Wetenschappelijk jaaroverzicht 2013

Wetenschappelijk jaaroverzicht 2013

Wetenschappelijk jaaroverzicht 2013

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Inhoud

Samenstelling Wetenschapscommissie

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Woord vooraf

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Wetenschappelijk jaarverslag Wetenschapscommissie 2013

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Wetenschappelijk jaaroverzicht 2013 per vakgroep

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Anesthesiologie

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Cardiologie 20 Chirurgie 25 Dermatologie 38 Gynaecologie 41 Intensive care geneeskunde

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Interne geneeskunde

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Kindergeneeskunde 56 Klinische chemie

61

Klinische fysica

63

KNO 64 Leerhuis 65 Maag, darm- en levergeneeskunde

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Medische microbiologie

71

Neurologie 77 Neurochirurgie 79 Oogheelkunde 80 Orthopedie 81 Pathologie 82 Psychiatrie 88 Poliklinische apotheken

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Radiologie 90 Reumatologie 95 Spoedeisende geneeskunde

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Urologie 97 Ziekenhuisapotheek 98 Promoties ASz 2013

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Wetenschapsdag ASz 2013

101

Mondelinge presentaties

102

Poster presentaties

108

Verantwoording 124

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Samenstelling Wetenschapscommissie Dagelijks bestuur dr. M.C.J.M. Kock, voorzitter, radioloog dr. M-D Levin, vice-voorzitter, internist-hematoloog drs. C.N. van Waardhuizen MSc, beleidsadviseur mw. E.Y. de Kruyf, secretariaat

Leden wetenschapscommissie dr. ir. B. van den Berg, klinisch fysicus dr. A. Bischoff, KNO-arts dr. E.F.H. van Bommel, internist-nefroloog drs. R.P.M. Ceulen, dermatoloog drs. L.P.L.H. Cuijpers, klinisch psycholoog dr. M.A. Fouraux, klinisch chemicus (METC) dr. H.M.E. Frenay, arts-microbioloog mw. R. van Hof, medisch informatiespecialist drs. A.M. van der Velden, arts-assistent spoedeisende geneeskunde drs. A.D. Klaren, manager Leerhuis & Kwaliteit, Veiligheid en Innovatie drs. S. Hendriks, intensivist-anesthesioloog drs. A.M.J.V. Schyns – van den Berg, intensivist-anesthesioloog dr. P.W. Plaisier, chirurg drs. J.M.M. van de Ridder, adviseur Medische Vervolgopleidingen Leerhuis dr. T.C.J. Sas, kinderarts dr. A.C. de Mol, kinderarts-neonatoloog drs. E.M. de Vogel, ziekenhuisapotheker drs. M.M. Beex – Oosterhuis, ziekenhuisapotheker drs. T.A.G. Tijssen, ziekenhuisapotheker dr. P.J. Westenend, patholoog dr. L.J.P.M. van Woerkens, cardioloog dr. D. Zemel, neuroloog dr. F.H.J. Wolfhagen, MDL arts dr. D. Cheung, longarts drs. S. Rombout-de Weerd, gynaecoloog dr. N.B. Swarte, gynaecoloog dr. N. van Putte – Katier, radioloog mw. J. Erkelens, AAV, arts-assistent ziekenhuis apotheek mw. J. Brakel, AAV, arts-assistent chirurgie dr. R. Castel, AAV, arts-assistent klinisch chemicus dr. I.J.H. van Vlodrop, arts-assistent klinisch chemicus mw. K. Koppelaar, IC verpleegkundige R. Hemerik, fondsenwerver (buitengewoon lid)

Hoofdredactie wetenschappelijk tijdschrift ‘WASz’ drs. A.M. van der Velden, arts-assistent spoedeisende geneeskunde mw. C. Spruyt, arts-assistent spoedeisende geneeskunde mw. R. Hagens, arts-assistent spoedeisende geneeskunde dr. N.B. Swarte, gynaecoloog 3

Samenstelling Wetenschapscommissie

Woord vooraf

Hierbij presenteren wij u de wetenschappelijke output van het ASz over het jaar 2013. Ook dit jaar hebben wij getracht alle informatie rondom wetenschap in het ASz handzaam bijeen te brengen. Er zijn vanuit de wetenschapscommissie en het Leerhuis inmiddels veel faciliteiten aanwezig om wetenschappelijk onderzoek te faciliteren. Daar gaan wij hierna nader op in. Wij prijzen alle vakgroepen en afdelingen van het ASz die mooie wetenschappelijke data hebben verzameld, onderzocht en gepubliceerd. Op deze manier zorgen wij ervoor dat de kwaliteit van onze patiëntenzorg nóg beter wordt en wij verder kunnen innoveren. Namens de wetenschapscommissie, Dr. M.C.J.M. (Marc) Kock

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Wetenschappelijk jaarverslag Wetenschapscommissie 2013

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Wetenschapscommissie De wetenschapscommissie is opgezet met als doel medisch wetenschappelijk onderzoek te ondersteunen, te stimuleren en om een breed gedragen goed onderbouwd wetenschapsbeleid te maken. In 2009 is een bredere basis gelegd en participeert bijna iedere afdeling van ons ziekenhuis binnen de wetenschapscommissie. In 2010 is een beleidsmedewerker wetenschapscommissie aangesteld. Het dagelijks bestuur is gevormd welke maandelijks samenkomt. De voltallige wetenschapscommissie komt 4 maal per jaar samen. In 2012 zijn statici van de afdeling Biostatistiek van het Erasmus MC aangesteld voor een dag in de week om statistiek consulten aan te bieden. In 2014 is een klinisch epidemioloog aangesteld als wetenschapscoördinator en om consulten aan te bieden ten aanzien van studieopzet, epidemiologievraagstrukken en dergelijke. De wetenschapscommissie wordt ondersteund door het secretariaat van het Leerhuis, de statistici, beleidsadviseur, klinisch epidemioloog / wetenschapscoördinator.

Vergaderdata wetenschapscommissie 2013 Dinsdag 5 maart van 17.15 uur tot 19.00 uur zaal 2 Dordwijk Dinsdag 17 september van 17.15 uur tot 19.00 uur zaal 5 Dordwijk Dinsdag 19 november van 17.15 uur tot 19.00 uur zaal 5 Dordwijk

Vergaderdata dagelijks bestuur wetenschapscommissie 2013 Dinsdag 8 januari Dinsdag 12 februari Dinsdag 5 maart Disndag 2 april Dinsdag 7 mei Dinsdag 2 juli Dinsdag 6 augustus Dinsdat 10 september Dinsdag 1 oktober

Albert Schweitzer Stipendium De wetenschapscommissie heeft in 2010 in samenwerking met het Leerhuis en Raad van Bestuur het Albert Schweitzer Stipendium in het leven geroepen. De wetenschapscommissie toetst de aanvragen die voor het wetenschapsfonds in aanmerking wensen te komen op transparante wijze. Deze inschrijfronde is een- tot tweejaarlijks, afhankelijk van het overgebleven budget. Jaarlijks wordt momenteel een budget van 70.000 euro toegekend vanuit budget van het Leerhuis. Het Albert Schweitzer Stipendium is bedoeld voor patiëntgebonden, klinisch relevant onderzoek dat wordt uitgevoerd in en door het ASz en is geïnitieerd vanuit het ASz. Deze zijn bij voorkeur binnen de inhoudelijke prioriteiten die door de Raad van Bestuur zijn benoemd. Het indienen en beoordelen van deze projecten verloopt volgens een vaste procedure in een aantal fases. Doel van deze procedure is om de rechtsgelijkheid tussen indieners te garanderen, de transparantie van de beoordeling te vergroten en een vergelijking met subsidieprocedures elders mogelijk te maken. Het Stipendium biedt onderzoekers de mogelijkheid zich fulltime bezig te houden met research activiteiten. In 2013 zijn de volgende onderzoeksaanvragen gehonoreerd:

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2013 Aanvrager Yusuf Karamermer

Specialisme

Onderwerp

Radiologie

Renal DENervation in End-stage Renal Failure (DENERF)

Ingrid Steenis

Afdeling B3, Oncologie

Lijninfecties in zicht

Karlijn Stouten

GKCL

Waarde en bruikbaarheid van verschillende hepcidine testen om ijzer status te bepalen in patiënten met ijzer deficiëntie anemie en anemie bij chronische ziekte

Elles Zock

Neurologie

Reducing delay in acute stroke care

Carlo Holtzer

Plastische chirurgie

Zijn er functiestoornissen van de bovenste extremiteit na percutane coronaire interventie via de arteria radialis

Martijn van Hooft

SEH

Remifentanil-TCI for procedural sedation and analgesia in the Emergency Department: a randomized controlled trial

Wetenschappelijk tijdschrift ‘WASz’ Het wetenschapstijdschrift van het ASz, de WASz, wordt twee keer per jaar in reguliere vorm uitgegeven en een keer in de vorm van een abstractenboek van de wetenschapsdag. Door middel van het tijdschrift worden medewerkers, verwijzers en andere geinteresseerden periodiek op de hoogte gehouden van allerlei wetenschappelijke activiteiten van het Albert Schweitzer ziekenhuis. De kosten voor de uitgifte van de WASz worden volledig gedragen door de advertentie opbrengsten. De oplage van het WASz was 1000 en is verspreid aan de specialisten, arts-assistenten, Raad van Bestuur, bedrijfsleiders, stafhoofden, wetenschapsbureaus, STZ ziekenhuizen, huisartsen, fysiotherapeuten, apothekers en overig geïnteresseerden.

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Cursussen De volgende cursussen zijn aangeboden in 2013.

Scholing

Door wie?

Frequentie

Good Clinical Practice

ROCHE

1 x per jaar (oktober)

BROK

Vanuit STZ

n.v.t.

Wetenschappelijk Engels

Externe partij: Text en

1 x per jaar 6 bijeenkomsten

training

(oktober, november en

SPSS c.q. opzet ws onder-

Statistici c.q. Wetenschaps-

3 workshops (januari en

zoek

coördinator

februari)

Evidence Based practice

n.v.t.

n.v.t.

Cursus poster maken

Onderwijskundige

1 keer per jaar

PubMed

Medisch informatie specialist 3 x in groepsverband

december)

Op aanvraag door dede

3 x individueel

medisch informatie specialist

Jaarlijkse Wetenschapsdag De 9e jaarlijkse wetenschapsdag van het Albert Schweitzer ziekenhuis heeft op 20 juni 2013 plaatsgevonden in het Auditorium van het ASz. Op de wetenschapsdag waren 120 deel nemers aanwezig. Er zijn 23 posters getoond inclusief posterpresentaties en 8 voordrachten gegeven. -D e posterprijs is dit jaar gegaan naar mw. B. Postema – van der Heijde van de vakgroep anesthesiologie (Early Goal Directed Therapy with Vigileo cardiac output measurements). -D e prijs beste presentatie is dit jaar gegaan naar mw. N. de Graaf, verpleegkundige specialistisch longziekten (Ademhalingsondersteuning (thuis) bij patiënten met zeer ernstig COPD in de palliatieve fase. Leidt dit tot minder ziektelast; hogere kwaliteit van leven en minder ziekenhuisopnames?) -D e prijs beste publicatie is R. Castel, arts-assistent klinisch chemicus. Titel publicatie: The transferrin/log (ferritin) ratio: a new tool for the diagnosis of iron deficiency anemia. Speciale aandacht hadden we dit jaar voor de boekpresentatie van dr. E.F.H. van Bommel “Idiopatische retroperitoneal fibrose”(iRPF), een chronische ontsteking achterin de buik. Dr. van Bommel heeft baanbrekend werk verzet door dit belangrijke onderwerp op deze manier de afgelopen jaren te onderzoeken en zo te publiceren. Wij zijn daar zeer trots op!

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Wetenschapslunch In 2013 is een maandelijkse wetenschapslunch opgezet waar onderzoekers hun lopende onderzoek kunnen presenteren. Het doel is om van elkaar te leren, opbouwende kritiek te leveren, interdisciplinaire samenwerking t.a.v. wetenschappelijk onderzoek te stimuleren. De wetenschapslunch is opgezet zodat onderzoekers vaker dan 1x per jaar op de wetenschapsdag elkaar kunnen ontmoeten en ideeen uit wisselen. In 2013 zijn de volgende vakgroepen als sprekers aan bod gekomen:

Datum

Onderwerp

Spreker/vakgroep

29-01-2013

Slaapapneu en zwangerschap

Ingrid Vlot – AIOS gynaecologie

Klachten en anatomische afwijkingen

Josine Klop en Irene Koning – AIOS

één of twee jaar na een totaalruptuur

gynaecologie

Victoza bij patiënten met diabetes

Evert van Velsen – AIOS Interne

26-02-2013

type 2 Lupus anticoagulans bij diepe

Marieke van der Zwan – AIOS Interne

veneuze trombose en longembolie 26-03-2013

Pre-hospitale sepsis behandeling

Merel Willeboer – AIOS SEH

28-05-2013

Digitale microscopie

Francoise Verheijen – Klinische Chemie

24-09-2013 29-10-2013

Moleculaire diagnostiek

Jürgen Riedl – Klinische Chemie

Renale denervatie

Yusuf Karamer – AIOS Radiologie

MRI bij DCIS (Pink Ribbon)

Albert ter Braak – AIOS Radiologie

ANIOS en wetenschap; hoe pak ik

Linda van Gelder – ANIOS Chirurgie

dit aan? 26-11-2013

Stoma trials: stand van zaken

Maartje Sier – AIOS Chirurgie

Bewegingsbeperkingen gedurende

Marieke Meinardi – Geratrie

en na oncologische behandeling van de oudere patiënt Meten van aandacht

Erwin de Groot - Geriatrie

Beleidsplan In 2013 heeft de Wetenschapscommissie haar dienstverlening verder geprofessionaliseerd. In een addendum bij het beleidsplan “Zorg voor Wetenschap” heeft de Wetenschaps commissie de verdere lijnen naar de toekomst uitgezet, voorzien van een praktisch overzicht van prioriteiten ten aanzien van beleidsplan ten behoeve van de Raad van Bestuur. Om de strategische punten te realiseren zijn de concrete doelstellingen voor de periode 2012 - 2015 vastgelegd in de vorm van een plan van aanpak om het wetenschapsbeleid te verankeren in het ziekenhuisbeleid voor de komende vijf jaar. De huidige ontwikkelingen en snelle veranderingen maken het echter wel aannemelijk dat tussentijds doelen aangepast en/of toegevoegd zullen moeten worden, afhankelijk van het urgentieniveau. De praktische tools om deze doelen te realiseren zullen door de wetenschapscommissie worden uitgewerkt.

