stroke and subsequently a direct call for medical advice so trombolysis can be given in more patients and faster after the start of the event.

105

Neurologie

Inter-observer agreement in standardized case history evaluation of carpal tunnel syndrome D. Westerman1, H. Kerkhoff1, G.H. Visser2, R.P. Kleyweg1 1

Department of Neurology, Albert Schweitzer Hospital. Department of Neurology and Neurophysiology, Erasmus Medical Centre, Rotterdam

2

Background / Achtergrond A case history is the cornerstone for the diagnosis of carpal tunnel syndrome (CTS). The value of a physical examination in CTS seems limited..

Objective / Doel In this study we investigated the inter-observer agreement in case histories of CTS and the potential additional value of physical neurological examination.

Methods / Methoden We examined to what extent two physicians, using the same standardized method of interview and physical examination, came to the same conclusions about patients with possible CTS.

Results / Resultaten Over six months 159 patients were evaluated, of which 116 (75.4%) were included in the study. The inter-observer agreement was high (kappa = 0.77). Physical examination changed the initial diagnosis based on the case history in only three cases.

Conclusion / Conclusie This study shows a high level of agreement between observers in the diagnosis of CTS. Furthermore, neurological examination rarely changed the diagnosis based on patient history, suggesting a limited role for neurological examination.

106

Interne geneeskunde The sense and the nonsense of health care paths R. Atiqi1, M. Niemeijer2, R. Cleophas3, T.J. Cleophas1. 1

Afdeling Interne geneeskunde, Albert Schweitzer ziekenhuis. Afdeling Cardiologie, Martini ziekenhuis. 3 onbekend 2

Medisch Contact. 2009, 37:1532-3.

Background / Achtergrond Health care paths are computer-aided clinical protocols linked to diagnostic treatment combinations. they are at the verge of being implemented inn the Netherlands, and some pilot studies have been performed to evaluate their performance. They must enhance the transparency of care and costs containment. In addition, they should minimize the risk of omissions in the diagnostic and therapeutic procedures and reduce the numbers of erroneous diagnoses.

Objective / Doel To predict whether health care paths can improve the quality of care.

Methods / Methoden In an early stage prior to the implementation of the health care paths, and in a later stage, just before the implementation, the diagnostic and therapeutic procedures have been mapped out of 107 patients that had been admitted to hospital because of chest pain (DBC-series 200) in the Martini Hospital Groningen and Albert Schweitzer Hospital Dordrecht in the Netherlands.

Results / Resultaten In 2005 omissions were observed in 86% of the patients included in the main stream path. Also very many omissions were observed in the noting down of risk factors for cardiovascular disease (59%). Yet, all of this did not lead to inacceptable lengthy waiting lists or lengthy periods of hospital stay (2-7 days) or erroneous diagnoses, only 5%. In 2008, after the medical staffs of the hospitals were familiarized with the diagnostic treatment combinations and health care paths systematics, the numbers of omissions appeared not to have decreased significantly (0 and 37%, p<0.001 and p<0.05, respectively). This, however, did not lead to shorter waiting lists, shorter periods of hospital stay or less frequent erroneous diagnostic treatment combination codings (9%).

Conclusion / Conclusie It is remarkable that in 2005 with so many omissions in the patients’ work-up by the cardiologists, se few erroneous diagnoses were made. The traditionel diagnostics in cardiology, in spite of very many omissions, reaches a right diagnosis in a markedly large percentage of the cases. It is questioned whether the benefit / risk ratio of the health care paths can counterbalance the benefit / risk ratios of the traditional, albeit sometimes somewhat sloppy work-up of the cardiologists.

107

Interne geneeskunde

Prevalence of iatrogenic admissions to the departments of medicine / cardiology / pulmonology in a 1250 beds general hospital R. Atiqi1, E. van Bommel1, T.J. Cleophas1. 1

Afdeling Interne geneeskunde, Albert Schweitzer ziekenhuis.

Int J Clin Pharmacol Ther. 2009 Sep, 47(9):549-55.

Background / Achtergrond A recent meta-analysis in this journal showed incidences between 3.4 and 33.9%. Studies performed by pharmacists and epidemiologists produced lower incidences than internists’ studies.

Objective / Doel We reassessed the prevalence of iatrogenic admissions in a study of internists. Iatrogenic disease was defined as adverse drug reactions according to the World Health Organisation Definition and complications induced by non-drug medical interventions.

Methods / Methoden Subsequent admissions at the departments of medicine / cardiology / pulmonology in a 1250 beds general hospital in the Netherlands from May 2007-August 2007 were studied.