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Wetenschappelijk jaaroverzicht 2013 per vakgroep

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Anesthesiologie

PubMed publicaties Patients with severe radiographic osteoarthritis have a better prognosis in physical functioning after hip and knee replacement: a cohort-study. Keurentjes JC, Fiocco M, So-Osman C, Onstenk R, Koopman-Van Gemert AW, Pöll RG, Kroon HM, Vliet Vlieland TP, Nelissen RG. PLoS One. 2013;8(4):e59500. INTRODUCTION: Although Total Hip and Knee Replacements (THR/TKR) improve Health- Related Quality of Life (HRQoL) at the group level, up to 30% of patients are dissatisfied after surgery due to unfulfilled expectations. We aimed to assess whether the pre-operative radiographic severity of osteoarthritis (OA) is related to the improvement in HRQoL after THR or TKR, both at the population and individual level. METHODS: In this multi-center observational cohort study, HRQoL of OA patients requiring THR or TKR was measured 2 weeks before surgery and at 2-5 years follow-up, using the Short-Form 36 (SF36). Additionally, we measured patient satisfaction on a 11-point Numeric Rating Scale (NRSS). The radiographic severity of OA was classified according to Kellgren and Lawrence (KL) by an independent experienced musculoskeletal radiologist, blinded for the outcome. We compared the mean improvement and probability of a relevant improvement (defined as a patients change score ≥ Minimal Clinically Important Difference) between patients with mild OA (KL Grade 0-2) and severe OA (KL Grade 3+4), whilst adjusting for confounders. RESULTS: Severe OA patients improved more and had a higher probability of a relevant improvement in physical functioning after both THR and TKR. For TKR patients with severe OA, larger improvements were found in General Health, Vitality and the Physical Component Summary Scale. The mean NRSS was also higher in severe OA TKR patients. DISCUSSION: Patients with severe OA have a better prognosis after THR and TKR than patients with mild OA. These findings might help to prevent dissatisfaction after THR and TKR by means of patient selection or expectation management. PMCID: PMC3616074 PMID: 23573200 [PubMed - in process]

Hip and knee replacement patients prefer pen-and-paper questionnaires: Implications for future patient-reported outcome measure studies. Keurentjes JC, Fiocco M, So-Osman C, Ostenk R, Koopman-Van Gemert AW, Pöll RG, Nelissen RG. Bone Joint Res. 2013 Nov 7;2(11):238-44. OBJECTIVES: Electronic forms of data collection have gained interest in recent years. In orthopaedics, little is known about patient preference regarding pen-and-paper or electronic questionnaires. We aimed to determine whether patients undergoing total hip (THR) or total knee replacement (TKR) prefer pen-and-paper or electronic questionnaires and to identify

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variables that predict preference for electronic questionnaires. METHODS: We asked patients who participated in a multi-centre cohort study investigating improvement in health-related quality of life (HRQoL) after THR and TKR using pen-and- paper questionnaires, which mode of questionnaire they preferred. Patient age, gender, highest completed level of schooling, body mass index (BMI), comorbidities, indication for joint replacement and pre-operative HRQoL were compared between the groups preferring different modes of questionnaire. We then performed logistic regression analyses to investigate which variables independently predicted preference of electronic questionnaires. RESULTS: A total of 565 THR patients and 387 TKR patients completed the preference question. Of the THR patients, 81.8% (95% confidence interval (CI) 8.4 to 84.7) preferred penand-paper questionnaires to electronic questionnaires, as did 86.8% (95% CI 83.1 to 89.8) of TKR patients. Younger age, male gender, higher completed level of schooling and higher BMI independently predicted preference of electronic questionnaires in THR patients. Younger age and higher completed level of schooling independently predicted preference of electronic questionnaires in TKR patients. CONCLUSIONS: The majority of THR and TKR patients prefer pen-and-paper questionnaires. Patients who preferred electronic questionnaires differed from patients who preferred penand-paper questionnaires. Restricting the mode of patient-reported outcome measures to electronic questionnaires might introduce selection bias. Cite this article: Bone Joint Res 2013;2:238-44. PMCID: PMC3834769 PMID: 24203164 [PubMed]

Frequent use of blood-saving measures in elective orthopaedic surgery: a 2012 Dutch blood management survey. Voorn VM, Marang-van de Mheen PJ, Wentink MM, So-Osman C, Vliet Vlieland TP, Koopman-van Gemert AW, Nelissen RG, Van Bodegom-Vos L; LISBOA study group. BMC Musculoskelet Disord. 2013 Aug 5;14:230. doi: 10.1186/1471-2474-14-230. BACKGROUND: Blood loss in hip and knee arthroplasties may necessitate allogeneic blood transfusions. Different blood-saving measures (BSMs) were introduced to reduce these transfusions. Purpose of the present study was to assess the frequency of BSM use, stratified by type and hospital setting of orthopaedic departments in the Netherlands. METHODS: An internet-based questionnaire was sent to all heads of orthopaedic departments of Dutch hospitals and private clinics (n = 99). Questions were asked on how often BSMs were used, reported on a 5-point Likert scale (never, almost never, regularly, almost always, always). In addition there were questions about discontinuation of anticoagulants preoperatively, the number of annually performed arthroplasties (size) and hospital setting. RESULTS: The survey was completed by 81 (82%) departments. BSMs used frequently (regularly, almost always, always) were erythropoietine (EPO), with 55 (68%) departments being frequent users; acute normovolemic hemodilution, used frequently in 26 (32%) departments; cell saver in 25 (31%) and postoperative drainage and re-infusion in 56 (69%) departments. When compared by size, frequent EPO use was more common in large departments (with 22 (88%) large departments being frequent users versus 13 (63%) small departments and 16 (55%) intermediate departments, p = 0.03). No differences by size or type were observed for other BSMs.

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Anesthesiologie

CONCLUSIONS: Compared with previous survey’s there is a tremendous increase in use of BSMs. EPO and autologous blood salvage techniques are the most often used modalities. Costs might be saved if use of non-cost-effective BSMs is stopped. PMCID: PMC3750265 PMID: 23915322 [PubMed - indexed for MEDLINE]

Overige publicaties A rare cause of cardiac failure following transthoracic oesophagectomy. Wicherts DA, Hendriks S, Hesp WLEM, Hoeven van JAB, Ponssen HH. The Neth J Crit Care 2013; 17 (1): 30-33.

2-days introduction program Medical doctors in a large teaching hospital in the Netherlands. Koopman AWMM, Kooi GS, Juliana IC. BMJ Quality mei 2013. http://quality.bmj.com/project/876.

Pre-operatie Iron” use as blood sparing technique in orthopaedic surgery (the POP-I-study. Van Nordennen JJ, Koopman-van Gemert AWMM, So-Osman C, Zwaginga JJ and Nelissen RGHH. Vox Sanguinis, Volume 105; Issue Supplement S1, pagina 267.

Post-transfusion red blood cell alloimmunization incidence after a first single routine or extended matched transfusion. Schonewille H, Hudig C, te Boekhorst PA, de Vries RRP, Berendes P, Koopman- van Gemert AWMM and Brand A. Vox Sanguinis, Volume 105; Issue Supplement S1, pagina 267.

Rapid Response Teams: verleden, heden en toekomst. So KL. Anesthesiologie & Intensive Care Nascholingstijdschrift over perioperatieve geneeskunde 2013 vol.3 ; p.13-16.

Bloedtransfusie besparende technieken bij electieve orthopedische chirurgie. Van TOMaat- naar de POP-i- studie. Koopman-van Gemert AWMM, So-Osman C, Nordennen van JJ, . Kuijpers – Visser AG namens de POP-i-studie groep. WASz 2013; 5 (1) : 14-17.

De POP-i-studie gestart! Nordennen van JJ, Koopman-van Gemert AWMM, So-Osman C, Kuijpers – Visser AG namens de POP-i-studie groep. WASz 2013; 5(3): 36-38.

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Early Goal Directed Therapy. Frank M, Postema-van der Heijden B, Kuijpers AG. WASz 2013; 5(3): 8-9.

Lachgas, weer in de mode? Schyns-van den Berg AMJV. Proceedings IGO Doelen Congres 2013, Hoofdstuk 9, Obstetrie perinataal congres 19 april 2013.

Effectiveness of a classroom based Crew Resource Management training in the Intensive Care Unit: a controlled study. Kemper P, Bruyne M de, Dyck C van, So KL, Tangkau P and Wagner C. Nederlandse Vereniging voor Medisch Onderwijs (NVMO), Hotel Zuiderduin,, 7 november 2013, Egmond aan zee.

Boek of hoofdstuk in een boek Klassikale CRM-training, een voorbeeld van de Intensive Care. So KL en Kemper P. In: Kernboek “Medisch teamwork: CRM in de gezondheidszorg” eds: M.C. de Bruijne en F. Bleeker Bohn Stafleu van Loghum 2013; p.73-81 ISBN 9789031398973.

Voordrachten Opeens weer modern, lachgas? Schyns-van den Berg AMJV. ASz Alert Symposium : Rondom de Zwangere patiënt, 19 januari 2013 ASz Dordrecht. Geaccrediteerd door de Koninklijke Nederlandse Organisatie van Verloskundigen (KNOV).

Epiduraal en andere ruggenprikken tijdens partus: verhalen en realiteit. Falieres X. ASz Alert Symposium : Rondom de Zwangere patiënt, 19 januari 2013 ASz Dordrecht. Geaccrediteerd door de Koninklijke Nederlandse Organisatie van Verloskundigen (KNOV).

Fluxus. Koopman-van Gemert AWMM. ASz Alert Symposium : Rondom de Zwangere patiënt, 19 januari 2013 ASz Dordrecht. Geaccrediteerd door de Koninklijke Nederlandse Organisatie van Verloskundigen (KNOV).

Obese Zwangere. Koopman-van Gemert AWMM. ASz Alert Symposium : Rondom de Zwangere patiënt, 19 januari 2013 ASz Dordrecht. Geaccrediteerd door de Koninklijke Nederlandse Organisatie van Verloskundigen (KNOV).

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Anesthesiologie

The White Lung Mystery. Koopman-van Gemert AWMM. Symposium Ten Years of TRIP reporting: results and the future, Museum Volkenkunde Leiden, 19 maart 2013.

Medicamenteuze Opties bij Massaal Bloedverlies. Koopman-van Gemert AWMM. 4e Refresher Course Obstetrische Anesthesie, 28 maart 2013, Faculty Club Leuven.

Resuscitatie tijdens de zwangerschap. Schyns-van den Berg AMJV. 4e Refresher Course Obstetrische Anesthesie, 28 maart 2013, Faculty Club Leuven.

Jehova’s Getuigen. Koopman-van Gemert AWMM. Nationaal Co-assistenten-congres, 13 april 2013, Hotel Kijkduin Egmond aan Zee.

SubQstim for low back pain, technical aspects. Gultuna ECMT. Pain Fundamentals in adults, cadaver workshop for experienced pain physicians, 11-12 april 2013, Brussel.

Veiligheidsinstrumenten in de zorg. So KL. 19e IGO ( Infertiliteit, Gynaecologie en Obstetrie) Doelen Congres Rotterdam 19 april 2013 Keuzeblok Veiligheidsmanagement - iBMG-EUR; 31 mei 2013.

Subcutaneous stimulation as an additional therapy to Spinal Cord Stimulation for the treatment of low back pain and leg pain in Failed Back Surgery Syndrome: four year follow up. Hamm-Faber TE, Aukes JA, Gultuna I. International Neuromodulation Society (INS ) in Berlijn; 8-13 juni 2013.

Toedienen van pre-operatief ijzer: de POP-I studie. Kliniek van Bloedtransfusie. van Nordennen J en Koopman-van Gemert AWMM. Jaarlijks regionaal symposium Sanquin Zuid-West. Faculteit der Geneeskunde EMC, Rotterdam 27 juni 2013.

Post-operative analgesia after C section: parenteral drugs. Schyns-van den Berg AMJV. ESRA annual Congress (European Society for Regional Anesthesia), Glasgow 5-7 september 2013.

Neuraxial blocks in obstetrical Emergencies: is there a role? Schyns-van den Berg AMJV. SRA annual Congress (European Society for Regional Anesthesia), Glasgow 5-7 september 2013.

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General Anesthesia for C section, what’s new? Schyns-van den Berg AMJV. SRA annual Congress (European Society for Regional Anesthesia), Glasgow 5-7 september 2013.

The art of patient selection. Aukes H. ECMT: European Continuing Medical Training Clinical nursing experts meeting in neuro modulation. Venue EHC Hospital De Morges, Morges, Switzerland 5-6 oktober.

Basic principles of Peripheral Nerve Field Stimulation (PFNS). Aukes H. ECMT: European Continuing Medical Training Clinical nursing experts meeting in neuro modulation. Venue EHC Hospital De Morges, Morges, Switzerland. 5- 6 oktober 2013.

Pain management; The role of the nurse within the paindepartment. Hamm-Faber T. ECMT: European Continuing Medical Training Clinical nursing experts meeting in neuromodulation, Venue EHC Hospital De Morges, Morges, Switzerland, 5-6 oktober 2013.

Nurse involved in clinical research. Hamm-Faber T. ECMT: European Continuing Medical Training Clinical nursing experts meeting in neuromodulation Venue EHC Hospital De Morges, Morges, Switzerland 5-6 oktober 2013

Pijnbestrijding bij een sectio. Schyns-van den Berg AMJV. Smiths Medical Symposium: pijnmanagement bij bevalling en sectio: prik, infuus of ruggenprik?, Erasmus MC Rotterdam 24 oktober 2013.

Pijnbestrijding en toepassing van Remifentanil in de verloskamers. Leeuw van der BMF. Smiths Medical Symposium: pijnmanagement bij bevalling en sectio: prik, infuus of ruggenprik? Erasmus MC Rotterdam 24 oktober 2013.

Medisch teamwork - toepassen van Crew Resource Management principes in onderwijs - Ervaringen met TRM op de IC. So KL. Nederlandse Vereniging voor Medisch Onderwijs (NVMO), Hotel Zuiderduin,, 7 november 2013, Egmond aan zee.

Levenslang leren en ontwikkelen door medische professionals: van ‘competentiegericht’ opleiden naar individuele ‘Appraisal and Assessment’. So KL en Vermeer E. Nederlandse Vereniging voor Medisch Onderwijs (NVMO), Hotel Zuiderduin,, 7 november 2013, Egmond aan zee.

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Anesthesiologie

Dossieranalyse als motor voor kwaliteitsverbetering. So KL. Symposium Kwaliteit van ziekenhuiszorg, NVZ/ Orde/ NFU/ DHD, JBZ Den Bosch, 21 november 2013.

Rondom… Workshop luchweg management Obese patiënt. van Barneveld JC. ASz Alert Symposium Luchtwegmanagement, ASz, 14 december 2013, Dordrecht.

Posters The management of critical bleeding events during surgery using Rotem analyses. Koopman - van Gemert AWMM, Ven van de LLM, Ridder de MAJ. 3Th Update in transfusion Congress In Zwolle, 1-2 February 2013.

Un unusual cause of intestinal ischemia. Bosch EJ, Dam van MJ. Intensivistendagen 2013, Ede 13-15 februari 2013.

A 2-days introduction program Medical doctors in a large teaching hospital in the Netherlands. Koopman-van Gemert AWMM, Kooi S, Juliana I. International Quality in Safety and Health Care Congress, 16-19 April 2013, London.

Saving lives by studying the deaths: identify and prioritise hospitalwide interventions by standardized chart review. So KL. International Forum on Quality & Safety in healthcare; London, 17 april 2013.

A comparison of Health-related Quality of Life after Primary Total Hip and Knee Replacement. Keurentjes JC, Vliet Vlieland TPM, So-Osman C, Fiocco M, Pöll RG, Koopman-van Gemert AWMM, Onstenk R, Brand A, Nelissen RGHH. American Academy of Orthopaedic Surgeons - AAOS, 19-22 mei 2013 Illinois, USA.

Little Radiographic Osteoarthritis Lowers Probability of Relevant Improvement in Patient Reported Physical Functioning And General Health in Knee Replacement, but not in Hip Replacement. Keurentjes JC, Fiocco M, So Osman C, Koopman-van Gemert AWMM, Pöll RG, Onstenk R, Kroon HM, Vliet Vlieland TPM, Nelissen RGHH. American Academy of Orthopaedic Surgeons - AAOS, Illinois, 19-22 mei 2013.

Pre-OPerative Iron use as Blood Sparing technique in Orthopaedic Surgery USE (the POP-i-study). Nordennen van JJ, Koopman-van Gemert AWMM, So-Osman C, Zwaginga JJ and Nelissen RGHH (on behalf of the POP-I study group). ISBT Amsterdam 2-4 June 2013.

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Post-transfusion red blood cell alloimmunization incidence after a first single routine or extended matched transfusion. Schonewille H, Hudig C, te Boekhorst PA, de Vries RRP, Berendes P, Koopman- van Gemert AWMM and Brand A. 2-4 June ISBT Amsterdam.

Cost-effectiveness of transfusion alternatives in elective orthopedic surgery: a randomized controlled study on Patient Blood Management. So-Osman C, Nelissen RGHH, Koopman-van Gemert AWMM, Onstenk R, Pöll R, Brand R, Hout van den W and Brand A. EFFORT Congres, 5-8 June 2013, Istanbul.

Subcutaneous stimulation as add on therapy to SCS to treat low back pain in FBSS: A multicenter RCT (SubQ study). Gorp van EJJAA, Gultuna I, Aukes JA, Kallewaard JW, e.a.. International Neuromodulation Society (INS ) in Berlijn; 8-13 juni 2013.

Subcutaneous stimulation as an additional therapy to Spinal Cord Stimulation fort he treatment of low back pain and leg pain in Failed Back Surgery Syndrome. 4 year follow up. Hamm-Faber TE, Aukes JA, Gultuna I. International Neuromodulation Society (INS ), 8-13 juni 2013, Berlijn.

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Anesthesiologie

Cardiologie

Pudmed publicaties Effect of collaterals on deaths and re-infarctions in patients with coronary artery disease: a meta-analysis. Akin S, Yetgin T, Brugts JJ, Dirkali A, Zijlstra F, Cleophas TJ. Neth Heart J. 2013 Mar;21(3):146-51. BACKGROUND: It is generally believed that there is a beneficial effect of collaterals on death and re-infarction statistics in patients with coronary artery disease (CAD) but studies to date are small and inconsistent. OBJECTIVE: To meta-analyse the studies published in this field in order to obtain more powerful information. METHODS: We searched Medline and major journals (2000 to 2011) for studies evaluating the effect of coronary collaterals on mortality. Publication bias, lack of heterogeneity, and lack of robustness were assessed using the standard procedures for such purposes. RESULTS: A total of 10 studies describing mortality, enrolling 6791 participants,were included in this analysis. In patients with collateralisation a significant relation with reduced mortality was seen compared with those without collateralisation, at an odds ratio of 0.47, p < 0.0001, and a reduction in deaths and re-infarctions at 0.54, p < 0.0001. Some publication bias, some heterogeneity and some lack of robustness were demonstrated. A meta-regression with the odds ratios of the presence of traditional atherosclerotic risk factors as predictors and the odds ratios of mortality and the composite deaths and re-infarctions as outcome showed no relationships. CONCLUSIONS: In CAD patients from the post-percutaneous coronary intervention era the presence of collaterals reduced mortality by 0.47 (p < 0.0001) and deaths and re-infarctions by 0.54 (p < 0.0001). Furthermore, in the present meta-data, the atherosclerotic risk factors were no more present in patients with collaterals than they were in those without. PMCID: PMC3578529 PMID: 23208154 [PubMed]

Comparison of 3 biodegradable polymer and durable polymer-based drug- eluting stents in all-comers (BIO-RESORT): Rationale and study design of the randomized TWENTE III multicenter trial. Lam MK, Sen H, Tandjung K, van Houwelingen KG, de Vries AG, Danse PW, Schotborgh CE, Scholte M, Löwik MM, Linssen GC, Ijzerman MJ, van der Palen J, Doggen CJ, von Birgelen C. Am Heart J. 2014 Apr;167(4):445-51. AIM: To evaluate the safety and efficacy of 2 novel drug-eluting stents (DES) with biodegradable polymer-based coatings versus a durable coating DES. METHODS AND RESULTS: BIO-RESORT is an investigator-initiated, prospective, patientblinded, randomized multicenter trial in 3540 Dutch all-comers with various clinical syndromes, requiring percutaneous coronary interventions (PCI) with DES implantation. Random-

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ization (stratified for diabetes mellitus) is being performed in a 1:1:1 ratio between ORSIRO sirolimus-eluting stent with circumferential biodegradable coating, SYNERGY everolimus-eluting stent with abluminal biodegradable coating, and RESOLUTE INTEGRITY zotarolimus-eluting stent with durable coating. The primary endpoint is the incidence of the composite endpoint target vessel failure at 1 year, consisting of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularization. Power calculation assumes a target vessel failure rate of 8.5% with a 3.5% non-inferiority margin, giving the study a power of 85% (α level .025 adjusted for multiple testing). The impact of diabetes mellitus on post-PCI outcome will be evaluated. The first patient was enrolled on December 21, 2012. CONCLUSIONS: BIO-RESORT is a large, prospective, randomized, multicenter trial with three arms, comparing two DES with biodegradable coatings versus a reference DES with a durable coating in 3540 all-comers. The trial will provide novel insights into the clinical outcome of modern DES and will address the impact of known and so far undetected diabetes mellitus on post-PCI outcome. PMID: 24655691 [PubMed - in process]

Current discharge management of acute coronary syndromes: data from the Rijnmond Collective Cardiology Research (CCR) study. Yetgin T, van der Linden MM, de Vries AG, Smits PC, van Mechelen R, Yap SC,Boersma E, Zijlstra F, van Geuns RJ; CCR Study Investigators. Neth Heart J. 2014 Jan;22(1):20-7. doi: 10.1007/s12471-013-0484-x. BACKGROUND: Medical discharge management of acute coronary syndromes (ACS) remains suboptimal outside randomised trials and constitutes an essential quality benchmark for ACS. We sought to evaluate the rates of key guideline-recommended pharmacological agents after ACS and characteristics associated with optimal treatment at discharge. METHODS: The Rijnmond Collective Cardiology Research (CCR) registry is an ongoing prospective, observational study in the Netherlands that aims to enrol 4000 patients with ACS. We examined discharge and 1-month follow-up medication use among the first 1000 patients enrolled in the CCR registry. Logistic regression was performed to identify patient and hospital characteristics associated with collective guideline-recommended pharmacotherapy at hospital discharge. RESULTS: At discharge, 94% of patients received aspirin, 100% thienopyridines, 80% angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers, 87% β-blockers, 96% statins, and 65% the combination of all 5 agents. ST-segment elevation myocardial infarction, hypertension, hypercholesterolaemia, and enrolment in an interventional centre were positive independent predictors of 5-drug combination therapy at discharge. Negative independent predictors were unstable angina and advanced age. CONCLUSION: Current data from the CCR registry reflect a high quality of care for ACS discharge management in the Rotterdam-Rijnmond region. However, potential still remains for further optimisation. PMCID: PMC3890006 PMID: 24155103 [PubMed]

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Kwaliteit, Veiligheid en Innovatie Cardiologie

Echocardiographic features of an atypical presentation of rapidly progressive cardiac amyloidosis. Brugts JJ, Houtgraaf J, Hazenberg BP, Kofflard MJ. World J Cardiol. 2013 May 26;5(5):154-6. doi: 10.4330/wjc.v5.i5.154. We present the case of a 66 year old male who presented with dyspnea and reduced exercise tolerance. Echocardiography demonstrated impaired left ventricular (LV) function and restrictive diastolic function with pronounced concentric left ventricular hypertrophy (LVH) without a history of hypertension and no aortic valve stenosis. Differential diagnostics of concentric LVH are discussed in detail. In the current case, cardiac amyloidosis (AL) amyloidosis was diagnosed and confirmed by serum amyloid P (SAP) scintigraphy and abdominal fat aspiration biopsy. This case shows the rapid decline in clinical condition with progression of cardiac involvement of AL. As discussed in detail, cardiac involvement in AL-amyloidosis generally denotes a poor prognosis, regardless of the method of treatment. PMCID: PMC3663131 PMID: 23710304 [PubMed]

Sexuality of patients with chronic heart failure and their spouses and the need for information regarding sexuality. Driel AG, de Hosson MJ, Gamel C. Eur J Cardiovasc Nurs. 2013 Apr 10. [Epub ahead of print] BACKGROUND: Psychological and physiological effects of chronic heart failure (CHF) can influence sexuality. Both CHF patients and their partners may experience changes and have questions about sexuality. Despite this, healthcare professionals give little information regarding sexuality. This may be due to the paucity of literature describing patients’ concerns and questions about sexuality and CHF. AIMS: The aims of this study were to describe the sexuality of patients and their partners and to describe their needs for information regarding sexuality. METHODS: A prospective, descriptive cross-sectional design was used. A convenience sample was obtained in three hospitals (Belgian and the Netherlands). Patients and partners completed two questionnaires: Sexual Adjustment Scale (SAS) and the Needs of Sexual Counseling Scale for Chronic Heart Failure (NSCS-CHF). RESULTS: There were 52 patients and 32 partners who participated in the study. No or slight disturbance was seen in sexual discussions and intimacy. Marked or serious disturbance was reported in sexual activity. A mixed profile was seen in sexual performance, sexual interest and sexual pleasure. The majority of patients with CHF and their partners want information regarding sexuality. The NSCS-CHF clearly identified the information needs of patients and partners and most needs concerned the areas of symptoms, the relationship and relaxation. CONCLUSION: The questionnaires were easy to complete and changes in sexuality and information needs were identified. The NSCS-CHF needs further validation as a research instrument. Healthcare professionals can use both questionnaires to bring up the topic of sexuality and to identify topics that require further discussion or counselling with patients and partners. PMID: 23575920 [PubMed - as supplied by publisher]

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Cardiac metastasis of malignant melanoma: a case report. Aerts BR, Kock MC, Kofflard MJ, Plaisier PW. Neth Heart J. 2014 Jan;22(1):39-41. doi: 10.1007/s12471-013-0441-8. The heart is regularly involved in metastatic neoplasms with cardiac metastases being found in up to 20% of autopsies. We present a case about a 42-year-old Caucasian female with a fatal metastatic melanoma to the heart. The five- year survival rate for stage IV melanoma (melanoma with metastases to other organs) is 15 to 20%. If patients with malignant melanoma present with new onset of cardiac symptoms, clinicians should always be aware of the possibility of cardiac metastases and perform further investigations. PMCID: PMC3890009 PMID: 23821495 [PubMed]

Obstructive cardiac tumour perfused by large vascular network from right coronary artery. Brugts JJ, Liesting C, van Woerkens L, Kofflard MJ. Arch Cardiovasc Dis. 2013 Mar;106(3):178-9. doi:10.1016/j.acvd.2011.09.009. PMID: 23582680 [PubMed - indexed for MEDLINE]

Overige publicaties TCT-22 The STENTYS Self-Expanding Drug-Eluting Stent in Coronary Bifurcation Lesions at 6 Months Follow-up: Results from the OPEN II Trial. Naber C, Nef H, Külekçi K, et al. J Am Coll Cardiol. 2013;62(18_S1):B8-B9. doi:10.1016/j.jacc.2013.08.751.

Elevated highly-sensitive cardiac Troponin T is associated with hypertrophy and fibrosis in patients with hypertrophic cardiomyopathy. Gommans DHF, Cramer GE, Bakker J, Fouraux MA, Verheugt FWA, Brouwer MA, Kofflard MJM. Neth Heart J 2013;21 (Suppl):12.

ABC van de cardiologie: inleiding in de diagnostiek en behandeling van hartziekten – Recencsie publicatie. van Driel AG. Cordiaal – Vol. 34, nr 2 (Mei 2013); p. 62-63.

Patiëntveiligheid en cardiologische zorg – Verslag Advies. van Driel AG. Cordiaal – Vol. 34, nr 1 (Maart 2013); p. 30-31.

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Cardiologie

Voordrachten In hypertrophic cardiomyopathy the presence of edema is associated with a more advanced stage of disease. Gommans DHF, Cramer GE, Bakker J, Fouraux MA, Michels M, ten Cate FJ, Verheugt FWA, Brouwer MA, Kofflard MJM. AHA scientific sessions 2013, Dallas.

Hypertrofe obstructieve cardiomyopathie. Kofflard MJM. Congres van de Nederlandse Hartfunctie Vereniging, De Reehorst, Ede 20 april 2013. Geaccrediteerd voor hartfunctie laboranten.

Posters Elevated high-sensitivity cardiac troponin is associated with hypertrophy and fibrosis assessed with CMR in patients with hypertrophic cardiomyopathy. Gommans DHF, Bakker J, Cramer GE, Fouraux MA, Kurvers MJ, Verheugt FWA, Brouwer MA, Kofflard MJM. SCMR scientific sessions 2013, San Francisco and moderated poster presentation at scientific sessions of Albert Schweitzer Hospital, Dordrecht 2013.

Stress-induced troponin rise in patients with hypertrophic cardiomyopathy: associations with sarcomere mutation and MRI characteristics. Cramer GE, Gommans DHF, Michels M, Fouraux M, Bakker J, Verheugt FWA, ten Cate FJ, Brouwer MA, Kofflard MJM. European Muscle conference 2013, Amsterdam.

Empowerment of nurses in hospital policy by implementation of a nursing advisory board. van Driel AG. International Forum on Quality and Safety in Healtcare – London 16th – 19th April.