Results / Resultaten 2000 consecutive admissions were studied: 576 (29%, 26-32%) were classified as possibly iatrogenic; out of these 380 (19%, 17-22%) as definitely iatrogenic, out of whom 229 (12%, 10-14%) had already been classified as iatrogenic by the admitting physicians. Patients with cardiac disease, hypertension, gastrointestinal conditions, anticoagulant treatment and use of NSAIDs were, particularly, at risk of iatrogenic admission with percentages of 22 (16-24), 13 (11-18), 12 (9-15), and 7 (5-11) %. An independent predictor of iatrogenic admissions was age with an odds ratio of 1.27 per 10 years (p = 0.0001).

Conclusion / Conclusie 1. At least 19% of admissions to the departments of internal medicine / cardiology / pulmonology, and, maybe, even percentages up to 29% were due to adverse drug effects. 2. A large difference between the numbers of iatrogenic admission according to the physicians in charge of admission and the investigators, 229 versus 380 patients, was observed. 3. Most often iatrogenic admissions were observed with cardiac disease, hypertension, gastrointestinal conditions, anticoagulant treatment, and use of NSAIDs.

108

Interne geneeskunde

Primaire myelofibrose: voorbij janus S. Slot1, C. Schilthuizen2, M-D. Levin2, S. Zweegman1. 1

Afdeling Hematologie, VUMC. Afdeling Interne geneeskunde, Albert Schweitzer ziekenhuis.

2

Ned Tijdschr voor Hematologie. 2009, 6:300-9.

Abstract Met de ontdekking van mutaties die leiden tot constitutieve activering van het janus-tyrosinekinase JAK2 is een voorheen onbekende proliferatieve stimulus bij myeloproliferatieve ziekten omschreven. Deze heeft geleid tot een nieuwe vorm van therapie. Daarnaast is het van nut gebleken bij de diagnosestelling van de diverse vormen van myeloproliferatieve ziekten. De aanwezigheid van de JAK2-mutatie ondersteunt de diagnose ‘primaire myelofibrose’ in ongeveer de helft van de patiënten. De verschillen in fenotype van de diverse myeloproliferatieve ziekten bij hetzelfde genotype en het feit dat er myeloproliferatieve ziekten zonder JAK2-mutaties voorkomen, doen vermoeden dat er nog onbekende pre-JAK2-events en/of additionele mutaties bestaan. Voortschrijdend pathofysiologisch inzicht en de introductie van non-myeloablatief transplanteren heeft de behandelmogelijkheden voor patiënten met myeloproliferatieve ziekten en in het bijzonder primaire myelofibrose verbeterd.

109

Klinische Chemie Digital morphology: towards auto-validation J.A. Riedl1, W. van Gelder1. 1

Geïntegreerd Klinisch Chemisch Laboratorium, Albert Schweitzer ziekenhuis.

Background / Achtergrond Differential counting and morphological analysis of nucleated cells in blood smears is of great diagnostic importance to the clinician. An exciting development in the haematology field was the introduction of an automated microscopy system, the DM96. This computerized system provides an automated morphological analysis of blood smears, including an automated classification of all nucleated cells. We have previously shown that the DM96 is capable of correctly classifying leukocytes in peripheral blood and body fluid samples (1,2). In this study we analysed the pre-classification performance of the DM96 when compared to a group of highly trained morphology experts using a large-scale leukocyte database.

Objective / Doel In this study we analysed the pre-classification performance of the DM96 when compared to a group of highly trained morphology experts using a large-scale leukocyte database.

Methods / Methoden A total of 1660337 leukocytes in 6946 blood smears were analysed on the DM96 and manually by experts and pre-classification scores were determined.

Results / Resultaten Preliminary analysis of this large dataset demonstrates regression coefficients ranging from 0.95-0.99 for neutrophils, lymphocytes and eosinophils and 0.87 for basophils and monocytes. Interestingly, sensitivity for blast detection was calculated and is 100%.

Conclusion / Conclusie Using a large leukocyte database of > 1.5 x 106 leukocytes we show that the DM96 is capable of correct classification of the five main peripheral blood leukocyte classes (lymphocytes, neutrophils, eosinophils, basophils and monocytes). We postulate that, using confidence limits, auto-validation is the (logical) next step towards standardisation of morphological assessment of peripheral blood smears in general. Interestingly, blast cells are not missed by the DM96, rendering the DM96 extremely suitable for automated screening of peripheral blood smears of for instance acute leukaemia remission and MDS patients.