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Chirurgie

PubMed publicaties Clinical studies on intra-abdominal hypertension and abdominal compartment syndrome. Atema JJ, van Buijtenen JM, Lamme B, Boermeester MA. J Trauma Acute Care Surg. 2014 Jan;76(1):234-40. PMID: 24368386 [PubMed - indexed for MEDLINE]

Parastomal hernia is an independent risk factor for incisional hernia in patients with end colostomy. Timmermans L, Deerenberg EB, Lamme B, Jeekel J, Lange JF. Surgery. 2014 Jan;155(1):178-83. doi: 10.1016/j.surg.2013.06.014. Epub 2013 Nov 12. BACKGROUND: Incisional hernia (IH) is the most frequent complication after abdominal operation, with an incidence of 11-20% and up to 35% in risk groups. Known risk groups for IH are abdominal aortic aneurysm and obesity. Our hypothesis is that parastomal hernia (PH) might also represent a risk factor for developing IH. Identifying risk factors can help determine the need for preventive measures such as primary mesh augmentation. METHODS: In a multicenter cross-sectional study, all patients who were operated between 2002 and 2010 by means of a Hartmann procedure or abdominoperineal resection were invited for a follow-up visit to our outpatient clinic. Primary outcome measures were the prevalence of IH and PH. All possible risk factors for IH were scored. A physical examination was performed and, when available, computed tomography was scored for IH and PH. RESULTS: A total of 150 patients were seen in the outpatient clinic. The median follow-up was 49 months (range, 30-75). IH had a prevalence of 37.1%, and PH had a prevalence of 52.3% during physical examination. On CT the prevalence was even greater, ie, 48.3% and 52.9%. IH and PH were both present in the same patient in 30% of all examined and in 35.6% after CT examination. PH was found to be a risk factor for IH on univariate and multivariate logistic regression analyses of variance, with an odds ratio of 7.2 (95% confidence interval 3.3-15.7). In addition, an emergency operation was found to be a risk factor for IH with an odds ratio of 5.8 in the multivariate analyses. CONCLUSION: Patients with a PH have a 7 times greater chance of developing an IH compared to patients without PH. PMID: 24238119 [PubMed - in process]

Adductor longus tendon rupture mistaken for incarcerated inguinal hernia. Aerts BR, Plaisier PW, Jakma TS. Injury. 2014 Mar;45(3):639-41. doi: 10.1016/j.injury.2013.10.049. Epub 2013 Nov 12.

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Chirurgie

An incarcerated inguinal hernia is a common diagnosis, since the risk of an inguinal hernia incarcerating or strangulating is around 0.3-3%. An acute rupture of the adductor longus tendon is rarely seen and mostly affects (semi-) professional sportsmen. We present a case of a patient with an assumed incarcerated inguinal hernia which turned out to be a proximal adductor longus tendon rupture. If patients without a history of inguinal hernia present themselves with acute groin pain after suddenly exorotating the upper leg, a rupture of the adductor longus tendon should be considered. Both surgical and non-surgical treatment can be performed. PMID: 24360075 [PubMed - in process]

Laparoscopic and open subtotal colectomies have similar short-term results. Hoogenboom FJ, Bosker RJ, Groen H, Meijerink WJ, Lamme B, Pierie JP. Dig Surg. 2013;30(4-6):265-9. doi: 10.1159/000353132. Epub 2013 Aug 20. Comment in Dig Surg. 2013;30(4-6):270-1. BACKGROUND: Laparoscopic subtotal colectomy (STC) is a complex procedure. It is possible that short-term benefits for segmental resections cannot be attributed to this complex procedure. This study aims to assess differences in short-term results for laparoscopic versus open STC during a 15-year single-institute experience. METHODS: We reviewed consecutive patients undergoing laparoscopic or open elective or subacute STC from January 1997 to December 2012. RESULTS: Fifty-six laparoscopic and 50 open STCs were performed. The operation time was significantly longer in the laparoscopic group, median 266 min (range 121-420 min), compared to 153 min (range 90-408 min) in the open group (p < 0.001). Median hospital stay showed no statistical difference, 14 days (range 1-129 days) in the laparoscopic and 13 days (range 1-85 days) in the open group. Between-group postoperative complications were not statistically different. CONCLUSIONS: Laparoscopic STC has short-term results similar to the open procedure, except for a longer operation time. The laparoscopic approach for STC is therefore only advisable in selected patients combined with extensive preoperative counseling. PMID: 23970165 [PubMed - in process]


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Substantial breast cancer risk reduction and potential survival benefit after bilateral mastectomy when compared with surveillance in healthy BRCA1 and BRCA2 mutation carriers: a prospective analysis. Heemskerk-Gerritsen BA, Menke-Pluijmers MB, Jager A, Tilanus-Linthorst MM,Koppert LB, Obdeijn IM, van Deurzen CH, Collée JM, Seynaeve C, Hooning MJ. Ann Oncol. 2013 Aug;24(8):2029-35. doi: 10.1093/annonc/mdt134. Epub 2013 Apr 10. BACKGROUND: To prospectively assess the efficacy of bilateral risk-reducing mastectomy (BRRM) when compared with surveillance on breast cancer (BC) risk and mortality in healthy BRCA1 and BRCA2 mutation carriers. PATIENTS AND METHODS: Five hundred and seventy healthy female mutation carriers (405 BRCA1, 165 BRCA2) were selected from the institutional Family Cancer Clinic database. Eventually, 156 BRCA1 and 56 BRCA2 mutation carriers underwent BRRM. The effect of BRRM versus surveillance was estimated using Cox models. RESULTS: During 2037 person-years of observation (PYO), 57 BC cases occurred in the surveillance group versus zero cases during 1379 PYO in the BRRM group (incidence rates, 28 and 0 per 1000 PYO, respectively). In the surveillance group, four women died of BC, while one woman in the BRRM group presented with metastatic BC 3.5 years after BRRM (no primary BC), and died afterward, yielding a HR of 0.29 (95% CI 0.02-2.61) for BC-specific mortality. CONCLUSIONS: In healthy BRCA1/2 mutation carriers, BRRM when compared with surveillance reduces BC risk substantially, while longer follow-up is warranted to confirm survival benefits. PMID: 23576707 [PubMed - indexed for MEDLINE]

Randomized trial of Legflow(®) paclitaxel eluting balloon and stenting versus standard percutaneous transluminal angioplasty and stenting for the treatment of intermediate and long lesions of the superficial femoral artery (RAPID trial): study protocol for a randomized controlled trial. Karimi A, de Boer SW, van den Heuvel DA, Fioole B, Vroegindeweij D, Heyligers JM, Lohle PN, Elgersma O, Nolthenius RP, Vos JA, de Vries JP. Trials. 2013 Mar 28;14:87. BACKGROUND: Restenosis after percutaneous transluminal angioplasty (PTA) of the super ficial femoral artery (SFA) may occur in 45% of patients at 2 years follow-up. Paclitaxel-coated balloons have been found to reduce neointimal hyperplasia, and thus reduce restenosis. Recently, the Legflow(®)paclitaxel-coated balloon (Cardionovum Sp.z.o.o., Warsaw, Poland) (LPEB) has been introduced. This balloon is covered with shellac, a Food and Drug Administration (FDA) approved natural resin, to obtain an equally distributed tissue concentration of paclitaxel. The RAPID trial is designed to assess restenosis after PTA using the Legflow balloon combined with nitinol stenting versus uncoated balloons with nitinol stenting in SFA lesions >5 cm. METHODS/DESIGN: A total of 176 adult patients with Rutherford class 2 to class 6 symptoms due to intermediate (5-15 cm) or long (>15 cm) atherosclerotic lesions in the SFA will be randomly allocated for treatment with LPEB with nitinol stenting or uncoated balloon angioplasty with stenting. Stenting will be performed using the Supera(®) stent in both groups (IDEV Technologies Inc., Webster, TX). The primary endpoint is the absence of binary restenosis of the treated SFA segment. Secondary outcomes are target lesion revascularization

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Chirurgie

(TLR), clinical and hemodynamic outcome, amputation rate, mortality rate, adverse events, and device-specific adverse events. Follow up consists of four visits in which ankle-brachial indices (ABI), toe pressure measurements, and duplex ultrasound (DUS) will be performed. Furthermore, a peripheral artery questionnaire (PAQ) will be completed by the patients at each follow-up. In the event that DUS reveals a symptomatic >50% restenosis, or a >75% asymptomatic restenosis, additional digital subtraction angiography will be performed with any necessary re-intervention. DISCUSSION: The RAPID trial is a multicenter randomized controlled patient blind trial that will provide evidence concerning whether the use of the Legflow paclitaxel/shellac coated balloons with nitinol stenting significantly reduces the frequency of restenosis in intermediate and long SFA lesions compared to standard PTA and stenting. TRIAL REGISTRATION: ISRCTN47846578. PMCID: PMC3651710 PMID: 23537403 [PubMed - in process]

Comparison of extended hemicolectomy versus transverse colectomy in patients with cancer of the transverse colon. van Rongen I, Damhuis RA, van der Hoeven JA, Plaisier PW. Acta Chir Belg. 2013 Mar-Apr;113(2):107-11. BACKGROUND: Cancer of the transverse colon is rare and postoperative mortality tends to be high. Standard surgical treatment involves either extended hemicolectomy or transverse colectomy, depending on the location of the tumour. The aim of the present study was to compare postoperative mortality and five-year survival between these types of surgery. METHODS: For this observational study, data on patients with a tumour of the transverse colon, treated by open resection in the Dordrecht Hospital from 1989 through 2003, were derived from the database of the regional cancer registry. Information on type of resection, tumour stage, complications, postoperative mortality (30-day) and survival was abstracted from the medical files. Patients with multi-organ surgery, (sub)total colectomy or stage IV disease were excluded from the analysis, leaving a total series of 103 patients. RESULTS: Transverse colectomy comprised one third of operations, predominantly involving partial resections. Postoperative mortality was 6% (2/34) after transverse colectomy and 7% (5/69) after extended hemicolectomy. Five-year survival was slightly higher for the hemico lectomy group (61% versus 50%), but this difference did not reach statistical significance (p = 0.34). CONCLUSION: Our results confirm the high postoperative risk after surgery for cancer of the transverse colon and show that this risk does not depend on the type of surgery. Considering the satisfactory results after partial transverse colectomy, segmental resections may be considered as an option for the treatment of localised tumours of the transverse colon. PMID: 23741929 [PubMed - indexed for MEDLINE]

Body image issues after bilateral prophylactic mastectomy with breast reconstruction in healthy women at risk for hereditary breast cancer. Gopie JP, Mureau MA, Seynaeve C, Ter Kuile MM, Menke-Pluymers MB, Timman R,Tibben A. Fam Cancer. 2013 Sep;12(3):479-87. doi: 10.1007/s10689-012-9588-5. The outcome of bilateral prophylactic mastectomy with breast reconstruction (BPM-IBR) in

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healthy BRCA1/2 mutation carriers can be potentially burdensome for body image and the intimate relationship. Therefore, in the current analysis the impact on body image, sexual and partner relationship satisfaction was prospectively investigated in women opting for BPM-IBR as well as cancer distress and general quality of life. Healthy women undergoing BPM-IBR completed questionnaires preoperatively (T0, n = 48), at 6 months (T1, n = 44) and after finishing breast reconstruction (median 21 months, range 12-35) (T2, n = 36). With multi-level regression analyses the course of outcome variables was investigated and a statistically significant change in body image and/or sexual and partner relationship satisfaction was predicted by baseline covariates. Body image significantly decreased at T1. At T2 sexual relationship satisfaction and body image tended to be lower compared to baseline. The overall partner relationship satisfaction did not significantly change. At T2, 37% of the women reported that their breasts felt unpleasantly, 29% was not satisfied with their breast appearance and 21% felt embarrassed for their naked body. Most body image issues remained unchanged in 30% of the women. A negative body image was predicted by high preoperative cancer distress. BPM-IBR was associated with adverse impact on body image in a substantial subgroup, but satisfaction with the overall sexual and partner relationship did not significantly change in time. The psychosocial impact of BPM-IBR in unaffected women should not be underestimated. Psychological support should ideally be integrated both before and after BPM-IBR. PMID: 23224779 [PubMed - in process]

Long-term psychological distress in women at risk for hereditary breast cancer adhering to regular surveillance: a risk profile. den Heijer M, Seynaeve C, Vanheusden K, Timman R, Duivenvoorden HJ, Tilanus-Linthorst M, Menke-Pluijmers MB, Tibben A. Psychooncology. 2013 Mar;22(3):598-604. doi: 10.1002/pon.3039. BACKGROUND: Some women at risk for hereditary breast cancer are at increased risk of psychological distress. In order to tailor support for individual women, the availability of a tool enabling the identification of psychologically vulnerable women at an early stage is warranted. The objectives of this study were (1) to explore long-term psychological distress in women at risk for hereditary breast cancer adhering to regular surveillance, and (2) to identify women being vulnerable for long-term psychological distress, defined in terms of a multifactorial risk profile. METHODS: General distress and cancer-related distress were assessed at baseline (T0) and after 5-8 years (T1) in 197 high-risk women adhering to breast cancer surveillance. Coping styles, occurrence of breast cancer in the family of origin, breast cancer risk perception, and frequency of breast self-examination, as assessed at T0, were examined as predictor variables for long-term distress (T1). RESULTS: Across time, women reported a significant reduction in intrusion and avoidance. Intrusion levels were increased among women who had lost a first-degree relative to breast cancer. Predictors of increased long-term distress were passive and palliative coping styles, excessive breast self-examination, and overestimation of breast cancer risk. On the other hand, coping through fostering reassuring thoughts was predictive for decreased long-term distress. CONCLUSION: On the basis of the identified risk profile, it is possible to identify vulnerable women at an early stage, who then may be offered additional and individually tailored support. PMID: 22315183 [PubMed - indexed for MEDLINE]

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Chirurgie

Do screen-detected breast cancers have positive margins less often than clinically detected breast cancers? de Munck L, Siesling S, Bart J, Menke-Pluijmers MB, Otter R, Willemse PH. Eur J Cancer Prev. 2013 Sep;22(5):398-403. doi:10.1097/CEJ.0b013e32835f3b70. Positive tumour margins after breast-conserving surgery (BCS) have been selected as one of the major quality criteria for the surgical treatment of localized primary breast cancer. The national guideline states that the rate of positive margins should not exceed 30% in ductal carcinoma in situ and 20% in invasive cancers. We aimed to determine whether BCS in women with screen-detected breast cancer (SDBC) will have positive margins less often compared with women with clinically detected breast cancer (CDBC). Furthermore, the choice of subsequent therapy is studied when margins were positive after initial BCS. Women 50-75 years of age who underwent BCS for invasive breast cancer between July 2008 and December 2009 were selected from the Netherlands Cancer Registry. Data were merged with the National Cancer Screening Program, regions North and East, to identify women with SDBC. The relation to screening history, clinical and pathological factors was evaluated for correlation with margin status using multilevel analysis. Of 1537 women with an invasive breast cancer, 873 (57%) were diagnosed through the screening programme. SDBCs were significantly smaller (87 vs. 69% T1 tumours, i.e. ≤2 cm), more often well differentiated (33 vs. 26%), preoperatively confirmed (98 vs. 96%), diagnosed in a nonteaching hospital (60 vs. 66%) and more often had negative lymph nodes (LNs) (80 vs. 68%). In 170 out of 1537 women, the resection margins were positive. Multivariable analysis showed that hospital, tumour size, multifocality, positive LNs and absent preoperative confirmation were predictors of positive margins. No difference was found between women with SDBC and CDBC. Of women with positive margins, 90% underwent additional surgery. Women diagnosed with SDBC do not have a lower risk of having positive margins after BCS than women with CDBC. Although positive margins may occur in 11% of women with invasive tumours, well below the percentage recommended by the national guideline, the presence of encouraging factors by SDBC such as a smaller tumour size, unifocality, negative LNs and the presence of preoperative confirmation should not lead to performing a more sparing excision than is considered usual for comparable CDBC. PMID: 23492953 [PubMed - indexed for MEDLINE]

Preoperative breast MRI can reduce the rate of tumor-positive resection margins and reoperations in patients undergoing breast-conserving surgery. Obdeijn IM, Tilanus-Linthorst MM, Spronk S, van Deurzen CH, de Monye C, Hunink MG, Menke MB. AJR Am J Roentgenol. 2013 Feb;200(2):304-10. doi: 10.2214/AJR.12.9185. OBJECTIVE: In breast cancer patients eligible for breast-conserving surgery, we evaluated whether the information provided by preoperative MRI of the breast would result in fewer tumor-positive resection margins and fewer reoperations. SUBJECTS AND METHODS: The study group consisted of 123 consecutive patients diagnosed with either breast cancer or ductal carcinoma in situ eligible for breast-conserving surgery between April 2007 and July 2010. For these patients, a first plan for breast-conserving surgery was made on the basis of clinical examination and conventional imaging. The final surgical plan was made with knowledge of the preoperative breast MRI. The rates of tumor-positive resection margins and reoperations were compared with those of a historical

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control group consisting of 119 patients who underwent 123 breast-conserving procedures between January 2005 and December 2006. The percentage of change in the surgical plan was recorded. RESULTS: Preoperative breast MRI changed the surgical plan to more extensive surgery in 42 patients (34.1%), mainly to mastectomy (29 patients, 23.6%). Ninety-four patients underwent 95 breast-conserving procedures. Significantly fewer patients had tumor-positive resection margins than in the control group (15.8%, 15/95 versus 29.3%, 36/123; p < 0.01). Patients in the study group underwent significantly fewer reoperations compared with the historical control group (18.9%, 18/95 vs 37.4%, 46/123; p < 0.01). CONCLUSION: Preoperative breast MRI can substantially decrease the rate of tumor-positive resection margins and reoperations in breast cancer patients eligible for breast-conserving surgery. PMID: 23345350 [PubMed - indexed for MEDLINE]

Models predicting non-sentinel node involvement also predict for regional recurrence in breast cancer patients without axillary treatment. Pepels MJ, Vestjens JH, de Boer M, Bult P, Van Dijck JA, Menke-Pluijmers M,van Diest PJ, Borm G, Tjan-Heijnen VC. Eur J Surg Oncol. 2013 Dec;39(12):1351-7. doi: 10.1016/j.ejso.2013.09.006. Epub 2013 Oct 2. BACKGROUND: Non-SN prediction models are frequently used in clinical decision making to identify patients that may not need axillary treatment, but these models still need to be validated by follow-up data. Our purpose was the validation of non-sentinel node (SN) prediction models in predicting regional recurrences in patients without axillary treatment. METHODS: We followed a cohort of 486 women with favorable primary tumor characteristics and pN0(i+)(sn) or pN1mi(sn) for median 4.5 years. None of the patients underwent axillary treatment. Based on four published non-SN prediction models, the threshold allowing separation into low versus high-risk on non-SN involvement was set at 10%. RESULTS: Overall 5-year regional recurrence rate was 3.0% (SE, ±0.1%). Using the Tenon scoring system, 438 low-risk patients had a 5-year regional recurrence rate of 2.3% (±0.8%), and 48 high-risk patients a recurrence rate of 10.1% (±0.4%). The MSKCC nomogram identified 300 low-risk patients with a recurrence rate of 2.8% (±1.1%), versus 166 high-risk patients with a rate of 3.4% (±0.5%) (20 patients not assessable). The Stanford nomogram identified 21 high-risk patients without recurrence, and 465 low-risk patients with a 3.2% (±0.9%) recurrence rate. A Dutch model discriminated between 384 low-risk patients with a recurrence rate of 2.2% (±0.8%) and 102 high-risk patients with a rate of 6.3% (±2.9%). CONCLUSION: The Tenon scoring system outperformed the other models as it identified the largest subgroup of patients with low recurrence rate. In patients resembling our cohort we would recommend axillary treatment if they had a Tenon score above 3.5. PMID: 24135686 [PubMed - indexed for MEDLINE]

The risk of primary and contralateral breast cancer after ovarian cancer in BRCA1/BRCA2 mutation carriers: Implications for counseling. Vencken PM, Kriege M, Hooning M, Menke-Pluymers MB, Heemskerk-Gerritsen BA, van Doorn LC, Collée MM, Jager A, van Montfort C, Burger CW, Seynaeve C. Cancer. 2013 Mar 1;119(5):955-62. doi: 10.1002/cncr.27839.

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BACKGROUND: The objective of this study was to assess the incidence of primary breast cancer (PBC) and contralateral breast cancer (CBC) in patients who had BRCA1/BRCA2-associated epithelial ovarian cancer (OC). METHODS: From the database of the Rotterdam Family Cancer Clinic, patients who had BRCA-associated OC without a history of unilateral breast cancer (BC) (at risk of PBC; n = 79) or with a history of unilateral BC (at risk of CBC; n = 37) were selected. The control groups consisted of unaffected BRCA mutation carriers (n = 351) or mutation carriers who had a previous unilateral BC (n = 294), respectively. The risks of PBC and CBC were calculated using the Kaplan-Meier survival method with death considered as a competing risk event. RESULTS: Women with BRCA-associated OC had lower 2-year, 5-year, and 10-year risks of PBC (3%, 6%, and 11%, respectively) compared with unaffected mutation carriers (6%, 16%, and 28%, respectively; P = .03), although they had a considerably higher mortality rate at similar time points (13%, 33%, and 61%, respectively, vs 1%, 2%, and 2%, respectively; P < .001). In BRCA mutation carriers with a previous unilateral BC, the 2-year, 5-year, and 10-year risks of CBC were nonsignificantly lower in patients with OC than in those without OC (0%, 7%, and 7%, respectively, vs 6%, 16%, and 34%, respectively; P = .06), whereas the mortality rate was higher in patients with OC (19%, 34%, and 55%, respectively, vs 4%, 11%, and 21%, respectively; P < .001). CONCLUSIONS: Patients with BRCA-associated OC had a lower risk of developing a sub sequent PBC or CBC than mutation carriers without OC, whereas the risk of dying from OC was greater than the risk of developing BC. These data may facilitate more tailored counseling for this patient subgroup, although confirmative studies are warranted. PMID: 23165859 [PubMed - indexed for MEDLINE]

Effectiveness of a hospital-based work support intervention for female cancer patients - a multi-centre randomised controlled trial. Tamminga SJ, Verbeek JH, Bos MM, Fons G, Kitzen JJ, Plaisier PW, Frings-Dresen MH, de Boer AG. PLoS One. 2013 May 22;8(5):e63271. doi: 10.1371/journal.pone.0063271. Print 2013. OBJECTIVE: One key aspect of cancer survivorship is return-to-work. Unfortunately, many cancer survivors face problems upon their return-to-work. For that reason, we developed a hospital-based work support intervention aimed at enhancing return-to-work. We studied effectiveness of the intervention compared to usual care for female cancer patients in a multi-centre randomised controlled trial. METHODS: Breast and gynaecological cancer patients who were treated with curative intent and had paid work were randomised to the intervention group (n = 65) or control group (n = 68). The intervention involved patient education and support at the hospital and improvement of communication between treating and occupational physicians. In addition, we asked patient’s occupational physician to organise a meeting with the patient and the supervisor to make a concrete gradual return-to-work plan. Outcomes at 12 months of follow-up included rate and time until return-to-work (full or partial), quality of life, work ability, work functioning, and lost productivity costs. Time until return-to-work was analyzed with Kaplan-Meier survival analysis. RESULTS: Return-to-work rates were 86% and 83% (p = 0.6) for the intervention group and control group when excluding 8 patients who died or with a life expectancy of months at follow-up. Median time from initial sick leave to partial return-to-work was 194 days (range 14-435) versus 192 days (range 82-465) (p = 0.90) with a hazard ratio of 1.03 (95% CI 0.64-

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1.6). Quality of life and work ability improved statistically over time but did not differ statistically between groups. Work functioning and costs did not differ statistically between groups. CONCLUSION: The intervention was easily implemented into usual psycho-oncological care and showed high return-to-work rates. We failed to show any differences between groups on return-to-work outcomes and quality of life scores. Further research is needed to study which aspects of the intervention are useful and which elements need improvement. TRIAL REGISTRATION: Nederlands Trial Register (NTR) 1658. PMCID: PMC3661555 PMID: 23717406 [PubMed - indexed for MEDLINE]

Collaborative authorship Validation of three models predicting in-hospital death in patients with an abdominal aortic aneurysm eligible for both endovascular and open repair. van Beek SC, Blankensteijn JD, Balm R; Dutch Randomised Endovascular Aneurysm Management (DREAM) trial collaborators. … Nolthenius RP… J Vasc Surg. 2013 Dec;58(6):1452-1457.e1. doi: 10.1016/j.jvs.2013.05.104. Epub 2013 Jul 21. Comment in J Vasc Surg. 2013 Dec;58(6):1743-4. OBJECTIVE: The Medicare, the Vascular Governance North West (VGNW), and the British Aneurysm Repair (BAR) models can be used to predict in-hospital death after an intervention for an asymptomatic abdominal aortic aneurysm (AAA). Validation of these models in patients with suitable aortic anatomy for endovascular repair and a general condition fit for open repair is lacking. We validated the Medicare, VGNW, and BAR models in patients from a randomized controlled trial comparing open and endovascular AAA repair. METHODS: A per-protocol analysis was done of 345 Dutch and Belgian patients with in-hospital death as the primary end point. The prediction models were validated taking into account discrimination (the ability to distinguish between death and survival) and calibration (the agreement between predicted and observed death rates). Discrimination was assessed using the area under the receiver-operating characteristics curve (AUC). An AUC >0.70 was considered to be sufficiently accurate. C alibration was assessed using the Hosmer-Lemeshow (HL) test, and P >.05 was considered to be sufficiently accurate. RESULTS: The AUC was 0.77 (95% confidence interval [CI], 0.64-0.90; HL test, P = .52) for the Medicare model, 0.88 (95% CI, 0.81-0.95; HL test, P = .31) for the VGNW model, and 0.79 (95% CI, 0.67-0.91; HL test, P = .15) for the BAR model. CONCLUSIONS: In AAA patients eligible for endovascular and open repair, the predictions of in-hospital death by the Medicare, VGNW, and BAR models were sufficiently accurate. Therefore, these models can be used to support deciding between endovascular and open repair. PMID: 23880548 [PubMed - indexed for MEDLINE]

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Overige publicaties More adverse events than expected in the outcome after use of the reamer-irrigator-aspirator. Jakma TSC, Röling MA, Punt B, Reynders-Frederix P. European Journal of Trauma and Emergency Surgery 10.1007/s00068-013-0345-8.

Sportletsels van de hand en pols, een overzicht. Aerts BRJ, Beumer A. Ned Tijdschr Handther 2013;22:3-7.

Mallet thumb: Report of a case. Aerts BRJ, Somford MP, Beumer A. OA Case Reports 2013;2:156.

Wat gebeurt er met het advies van de multidisciplinaire oncologiebespreking? Bakker WM, van Bruggen VEA, Eskens FALM, Mens JW, de Bruin G, Plaisier PW. Ned Tijdschr Oncol 2013;10:267-71.

The impact of metformin use on survival after surgery for non-small cell lung cancer. Hoekstra L, Plaisier PW, Schütte PR, Schnater JM, Damhuis R. Interact CardioVasc Thorac Surg 2013;17(suppl 1): S1-62. (doi:10.1093/icvts/ivt288.80)

A rare cause of cardiac failure following transthoracic esophagectomy. Wicherts DA, Hendriks S, Hesp WLEM, van der Hoeven JAB, Ponssen HH. Neth J Crit Care 2013;17:29-31.

Patiëntveiligheid: noodzakelijke cultuuromslag vereist medisch leiderschap. Plaisier PW, Akkersdijk GJM, Busch ORC. Ned Tijdschr Heelkd 2013; 22:22-4.

Mammacarcinoom. Raatgever AM, Plaisier PW, de Gooyer DJ. BijZijn-XL 2013;5:18-32.

Boek of hoofdstuk in een boek Borstkanker. Raatgever AM, Plaisier PW, de Gooyer DJ. In: van Spil JA, van Muilekom HAM, van de Walle – van de Geijn BFH. (red). Oncologie: handboek voor verpleegkundigen en andere hulpverleners. Houten: Bohn Stafleu Van Loghum; 2013.

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Voordrachten Sportletsels van de hand, pols en elleboog. Aerts BRJ, Beumer A. Voorjaarssymposium NGH, Breukelen, Mei 2013. Geaccrediteerd door Nederlands Gezelschap voor Handtherapie.

Fracturen van de proximale epifyse van de tibia bij kinderen. Aerts BRJ, Jakma TSC, Punt BJ ZWOT Rotterdam, november 2013.

Evaluatie van fertiliteitsparameters bij mannen met verworven niet-scrotale testes: een lange termijn onderzoek. van Brakel J, de Muink Keizer-Schrama SMPF, Dohle GR, Hazebroek FWJ. Chirurgendagen, Nederlandse Vereniging voor Heelkunde, Veldhoven, Mei 2013 Geaccrediteerd door Nederlandse Vereniging voor Heelkunde.

Geen MRI maken bij bloederige tepeluitvloed indien conventionele diagnostiek niet afwijkend is! van Gelder L, Pennings JP, Menke-Pluijmers MBE, Bisschops RHC, Plaisier PW. Chirurgendagen, Nederlandse Vereniging voor Heelkunde, Veldhoven, Mei 2013 Geaccrediteerd door Nederlandse Vereniging voor Heelkunde.