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Klinische Psychiatrie Steroïdpsychose bij behandeling van dreigende vroeggeboorte M.I.M.E. Koster1, M.H. De Jong2, M.Th. Derksen2, A.R. Van Gool1. 1 2

Yulius Geestelijke Gezondheid (voorheen RMPI De Grote Rivieren). Afdeling Psychiatrie, Albert Schweitzer Ziekenhuis.

Background / Achtergrond Bij dreigende vroeggeboorte worden naast weeënremmers corticosteroïden ter bevordering van foetale longrijping gebruikt. Bij gebruik van corticosteroïden kunnen psychiatrische bijwerkingen optreden. Zwangeren zijn in het algemeen jong en gezond. Het risico op psychiatrische bijwerkingen is daarom wellicht klein, maar het vóórkomen daarvan is niet uitgesloten.

Objective / Doel Beschrijving van psychiatrische bijwerkingen van de behandeling van dreigende vroeggeboorte met aandacht voor epidemiologie en behandeling.

Methods / Methoden Illustratie van het onderwerp door middel van een casusbeschrijving. Literatuuronderzoek naar psychiatrische bijwerkingen van corticosteroïden bij zwangeren in het bijzonder tijdens de behandeling van dreigende vroeggeboorte.

Results / Resultaten Casus: Een 30-jarige zwangere met een blanco psychiatrische voorgeschiedenis werd bij een zwangerschapsduur van 33 weken behandeld wegens dreigende vroeggeboorte. Naast nifedipine oraal als tocolyticum kreeg patiënte op twee opeenvolgende dagen 12 mg betamethason intramusculair toegediend. Binnen enkele dagen ontwikkelde zij een psychotisch toestandsbeeld. Vanuit psychotische belevingen poogde ze om zelf de vliezen te breken. Differentiaaldiagnostisch werd een delier overwogen. Opname op de PAAZ en behandeling met haloperidol bleken noodzakelijk. De psychose herstelde in drie weken, nog tijdens de zwangerschap, restloos. Zes weken na het begin van de psychose beviel ze van een gezonde dochter. Post partum staakte patiënte de haloperidol. Er deden zich geen psychiatrische problemen meer voor. Literatuur: Somatische bijwerkingen van corticosteroïden zijn goed gedocumenteerd. Neuropsychiatrische bijwerkingen krijgen veel minder aandacht. Deze zijn onvoorspelbaar, vaak ernstig en kunnen alle categorieën van psychopathologie betreffen, zoals stemmingslabiliteit, agitatie, cognitieve stoornissen, manieën en psychotische symptomen. Literatuur over de incidentie van neuropsychiatrische bijwerkingen van corticosteroïden tijdens zwangerschap werd niet gevonden.

Conclusion / Conclusie Neuropsychiatrische bijwerkingen ten gevolge van corticosteroïden tijdens de zwangerschap kunnen ernstig verlopen. Gezien de incidentie van dreigende vroeggeboorte zal dit waarschijnlijk met enige regelmaat voorkomen. Opvallend is dat in de literatuur hierover niets bekend is.

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Pathologie Evaluation of an internally controlled semi-quantitative real-time PCR for detection of Pneumocystis jirovecii in paraffin-embedded clinical samples P.J. Westenend1, M. Hermans2, R. Kroonen1, A-J Breugelmans1, C.M. Mooy1, A. vd Zee1. 1

Pathologisch Anatomisch Laboratorium, Dordrecht. Multidiciplinair Laboratorium voor Moleculaire diagnostiek, Jeroen Bosch Ziekenhuis.

2

Background / Achtergrond Pneumocystis pneumonia (PCP) in humans is caused by Pneumocystis jiroveci and is most prevalent in patients infected with HIV and in patients with impaired immunity related to malignancies or immunosuppressive medical treatment. Within the host lung two separate life forms of P. jiroveci can be distinguished; the trophozoite form and the cyst form. The clinical presentation of PCP is non-specific and P. jiroveci cannot be cultivated outside the human host. The conventional diagnosis of PCP relies on microscopic visualisation of histological preparations of clinical samples. Routine staining is often carried out with Grocott-Gomori methenamine silver but stains only cyst forms of P.jiroveci. With immunohistochemical staining both life forms can be detected. However, with routine staining, the quality of the sample and the load of infectious agent per sample are critical for the diagnostic outcome.

Objective / Doel We evaluated the performance of real-time PCR in comparison with conventional staining in the diagnosis of pneumonia caused by P.jirovecii.

Methods / Methoden Cytological samples with a request for P. jerovecii testing from 1998 until 2007 were retrieved from our files. Samples for which a cell block was available were tested with a PCR. Clinical data were retrieved from our files and supplemented with data from the hospital files.