Preoperatieve MRI voor lobulair carcinoom: nuttig? Pennings JP, van Gelder L, Storm RK, Rozendaal R, Plaisier PW, Bisschops RHC. Chirurgendagen, Nederlandse Vereniging voor Heelkunde, Veldhoven, Mei 2013 Geaccrediteerd door Nederlandse Vereniging voor Heelkunde.

Een tijdelijk ileostoma: meer dan de helft van de patiënten heeft complicaties. van Gelder L, Sier MF, Lamme B, Ubbink DT, Oostenbroek RJ. Chirurgendagen, Nederlandse Vereniging voor Heelkunde, Veldhoven, Mei 2013 Geaccrediteerd door Nederlandse Vereniging voor Heelkunde.

Een tijdelijk ileostoma: wanneer “even opheffen”? Sier MF, van Gelder L, Lamme B, Ubbink DT, Oostenbroek RJ. Chirurgendagen, Nederlandse Vereniging voor Heelkunde, Veldhoven, Mei 2013 Geaccrediteerd door Nederlandse Vereniging voor Heelkunde.

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De toegevoegde waarde van de MRI mammografie bij patiënten met bloederige tepeluitvloed. van Gelder L, Pennings JP, Menke-Pluijmers MBE, Bisschops RHC, Plaisier PW. Radiologendagen, ’s-Hertogenbosch, September 2013. Geaccrediteerd door Nederlandse Vereniging voor Radiologie.

Impact of metformin use on survival after surgery for NSCLC. Hoekstra LT, Plaisier PW, Schnater JM, Schütte PR, van Thiel E, Damhuis RAM. 21st European Conference on General Thoracic Surgery, Birmingham, UK, Mei 2013. Geaccrediteerd door European Society for Thoracic Surgery.

Fixation of high-flexion Total knee prostheses: 5year follow-up results of a 4-arm randomized controlled clinical and Roentgen stereophotogrammetric (RSA) study. Nieuwenhuijse MJ, van der Voort P, Kaptein BL, van der Linden - van der Zwaag HM, Valstar ER, Nelissen RG. Jaarvergadering NOV, Amsterdam, Februari 2013. Geaccrediteerd door de Nederlandse Orthopeden Vereniging.

Fixation of high-flexion Total knee prostheses: 5year follow-up results of a 4-arm randomized controlled clinical and Roentgen stereophotogrammetric (RSA) study. Nieuwenhuijse MJ, van der Voort P, Kaptein BL, van der Linden - van der Zwaag HM, Valstar ER, Nelissen RG. 3rd bi-annual International RSA Meeting, Lund, Zweden, Mei 2013.

Non-invasive dynamic identification of femoroacetabular impingement: a cadaveric validation study. Röling MA. International Society for Hip Arthroscopy, München, Duitsland, Oktober 2013.

Feedback form surgeons and residents differs! van Traas E, van de Ridder M, Oostenbroek R, Plaisier PW. International Surgical Week, Helsinki, Finland, Augustus 2013. Geaccrediteerd door International Society of Surgery.

Operatiesterfte na oncologische longresecties op vrijdag. Plaisier PW, Damhuis RAM, Maat APWM. Najaarsvergadering, ‘s-Hertogenbosch, November 2013. Geaccrediteerd door Nederlandse Vereniging voor Heelkunde.

Profylactische tepel- en huidsparende mastectomie laat meer klierweefsel in situ dan huidsparende matectomie. van Verschuer VMT, van Deurzen CHM, Koppert LB, Luiten EJ, Menke-Pluijmers MBE, Rothbarth J, Verhoef C, Westenend PJ. Najaarsvergadering, ‘s-Hertogenbosch, November 2013. Geaccrediteerd door Nederlandse Vereniging voor Heelkunde.

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Feedback in de chirurgische opleidingskliniek: mag ‘t wat vaker? Molendijk MJW, Busch ORC, Oostenbroek RJ, Plaisier PW, van de Ridder JMM. Najaarsvergadering, ‘s-Hertogenbosch, November 2013. Geaccrediteerd door Nederlandse Vereniging voor Heelkunde.

Feedback in de chirurgische opleidingskliniek: mag ‘t wat vaker? van de Ridder JMM, Traas E, van Loenhout RB , Oostenbroek RJ, Plaisier PW. NVMO congres 2013, November 2013, Egmond aan Zee. Geaccrediteerd door Nederlandse Vereniging voor Medisch Onderwijs.

Posters Fertility screening in men with acquired undescended testes: a long-term follow-up study. van Brakel J. 9th Joint Meeting of Paediatric Endocrinology Milan, Italy September, 2013.

Een nieuwe radiologisch geassisteerde methode om iatrogeen letsel van de nervus radialis te minimaliseren bij het plaatsen van distale vergrendel schroeven bij intramedullaire humerus pennen. van der Ende B, Theeuwes HP, Potters JW, Kerver AJH, Bessems JHJM, Kleinrensink GJ. Traumadagen, Amsterdam, November 2013.

Formation of an ileostomy: considerable morbidity and complications. van Gelder L, Sier M, Ubbink D, Plaisier PW, Lamme B, Oostenbroek R. International Surgical Week, Helsinki, Finland, Augustus 2013.

Bloody nipple discharge and conventional diagnostic imaging negative for malignancy: limited additional value of MRI. van Gelder L, Pennings J-P, Menke-Pluijmers MBE, Bisschops B, Plaisier PW. International Surgical Week, Helsinki, Finland, Augustus 2013.

To reverse or not to reverse ileostomies. Sier M, van Gelder L, Ubbink D, Plaisier PW, Lamme B, Oostenbroek R. International Surgical Week, Helsinki, Finland, Augustus 2013.

Feedback van chirurgen en assistenten verschilt! Traas E, van Loenhout RB, van de Ridder JMM, Oostenbroek RJ, Plaisier PW. Chirurgendagen, Nederlandse Vereniging voor Heelkunde, Veldhoven, Mei 2013.

Wat zijn de klachten van patiënten over assistenten, in het bijzonder chirurgische assistenten, en welke kosten brengt dit met zich mee? Plaisier PW, Oostenbroek RJ. Najaarsvergadering, ‘s-Hertogenbosch, November 2013.

Chest X-ray prior to discharge after VATS anatomical pulmonary resection: friend or foe? Troquay S, von Meyenfeldt E, Vissers Y, Bootsma G, Siebenga J. 21st European Conference on General Thoracic Surgery, Birmingham, UK, Mei 2013. 37

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Dermatologie

PubMed publicaties [A woman with thick nails and a white tongue].[Article in Dutch] Kouloubis N, van der Velden JJ. Ned Tijdschr Geneeskd. 2013;157(51):A7007. A 22-year-old women visited the dermatologist with hypertrophic finger- and toenails, palmoplantar keratoderma and oral leukokeratosis since her childhood. The diagnosis ‘pachyonychia congenita type 1’ was made. This is a rare dermatosis with an autosomal dominant inheritance pattern. The treatment is symptomatic. PMID: 24345363 [PubMed - in process]

Treatment of psoriasis with non-registered fumaric acid esters in The Netherlands: a nationwide survey among Dutch dermatologists. Fallah Arani S, Balak DM, Neumann HA, Kuipers MV, Thio HB. J Eur Acad Dermatol Venereol. 2013 Jul 3. doi: 10.1111/jdv.12205. [Epub ahead of print] BACKGROUND: Psoriasis vulgaris is a T-cell mediated disease that affects 2-3% of the worldwide white-skinned population. Fumaric acid esters are mentioned as an effective therapy for moderate-to-severe psoriasis vulgaris in adult patients in the new guidelines for psoriasis treatment. OBJECTIVES: To obtain an insight into the use of fumaric acid esters by Dutch dermatologists in the Netherlands. METHODS: This was a cross-sectional postal survey. An anonymous survey was posted to all Dutch dermatologists. In this survey, data were collected on the extent of fumaric acid esters use, the reasons for use, the reasons for non- or limited use of fumaric acid esters, the perception of fumaric acid esters as a mono-therapy with regards to the effectiveness, the safety, the adverse events and the overall satisfaction of fumaric acid esters as a mono-therapy. RESULTS: Sixty-three per cent of the 300 responders indicated to prescribe fumaric acid esters for the treatment of psoriasis. About 37% of the dermatologists indicated (almost) never to prescribe it. Biologicals were considered as the most effective therapy. Fumaric acid esters were regarded as the safest therapy. They were generally well-tolerated by the patients similar to that for methotrexate according to the respondents. CONCLUSION: A large proportion of the dermatologists in our survey indicated to prescribe fumaric acid esters. It is considered to be effective, safe and without adverse events profile that is favourable in the practice, also as compared with other systemic therapies such as methotrexate and biologicals. PMID: 23822581 [PubMed - as supplied by publisher]

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Enteric-coated mycophenolate sodium in psoriasis vulgaris: an open pilot study. Fallah Arani S, Waalboer Spuij R, Nijsten T, Neumann HA, Thio B. J Dermatolog Treat. 2014 Feb;25(1):46-9. doi: 10.3109/09546634.2012.723124. Epub 2013 Jan 20. BACKGROUND: Mycophenolate mofetil is a well-known immunosuppressive agent in transplantation medicine. The efficacy of enteric-coated mycophenolate sodium (EC-MPS) was confirmed in other inflammatory skin diseases, including atopic dermatitis and SCLE. OBJECTIVE: To investigate the efficacy and the tolerability/short-term safety of EC-MPS in patients with moderate to severe chronic plaque psoriasis. PATIENTS AND METHODS: An open-label pilot study in which 20 patients with a PASI >10 received EC-MPS 720 mg twice daily for 6 weeks followed by 360 mg twice daily for another 6 weeks. Patients who completed 12 weeks of treatment were followed-up for an additional 12 weeks. Treatment outcomes were assessed with PASI50% and PASI75%. RESULTS: Eighteen men and two women (mean age 46 years) entered the study. Sixty-five percent (13/20) finished the treatment period. By week 6, no patient achieved PASI 75% and 8/20 patients achieved a PASI 50%. Compared to week 6, 4/13 showed a deterioration of their psoriasis at week 12. Twenty-five percent (2/8) achieved a PASI 75% in week 24. The most-reported adverse events were itching (30%), diarrhea (10%), and a reversible elevation of the triglycerides level. CONCLUSION: EC-MPS does not seem effective as monotherapy for moderate to severe psoriasis, but might be used at a dosage of 1440 mg daily in well-selected patients with treatment-resistant psoriasis. PMID: 22998609 [PubMed - indexed for MEDLINE]

Comparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins. Biemans AA, Kockaert M, Akkersdijk GP, van den Bos RR, de Maeseneer MG, Cuypers P, Stijnen T, Neumann MH, Nijsten T. J Vasc Surg. 2013 Sep;58(3):727-34.e1. doi: 10.1016/j.jvs.2012.12.074. Epub 2013 Jun 13. BACKGROUND: Many case series have been published on treatments of varicose veins, but comparative randomized controlled trials remain sparse. OBJECTIVE: To compare the anatomic success rate, frequency of major complications, and quality-of-life improvement of endovenous laser ablation (EVLA), ultrasound-guided foam sclerotherapy (UGFS), and conventional surgery (CS), after 1-year follow-up. METHODS: A total of 240 consecutive patients with primary symptomatic great saphenous vein reflux were randomized to EVLA, UGFS, or CS, consisting of high ligation and short stripping. Primary outcome was anatomic success defined as obliteration or absence of the treated vein on ultrasound examination after 1 year. Secondary outcomes were complications, improvement of the “C” class of the CEAP classification, and improvement of diseasespecific (Chronic Venous Insufficiency Quality-of-Life Questionnaire) and general (EuroQol 5) quality-of-life scores. RESULTS: More than 80% of the study population was classified as C2 or C3 venous disease. After 1 year, the anatomic success rate was highest after EVLA (88.5%), followed by CS (88.2%) and UGFS (72.2%) (P < .001). The complication rate was low and comparable between treatment groups. All groups showed significant (P < .001) improvement of EuroQol 5 and Chronic Venous Insufficiency Quality-of-Life Questionnaire scores after therapy; 84.3% of

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Dermatologie

all treated patients showed an improvement of the “C” of the CEAP classification. CONCLUSIONS: After 1-year follow-up, EVLA is as effective as CS and superior to UGFS according to occlusion on ultrasound duplex. Quality of life improves after treatment in all groups significantly. PMID: 23769603 [PubMed - indexed for MEDLINE]

Boek of hoofdstuk in boek Percutaneous interventional cardiovascular surgery, chapter 47, interventions for varicose veins. Kockaert M. Edition 2012. pcrtextbook.com.