Results / Resultaten A total of 128 samples from 104 patients was analysed of which 87 were negative both by conventional staining methods and by real-time PCR. Fourteen samples were positive by conventional staining methods whereas 41 were positive in real-time PCR. In all PCR positive patients we identified an underlying risk factor.

Conclusion / Conclusie Real-time PCR is a more sensitive method for diagnosing P. jirovecii and can contribute to a timely diagnosis.

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Pathologie

Variable Life-Adjusted Display (VLAD) grafiek en Tissue Micro Array (TMA) als instrument voor de kwaliteitsborging van Her2neu. P.J. Westenend1, M. Riemens1, R.A.M. Damhuis2. 1 2

Pathologisch Anatomisch Laboratorium, Dordrecht. Afdeling Kankerregistratie en onderzoek, Integraal Kankercentrum Rotterdam.

Background / Achtergrond Voor de interne kwaliteitsborging van de Her2neu bepaling is standaardisatie van laboratoriumprocedures en het meenemen van controle materiaal in de vorm van bekende positieve en negatieve tumoren dan wel cellijnen een geaccepteerde procedure. Door participatie aan rondzendingen (SKML, Nordiq) is er ook een externe kwaliteitsborging. Nadeel van deze rondzendingen is dat ze slechts enkele malen per jaar worden gedaan. Ook voor het berekenen van het percentage positieve tumoren over een jaar geldt dat de informatie feitelijk te laat is. Er is dus behoefte aan een instrument dat meer real time informatie geeft.

Objective / Doel Variable Life-Adjusted Display (VLAD) grafieken zijn een grafisch hulpmiddel dat is ontwikkeld voor het real time monitoren van ernstige (dodelijke) complicaties, in eerste instantie in de hartchirurgie. In het afgelopen jaar hebben wij de toepasbaarheid van deze techniek voor de kwaliteitsbewaking van Her2neu getest.

Methods / Methoden De her2 bepaling is in ons laboratorium gestandaardiseerd door toepassing van automatische kleuring (Ventana Benchmark) en het meenemen van controle materiaal in de vorm van bekende positieve en negatieve tumoren. Het laboratorium heeft deelgenomen aan de Nordiq rondzendingen waarbij de resultaten als optimaal zijn beoordeeld. De resultaten van achtereenvolgende tests werden iedere 2 weken ingevoerd in een computerprogramma (Excel) en weergegeven in een VLAD grafiek. Deze grafiek toont het verschil tussen het aantal geobserveerde Her2 positieve tumoren en het aantal verwachtte positieve tumoren (wij gebruikten 17%, gemiddelde uit de IKR regio) uitgezet tegen het aantal testen. Bij een adequate uitvoering van de test schommelt de aldus geproduceerde lijn rond de X-as. Rond de X-as worden betrouwbaarheidsintervallen weergegeven. Wanneer de geproduceerde lijn naar boven afwijkt en de bovenste lijn van het betrouwbaarheidsinterval snijdt zijn er meer positieve tests dan verwacht mag worden voor een gemiddeld laboratorium. Omgekeerd bij afwijking naar beneden van de lijn en snijden van de lijn van het betrouwbaarheidsinterval is er sprake van te weinig Her2 positieve tests.

Results / Resultaten In augustus was er een afwijking van de lijn naar beneden met snijden van de onderste 5% lijn van het 90% betrouwbaarheidsinterval. De resultaten van de Her2 bepaling werden opnieuw beoordeeld waarbij geen verandering van score. Van de excisiepreparaten werd een eenvoudige TMA gemaakt en gekleurd voor Her2neu. Tevens werd een SISH voor Her2neu verricht. Ook hierbij werden geen discrepante resultaten verkregen.

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Pathologie

Conclusion / Conclusie Het gebruik van VLAD grafieken is goed in te passen in de laboratoriumdiagnostiek. Het invullen van de data kost weinig tijd en de grafische weergave is makkelijk intuïtief te begrijpen. Het verkrijgen van de data uit informatiesystemen (PALGA, LMS) kost de meeste tijd.

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Radiologie Analysis of abdominal aortic diameter and aortic expansion pattern in patients with idiopathic retroperitoneal fibrosis H.J.C. van Damme1, A.L.J.H. Aarnoudse2, T.R. Hendriksz1, E.F.H. van Bommel2. 1 2

Afdeling Radiologie, Albert Schweitzer ziekenhuis. Afdeling Interne Geneeskunde, Albert Schweitzer ziekenhuis.