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Gynaecologie

PubMed publicaties Transfusion policy after severe postpartum haemorrhage: a randomised non-inferiority trial. Prick B, Jansen A, Steegers E, Hop W, Essink-Bot M, Uyl-de Groot C, Akerboom B, van Alphen M, Bloemenkamp K, Boers K, Bremer H, Kwee A, van Loon A, Metz G,Papatsonis D, van der Post J, Porath M, Rijnders R, Roumen F, Scheepers H,Schippers D, Schuitemaker N, Stigter R, Woiski M, Mol B, van Rhenen D, Duvekot J. BJOG. 2014 Jan 10. doi: 10.1111/1471-0528. OBJECTIVE: To assess the effect of red blood cell (RBC) transfusion on quality of life in acutely anaemic women after postpartum haemorrhage. DESIGN: Randomised non-inferiority trial. SETTING: Thirty-seven Dutch university and general hospitals. POPULATION: Women with acute anaemia (haemoglobin 4.8-7.9 g/dl [3.0-4.9 mmol/l] 12-24 hours postpartum) without severe anaemic symptoms or severe comorbidities. METHODS: Women were allocated to RBC transfusion or non-intervention. MAIN OUTCOME MEASURES: Primary outcome was physical fatigue 3 days postpartum (Multidimensional Fatigue Inventory, scale 4-20; 20 represents maximal fatigue). Non-inferiority was demonstrated if the physical fatigue difference between study arms was maximal 1.3. Secondary outcomes were health-related quality of life and physical complications. Health-related quality of life questionnaires were completed at five time-points until 6 weeks postpartum. RESULTS: In all, 521 women were randomised to non-intervention (n = 262) or RBC transfusion (n = 259). Mean physical fatigue score at day 3 postpartum, adjusted for baseline and mode of delivery, was 0.8 lower in the RBC transfusion arm (95% confidence interval: 0.1-1.5, P = 0.02) and at 1 week postpartum was 1.06 lower(95% confidence interval: 0.3-1.8, P = 0.01). A median of two RBC units was transfused in the RBC transfusion arm. In the non-intervention arm, 33 women received RBC transfusion, mainly because of anaemic symptoms. Physical complications were comparable. CONCLUSIONS: Statistically, non-inferiority could not be demonstrated as the confidence interval crossed the non-inferiority boundary. Nevertheless, with only a small difference in physical fatigue and no differences in secondary outcomes, implementation of restrictive management seems clinically justified. PMID: 24405687 [PubMed - as supplied by publisher]

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Gynaecologie

Economic analysis comparing induction of labor and expectant management in women with preterm prelabor rupture of membranes between 34 and 37 weeks (PPROMEXIL trial). Vijgen SM, van der Ham DP, Bijlenga D, van Beek JJ, Bloemenkamp KW, Kwee A, Groenewout M, Kars MM, Kuppens S, Mantel G, Molkenboer JF, Mulder AL, Nijhuis JG, Pernet PJ, Porath M, Woiski MD, Weinans MJ, van Wijngaarden WJ, Wildschut HI, Akerboom B, Sikkema JM, Willekes C, Mol BW, Opmeer BC; PPROMEXIL study group. Acta Obstet Gynecol Scand. 2014 Apr;93(4):374-81. OBJECTIVE: To compare the costs of induction of labor and expectant management in women with preterm prelabor rupture of membranes (PPROM). DESIGN: Economic analysis based on a randomized clinical trial. SETTING: Obstetric departments of eight academic and 52 non-academic hospitals in the Netherlands. POPULATION: Women with PPROM near term who were not in labor 24 h after PPROM. METHODS: A cost-minimization analysis was done from a health care provider perspective, using a bottom-up approach to estimate resource utilization, valued with unit-costs reflecting actual costs. MAIN OUTCOME MEASURES: Primary health outcome was the incidence of neonatal sepsis. Direct medical costs were estimated from start of randomization to hospital discharge of mother and child. RESULTS: Induction of labor did not significantly reduce the probability of neonatal sepsis [2.6% vs. 4.1%, relative risk 0.64 (95% confidence interval 0.25-1.6)]. Mean costs per woman were €8094 for induction and €7340 for expectant management (difference €754; 95% confidence interval -335 to 1802). This difference predominantly originated in the postpartum period, where the mean costs were €5669 for induction vs. €4801 for expectant management. Delivery costs were higher in women allocated to induction than in women allocated to expectant management (€1777 vs. €1153 per woman). Antepartum costs in the expectant management group were higher because of longer antepartum maternal stays in hospital. CONCLUSIONS: In women with pregnancies complicated by PPROM near term, induction of labor does not reduce neonatal sepsis, whereas costs associated with this strategy are probably higher. PMID: 24392746 [PubMed - in process]

Management of late-preterm premature rupture of membranes: the PPROMEXIL-2 trial. van der Ham DP, van der Heyden JL, Opmeer BC, Mulder AL, Moonen RM, van Beek JH, Franssen MT, Bloemenkamp KW, Sikkema JM, de Groot CJ, Porath M, Kwee A,Woiski MD, Duvekot JH, Akerboom BM, van Loon AJ, de Leeuw JW, Willekes C, Mol BW, Nijhuis JG. Am J Obstet Gynecol. 2012 Oct;207(4):276.e1-10. OBJECTIVE: The evidence for the management of near term prelabor rupture of membranes is poor. From January 2007 until September 2009, we performed the PPROM Expectant Management versus Induction of Labor (PPROMEXIL) trial. In this trial, we showed that in women with preterm prelabor rupture of membranes (PPROM), the incidence of neonatal sepsis was low, and the induction of labor (IoL) did not reduce this risk. Because the PPROMEXIL trial was underpowered and because of a lower-than-expected incidence of neonatal sepsis, we performed a second trial (PPROMEXIL-2), aiming to randomize 200

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patients to improve the evidence in near-term PPROM. STUDY DESIGN: In a nationwide multicenter study, nonlaboring women with PPROM between 34 and 37 weeks’ gestational age were eligible for inclusion. Patients were randomized to IoL or expectant management (EM). The primary outcome measure was neonatal sepsis. RESULTS: From December 2009 until January 2011, we randomized 100 women to IoL and 95 to EM. Neonatal sepsis was seen in 3 neonates (3.0%) in the IoL-group versus 4 neonates (4.1%) in the EM group (relative risk, 0.74; 95% confidence interval, 0.17-3.2). One of the sepsis cases in the IoL group resulted in neonatal death because of asphyxia. There were no significant differences in secondary outcomes. CONCLUSION: The risk of neonatal sepsis after PPROM near term is low. Induction of labor does not reduce this risk. PMID: 22901981 [PubMed - indexed for MEDLINE]

Risk of developmental dysplasia of the hip in breech presentation: the effect of successful external cephalic version. Lambeek AF, De Hundt M, Vlemmix F, Akerboom BM, Bais JM, Papatsonis DN, Mol BW, Kok M. BJOG. 2013 Apr;120(5):607-12. OBJECTIVE: To evaluate the effect of successful external cephalic version on the incidence of developmental dysplasia of the hip (DDH) requiring treatment in singleton breech presentation at term. DESIGN: Observational cohort study. SETTING: Three large teaching hospitals in the Netherlands. POPULATION: Women with a singleton breech presentation of 34 weeks of gestation or more, who underwent an external cephalic version attempt. METHODS: We made a comparison of the incidence of DDH between children born in breech presentation and children born in cephalic presentation after a successful external cephalic version. MAIN OUTCOME MEASURE: The incidence of DDH requiring either conservative treatment, with a harness, or surgical treatment. RESULTS: A total of 498 newborns were included in the study, of which 40 (8%) were diagnosed with DDH and 35 required treatment. Multivariate analysis showed that female gender (OR 2.79, 95% CI 1.23-6.35) and successful external cephalic version (OR 0.29, 95% CI 0.090.95) were independently associated with DDH. CONCLUSIONS: A successful external cephalic version is associated with a lower incidence of DDH, although a high percentage of children born after a successful external cephalic version still appear to have DDH. A larger cohort study is needed to establish the definite nature of this relationship. Until then, we recommend the same screening policy for infants born in cephalic position after a successful external cephalic version as for infants born in breech position. PMID: 23145903 [PubMed - indexed for MEDLINE]

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Gynaecologie

Factors attributing to the failure of endometrial sampling in women with postmenopausal bleeding. Visser NC, Breijer MC, Herman MC, Bekkers RL, Veersema S, Opmeer BC, Mol BW,Timmermans A, Pijnenborg JM. Acta Obstet Gynecol Scand. 2013 Oct;92(10):1216-22. doi: 0.1111/aogs.12212. Epub 2013 Jul 22. OBJECTIVE: To determine which doctor- and patient-related factors affect failure of outpatient endometrial sampling in women with postmenopausal bleeding, and to develop a multivariable prediction model to select women with a high probability of failed sampling. DESIGN: Prospective multicenter cohort study. SETTING: Three teaching hospitals in the Netherlands. POPULATION: Women presenting with postmenopausal bleeding with an indication for endometrial sampling. METHODS: Multivariable logistic regression was performed to evaluate the impact of doctor’s training level and patient’s characteristics on failure of sampling. MAIN OUTCOME MEASURES: Failure of endometrial sampling, classified as technical failure or insufficient tissue for diagnosis. RESULTS: In 74 (20.8%) of the 356 included women, sampling technically failed,and in 84 (29.8%) the amount of tissue was insufficient for diagnosis. Nulliparity [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.8-7.9] and advanced age (OR 1.03 per year, 95% CI 1.00-1.06) were associated with technical failure. Advanced age was associated with insufficient sampling (OR 1.04 per year, 95% CI 1.01-1.07), and endometrial thickness >12 mm decreased the chance of insufficient sampling (OR 0.3, 95%CI 0.1-0.8). The prediction model for total failure had an area under the ROC curve of 0.64 (95% CI 0.58-0.70). CONCLUSIONS: In women with postmenopausal bleeding, the failure rate of endometrial sampling is relatively high and is associated with nulliparity and advanced age. Endometrial thickness >12 mm decreased the chance of failure. A multivariable prediction model for total failure based on patient characteristics has a moderate capacity to discriminate between women at high or low risk of failure. PMID: 23808392 [PubMed - indexed for MEDLINE]

Overige publicaties Stroke in Pregnancy. Auzin M, de Weerd S. J Womens Health, Issues Care 2013,2:5.

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Intensive care geneeskunde

Voordrachten The implementation of a protocol ‘Weanscreen’ will lead to lower sedation levels, more frequent sedation stops and proper positioning in the ICU. le Grand HM, Theunisse C, Ponssen HH, van Driel AG. Kwaliteitscongres, april 2013, Londen.

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Kwaliteit,care Intensive Veiligheid geneeskunde en Innovatie

Interne geneeskunde

PubMed publicaties Lower mortality and inflammation from post-transplantation encapsulating peritoneal sclerosis compared to the classical form. Habib SM, Korte MR, Betjes MG. Am J Nephrol. 2013;37(3):223-30. BACKGROUND: Encapsulating peritoneal sclerosis (EPS) may occur after kidney transplantation (post-transplantation EPS) or may be diagnosed during or after peritoneal dialysis treatment (classical EPS). The aim of the present study was to investigate to what extent both EPS entities differ in clinical presentation, radiological findings, outcome, and the systemic inflammatory response, as measured by plasma C-reactive protein (CRP) levels both prior to and after EPS diagnosis. METHODS: We performed a retrospective analysis of 15 post-transplantation EPS and 19 classical EPS patients who were diagnosed at seven hospitals in the Netherlands between January 1, 2000, and January 1, 2011. RESULTS: There were no inter-group differences in age, duration of peritoneal dialysis, clinical presentation, or radiology findings at diagnosis. Post-transplantation patients had experienced a lower number of peritonitis episodes per patient-year (0.2 (0.0-0.4) vs. 0.7 (0.3-1.2), p = 0.01) with a longer interval between the last peritonitis and EPS diagnosis (18.1 (4.6-34.3) vs. 4.4 (0.89-13.78) months, p = 0.01). Post-transplantation EPS patients showed a remarkably lower mortality rate (40.0 vs. 84.2%, p < 0.05). In both groups a pattern of elevated CRP values was observed, increasing within the year before EPS diagnosis. In the post-transplantation group the median CRP level at diagnosis was lower (56.0 vs. 144.50 mg/l, p < 0.05) than in the classical EPS group. CONCLUSION: Post-transplantation EPS has a similar clinical presentation as classical EPS but with a lower systemic inflammatory response and better outcome. PMID: 23467015 [PubMed - in process]

Localized encapsulating peritoneal sclerosis constricting the terminal ileum--an unusual appearance requiring surgical intervention. Habib SM, Hagen SM, Korte MR, Zietse R, Dor FJ, Betjes MG. Perit Dial Int. 2013 Sep-Oct;33(5):503-6. doi: 10.3747/pdi.2012.00105. Epub 2013 Jun 3. BACKGROUND: Encapsulating peritoneal sclerosis (EPS) is a rare complication of peritoneal dialysis (PD). It is characterized by encapsulation of the bowel, causing symptoms of intestinal obstruction. Exclusive involvement of parts of the bowel may occur and may be more common than previously thought. Our main objective was to investigate and report on patients with localized EPS. METHODS: Between July 2002 and December 2011, 9 of 17 EPS patients were referred to our department of surgery for a diagnostic laparotomy. Three of the 9 cases showed localized encapsulation of the small bowel and were selected for the purpose of this study.

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RESULTS: All 3 patients presented with an acute inflammatory state and symptoms of bowel obstruction. In 2 patients, EPS became clinically overt after kidney transplantation; the third patient was diagnosed while on hemodialysis. All shared a history of PD ranging from 31 to 101 months. In none of the patients was radiologic examination conclusive, although 2 showed peritoneal thickening and ascites. Each patient underwent laparotomy, confirming EPS. In all cases, a thickened peritoneal membrane became apparent, predominantly covering the ileocecal region of the intestine. In addition, a constrictive membrane at the level of the terminal ileum was noted. In 2 cases, the patients underwent enterolysis and dissection of the constricting fibrotic peritoneal membrane (peritonectomy) without bowel resection. The 3rd patient was managed with parenteral nutrition and tamoxifen. The postoperative course in 1 patient was complicated by infected ascites that resolved with antibiotic treatment. Eventually, all patients were doing well, with adequate oral intake and without the need for repeat surgery. CONCLUSIONS: Localized EPS may be more common than previously thought. It has a predilection for the level of the terminal ileum. We believe that an elective diagnostic laparotomy should be considered early, because this procedure offers both diagnostic opportunities and therapeutic options. Localized EPS cases may benefit most from enterolysis and peritonectomy. PMCID: PMC3797668 [Available on 2014/9/1] PMID: 23733660 [PubMed - in process]

Radioactive iodine in the treatment of medullary thyroid carcinoma: a controlled multicenter study. Meijer JA, Bakker LE, Valk GD, de Herder WW, de Wilt JH, Netea-Maier RT, Schaper N, Fliers E, Lips P, Plukker JT, Links TP, Smit JA. Eur J Endocrinol. 2013 Apr 15;168(5):779-86. OBJECTIVE: Radioactive iodine (RAI) therapy in medullary thyroid carcinoma (MTC)is applied in some centers, based on the assumption that cross-irradiation from thyroid follicular cells may be beneficial. However, no systematic studies on the effect of RAI treatment in MTC have been performed. The aim of this study was to analyze the effect of RAI treatment on survival in MTC patients. DESIGN: Retrospective multicenter study in eight University Medical Centers in The Netherlands. METHODS: Two hundred and ninety three MTC patients without distant metastases who had undergone a total thyroidectomy were included between 1980 and 2007. Patients were stratified by clinical appearance, hereditary stage, screening status, and localization. All patients underwent regular surgical treatment with additional RAI treatment in 61 patients. Main outcome measures were disease-free survival (DFS) and disease-specific survival (DSS). Cure was defined as biochemical and radiological absence of disease. RESULTS: In multivariate analysis, stratification according to clinical appearance (P=0.72), hereditary stage (P=0.96), localization (P=0.69), and screening status (P=0.31) revealed no significant effects of RAI treatment on DFS. Multivariate analysis showed no significant difference in DSS for the two groups stratified according to clinical appearance (P=0.14). Owing to limited number of events, multivariate analysis was not possible for DSS in the other groups of stratification. CONCLUSIONS: Based on the results of the present analysis, we conclude that RAI has no place in the treatment of MTC. PMID: 23462866 [PubMed - indexed for MEDLINE] 47