Background / Achtergrond The aortic diameter in patients with idiopathic retroperitoneal fibrosis tends to be larger than expected in general population. The pathogenesis of aortic dilation in peri-aortic inflammation remains unclear. Up to date, there are no data available on the growth pattern of the abdominal aorta in RPF patients. We performed a prospective study in 63 RPF patients.

Objective / Doel The objective of this study is to investigate the incidence of aortic dilation at presentation and to observe its growth tendency during follow-up.

Methods / Methoden At baseline a CT scan was performed, which was repeated during follow-up at 6, 12, 24, 48 months. The maximal overall aortic diameter as well as the maximal diameter within the retroperitoneal mass were measured independently by two radiologists.

Results / Resultaten Fifty percent of the study population had a dilation of the abdominal aorta above 25 mm at presentation. Patients presenting with an aortic ectasia or aneurysm suffered significantly more of hypertension and cardiovascular disease. They had larger body surface areas and were more often smokers. In the normal aortic diameter subgroup, twenty percent did show expansion, but only 10% of these showed significant expansion of 3 mm or more. In the ectatic subgroup, 40% showed expansion, of which 30% was significant. In the aneurysmal subgroup, 40% showed expansion, of which 70% was significant. Two patients underwent surgical correction of an aneurysm and were excluded from follow-up.

Conclusion / Conclusie Surprisingly, the overall abdominal aortic growth rate was negative in our population. We do not have a sufficient explanation for this finding. A protective role from Tamoxifen treatment could play a role. In conclusion, dilation of the abdominal aorta is increased significantly in patients presenting with idiopathic retroperitoneal fibrosis. Growth rates are increased in ectatic and aneurysmal aortas, thus these patients should be monitored closely. Subsequent investigation is needed to identify the relationship between peri-aortic fibrosis and the development of aortic dilation.

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Radiologie

Pictorial essay: the many faces of lymphoma A. Ghandi1, J. Bakker1, H. Berenschot2, M-D. Levin2. 1

Afdeling Radiologie, Albert Schweitzer ziekenhuis. Afdeling Interne geneeskunde, Albert Schweitzer ziekenhuis.

2

Abstract Malignant lymphoma is a frequent occurring disease and important part of the daily practice of radiologists, haematologists, and oncologists. The usual presentation with enlarged lymph nodes is well known. However, there are less common presentations of this disease in various extranodal sites, which have less frequent occurrence. In this pictorial essay we illustrate these rare presentations of malignant lymphoma in various organ systems, using different radiological imaging techniques. Primary occuring lymphomas will be the main focus of this essay. Central nervous system malignant lymphomas will be discussed first, followed by head and neck, continuing downwards the human body, ending with the cutaneaous lymphomas.

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Radiologie

Visceral fat volume and its association with mesenteric panniculitis. N. van Putte-Katier1, O.E. Elgersma2, T.R. Hendriksz2. 1 2

Erasmus MC, Rotterdam Afdeling Radiologie, Albert Scheitzer Ziekenhuis.

Background/ Objective Mesenteric panniculitis is a rare inflammatory disorder of unknown etiology affecting the mesentery. Recent studies have improved the understanding of adipose tissue and its active role in inflammatory mesenteric and intestinal disease. However, very little is known on the role of adipose tissue in the pathophysiology of mesenteric panniculitis. The purpose of this study was to determine whether increased mesenteric adipose tissue plays an important role in mesenteric panniculitis.

Methods / Methoden As part of a large hospital based prevalence study on mesenteric panniculitis, a nested case-control study was conducted. 94 patients (70% male) with mesenteric panniculitis were identified and compared to 94 individuals matched by gender and age. Total, subcutaneous and visceral fat volumes were measured on 10 x 5 mm contiguous CT-slices around the level of the umbilicus. A fat-density mask was constructed to include pixels with attenuation values ranging from -190 to -30 Hounsfield units

Results / Resultaten Mean age of individuals in both groups was 66,6 + 11,2 years. Persons with mesenteric panniculitis had a larger total fat volume (mean volume 2238 ml versus 2106 ml, p<0,05) and visceral fat volume (mean volume 1029 ml versus 916 ml, p<0,05). Subcutaneous fat volume (mean volume 1226 ml versus 1198 ml) was not significantly different between groups.

Conclusion / Conclusie Significant higher levels of visceral fat exist in patient with mesenteric panniculitis compared to individuals without mesenteric panniculitis. Further research is necessary to correlate these findings to the endocrine and metabolic functions of visceral fat in mesenteric panniculitis.

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