Interne geneeskunde

Influence of C-reactive protein levels and age on the value of D-dimer in diagnosing pulmonary embolism. Crop MJ, Siemes C, Berendes P, van der Straaten F, Willemsen S, Levin MD. Eur J Haematol. 2014 Feb;92(2):147-55. doi: 10.1111/ejh.12218. Epub 2013 Nov 22. BACKGROUND: Recently, the number of performed CT-angiographies to diagnose pulmonary embolism (PE) rised markedly, while the incidence of PE hardly increased. This low yield of CT-angiography leads to more patients exposed to radiation and higher costs. AIM: The diagnostic value of age, C-reactive protein (CRP) and D-dimer in PE was investigated. Additionally an age-adjusted D-dimer cutoff level [age-adjusted cutoff = age/100 mg/L] was compared with the conventional cutoff level in diagnosing PE for patients ≥50 yr. METHODS: This observational study (2004-2007) included all consecutive patients suspected for PE presenting on the emergency department with a performed CT-angiography after measuring CRP and D-dimer levels. RESULTS: Of 4609 patients suspected for PE, 1164 patients underwent CT-angiography of whom 309 (26.5%) had PE. Correlation between CRP and D-dimer was 0.42 (P < 0.001). D-dimer and age correlated positively (rs = 0.33,P < 0.001), but only in patients >50 yr and independent of PE. Multivariate regression analysis showed significant contribution of age, D-dimer and age-adjusted D-dimer for diagnosing PE, but not for CRP. Using an age-adjusted D-dimer cutoff value increased specificity from 37% to 50%, whereas sensitivity declined from 96% to 90%. Applying this age-adjusted cutoff level in patients ≥70 yr, specificity increased from 18% to 40%, while sensitivity decreased from 96% to 88%. CONCLUSIONS: In the prediction of PE, age and D-dimer levels are relevant, while CRP level is not. Using an age-adjusted D-dimer cutoff in older patients remarkably improves the specificity of D-dimer testing with a minor decline in sensitivity. This may increase the yield of CT-angiography in diagnosing PE. PMID: 24164492 [PubMed - in process]

Post-transplantation encapsulating peritoneal sclerosis without inflammation or radiological abnormalities. Habib SM, Dor FJ, Korte MR, Hagen SM, Betjes MG. BMC Nephrol. 2013 Sep 26;14:203. doi: 10.1186/1471-2369-14-203. BACKGROUND: Post-transplantation encapsulating peritoneal sclerosis (EPS) causing bowel obstruction has been identified as a serious complication after kidney transplantation in patients previously treated with peritoneal dialysis. Systemic inflammation and abnormalities on an abdominal computed tomography (CT) scan are important hallmarks of EPS. To our knowledge, this is the first report of a case being diagnosed with late-onset post-transplantation EPS without systemic inflammation or abnormalities on a CT scan which could only be diagnosed by laparotomy. CASE PRESENTATION: A 59-year old female presented because of symptoms of bowel obstruction 33 months after kidney transplantation. The patient had a 26-month history of peritoneal dialysis before her first kidney transplantation and was treated with peritoneal dialysis for 4 years before undergoing a second kidney transplantation. Physical examination was unremarkable and laboratory tests showed no signs of systemic inflammation (C-reactive protein <1 mg/L). An abdominal CT scan did not reveal any abnormalities fitting the diagnosis of EPS, except a “feces sign”. Given the severity of the progressive symptoms, a diagnostic laparotomy was performed, visualizing a classical EPS. Total peritonectomy and enterolysis were performed, leading to restoration of peristalsis. 48

CONCLUSION: EPS may occur several years after kidney transplantation in the absence of inflammation and typical radiological abnormalities. Obtaining a diagnosis of post-transplantation EPS is challenging, however, a low threshold for surgical exploration in case of high clinical suspicion and negative findings on the CT scan is mandatory. PMCID: PMC3849826 PMID: 24067112 [PubMed - in process]

Cinacalcet for secondary hyperparathyroidism: from improved mineral levels to improved mortality? Vervloet MG, du Buf-Vereijken PW, Potter van Loon BJ, Manamley N, Reichert LJ,Smak Gregoor PJ. Neth J Med. 2013 Sep;71(7):348-54. Secondary hyperparathyroidism is an almost inevitable complication of advanced kidney failure. The introduction of the calcimimetic cinacalcet for the treatment of secondary hyperparathyroidism in patients on dialysis was based on its ability to reduce elevated levels of parathyroid hormone (PTH). Subsequent clinical studies confirmed the beneficial effects of cinacalcet on biochemical parameters reflecting mineral disturbances and bone disease. In this review we summarise the impact of cinacalcet on biochemical, intermediate and clinical outcomes. We also present previously unpublished mineral metabolism data from 144 Dutch dialysis patients treated with cinacalcet who participated in the pan-European ECHO observational study. Although secondary hyperparathyroidism tended to be more severe in our Dutch cohort, compared with the entire ECHO cohort, cinacalcet was nevertheless effective in reducing PTH in these patients. Two recent clinical studies evaluated, respectively, the efficacy of cinacalcet in improving the intermediate endpoint of cardiovascular calcifications (ADVANCE trial), and its impact on clinical outcomes, including all-cause mortality and cardiovascular events (EVOLVE trial). The ADVANCE trial provided evidence that cinacalcet may indeed improve calcification in both large arteries and cardiac valves. The EVOLVE trial, however, did not meet its clinical primary endpoint (time to all-cause mortality, myocardial infarction, hospitalisation for unstable angina, heart failure or a peripheral vascular event), although secondary and sensitivity analysis suggested a beneficial effect. The clinical implications of these important studies are also addressed in this review. PMID: 24038560 [PubMed - in process]

A psychometric analysis of the Rotterdam Renal Replacement Knowledge-Test (R3K-T)using item response theory. Ismail SY, Timmerman L, Timman R, Luchtenburg AE, Smak Gregoor PJ, Nette RW,van den Dorpel RM, Zuidema WC, Weimar W, Massey EK, Busschbach JJ. Transpl Int. 2013 Dec;26(12):1164-72. doi: 10.1111/tri.12188. Epub 2013 Oct 7. Knowledge is a prerequisite for promoting well-informed decision-making. Nevertheless, there is no validated and standardized test to assess the level of knowledge among renal patients regarding kidney disease and all treatment options. Therefore, the objective of this study was to investigate the psychometric properties of such a questionnaire for use in research and practice. A 30-item list was validated in four groups: (1) 187 patients on dialysis, (2) 82 patients who were undergoing living donor kidney transplantation the following day, (3) the general population of Dutch residents (n = 515) and (4) North American residents

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Interne geneeskunde

(n = 550). The psychometric properties of the questionnaire were examined using multi dimensional item response theory (MIRT). Norm references were also calculated. Five items were found to distort ability estimates (Differential item functioning; DIF). MIRT analyses were subsequently carried out for the remaining 25 items. Almost all items showed good discrimination and difficulty parameters based on the fitted model. Two stable dimensions with 21 items were retrieved for which norm references for the Dutch and North American, dialysis and transplantation groups were calculated. This study resulted in a thorough questionnaire, the Rotterdam renal replacement knowledge-test, which enables reliable testing of patient’s knowledge on kidney disease and treatment options in clinic and research. PMID: 24118241 [PubMed - in process]

Efficacy and complications of urinary drainage procedures in idiopathic retroperitoneal fibrosis complicated by extrinsic ureteral obstruction. Mertens S, Zeegers AG, Wertheimer PA, Hendriksz TR, van Bommel EF. Int J Urol. 2014 Mar;21(3):283-8. doi: 10.1111/iju.12234. Epub 2013 Aug 22. OBJECTIVE: To investigate the efficacy and complications of urinary drainage procedures in patients with idiopathic retroperitoneal fibrosis complicated by ureteral obstruction. METHODS: A retrospective study of 30 idiopathic retroperitoneal fibrosis patients involving 44 obstructed urinary units who underwent urinary drainage from January 2002 through April 2010 was carried out. Data of all diagnostic procedures, blood and urine cultures, and hospital admissions were collected and analyzed. RESULTS: In 12 of 44 (27%) cases, percutaneous nephrostomy was carried out at the first step. Attempted ureteral stenting at the first step was successful in 25 of 32 (79%) cases, of which 20 (80%) cases could be managed successfully by ureteral stenting alone throughout the study period. Successful prolonged urinary drainage with percutaneous nephrostomy alone was accomplished in 10 cases, three at the first step and seven at the second step after failed intraureteral stent insertion or after unsuccessful maintenance of urinary drainage with an intraureteral stent. A total of 21 urinary tract infection episodes occurred in 11 patients. The incidence and accumulated incidence of acute pyelonephritis was 0.062 episodes/100 person-days and 30%, respectively. The incidence and accumulated incidence of urosepsis was 0.015 episodes/100 person-days and 6.6%, respectively. The overall number of complications did not differ between external and internal urinary drainage procedures (percutaneous nephrostomy, 21% vs intraureteral stent, 17.9%; P = 0.79). CONCLUSION: Both intraureteral stent and percutaneous nephrostomy placement are a safe way to relieve urinary obstruction in idiopathic retroperitoneal fibrosis patients, and they have comparable complication rates. Over time, the need for using both management options in the same patient might be required. Hence, these techniques should be regarded as complementary. PMID: 24033464 [PubMed - in process]

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Fine needle aspiration and medullary thyroid carcinoma: the risk of inadequate preoperative evaluation and initial surgery when relying upon FNAB cytology alone. Essig GF Jr, Porter K, Schneider D, Debora A, Lindsey SC, Busonero G, Fineberg D, Fruci B, Boelaert K, Smit JW, Meijer JA, Duntas L, Sharma N, Costante G, Filetti S, Sippel RS, Biondi B, Topliss DJ, Pacini F, Maciel RM, Walz PC, Kloos RT. Endocr Pract. 2013 Nov-Dec;19(6):920-7. doi: 10.4158/EP13143.OR. OBJECTIVES: To evaluate the diagnostic accuracy of fine-needle aspiration biopsy (FNAB) to preoperatively diagnose medullary thyroid cancer (MTC) among multiple international centers and evaluate how the cytological diagnosis alone could impact patient management. METHODS: We performed a retrospective chart review of sporadic MTC (sMTC) patients from 12 institutions over the last 29 years. FNAB cytology results were compared to final pathologic diagnoses to calculate FNAB sensitivity. To evaluate the impact of cytology sensitivity for MTC according to current practice and to avoid confounding results by local treatment protocols, changes in treatment patterns over time, and the influence of ancillary findings (e.g., serum calcitonin), therapeutic interventions based on FNAB cytology alone were projected into 1 of 4 treatment categories: total thyroidectomy (TT) and central neck dissection (CND), TT without CND, diagnostic emithyroidectomy, or observation. RESULTS: A total of 313 patients from 4 continents and 7 countries were included, 245 of whom underwent FNAB. FNAB cytology revealed MTC in 43.7% and possible MTC in an additional 2.4%. A total of 113 (46.1%) patients with surgical pathology revealing sMTC had FNAB findings that supported TT with CND, while 37 (15.1%) supported TT alone. In the remaining cases, diagnostic hemithyroidectomy and observation were projected in 32.7% and 6.1%, respectively. CONCLUSION: FNAB is an important diagnostic tool in the evaluation of thyroid nodules, but the low sensitivity of cytological evaluation alone in sMTC limits its ability to command an optimal preoperative evaluation and initial surgery in over half of affected patients. PMID: 23757627 [PubMed - in process]

Effectiveness of a hospital-based work support intervention for female cancer patients - a multi-centre randomised controlled trial. Tamminga SJ, Verbeek JH, Bos MM, Fons G, Kitzen JJ, Plaisier PW, Frings-Dresen MH, de Boer AG. PLoS One. 2013 May 22;8(5):e63271. doi: 10.1371/journal.pone.0063271. Print 2013. OBJECTIVE: One key aspect of cancer survivorship is return-to-work. Unfortunately, many cancer survivors face problems upon their return-to-work. For that reason, we developed a hospital-based work support intervention aimed at enhancing return-to-work. We studied effectiveness of the intervention compared to usual care for female cancer patients in a multi-centre randomised controlled trial. METHODS: Breast and gynaecological cancer patients who were treated with curative intent and had paid work were randomised to the intervention group (n = 65) or control group (n = 68). The intervention involved patient education and support at the hospital and improvement of communication between treating and occupational physicians. In addition, we asked patient’s occupational physician to organise a meeting with the patient and the supervisor to make a concrete gradual return-to-work plan. Outcomes at 12 months of follow-up included rate and time until return-to-work (full or partial), quality of life, work ability, work functioning,

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Interne geneeskunde

and lost productivity costs. Time until return-to-work was analyzed with Kaplan-Meier survival analysis. RESULTS: Return-to-work rates were 86% and 83% (p = 0.6) for the intervention group and control group when excluding 8 patients who died or with a life expectancy of months at follow-up. Median time from initial sick leave to partial return-to-work was 194 days (range 14-435) versus 192 days (range 82-465) (p = 0.90) with a hazard ratio of 1.03 (95% CI 0.641.6). Quality of life and work ability improved statistically over time but did not differ statistically between groups. Work functioning and costs did not differ statistically between groups. CONCLUSION: The intervention was easily implemented into usual psycho-oncological care and showed high return-to-work rates. We failed to show any differences between groups on return-to-work outcomes and quality of life scores. Further research is needed to study which aspects of the intervention are useful and which elements need improvement. TRIAL REGISTRATION: Nederlands Trial Register (NTR) 1658. PMCID: PMC3661555 PMID: 23717406 [PubMed - indexed for MEDLINE]

Aspirin in the treatment of decompression sickness: what can we learn from French experience? Westerweel PE, Fijen VA, Van Hulst RA. Int Marit Health. 2013;64(1):51. Comment in Int Marit Health. 2013;64(3):175. Comment on Int Marit Health. 2012;63(3):170-3. PMID: 23788166 [PubMed - indexed for MEDLINE]

Long-term safety and efficacy of a tamoxifen-based treatment strategy for idiopathic retroperitoneal fibrosis. van Bommel EF, Pelkmans LG, van Damme H, Hendriksz TR. Eur J Intern Med. 2013 Jul;24(5):444-50. doi: 10.1016/j.ejim.2012.11.010. BACKGROUND: Tamoxifen may be a viable treatment option for idiopathic retroperitoneal fibrosis (iRPF) but data are limited and its long-term safety and efficacy is unclear. We describe the long-term course and outcomes in a large group of patients with iRPF treated with tamoxifen monotherapy. METHODS: This is a single-center prospective, observational study of 55 patients with iRPF treated with tamoxifen for 2years from April 1998 through April 2011. Measurements included clinical improvement, laboratory parameters and follow-up computed tomographic (CT) scanning. Treatment success was the composite endpoint of clinical improvement, mass regression and definite resolution of ureteral obstruction. RESULTS: Forty-seven (85%) patients reported substantial resolution of symptoms after median treatment duration of 3.0weeks (IQR 1.4-4.8weeks). Repeated CT scanning showed mass regression in 39 (71%) patients at 4months and 47 (85%) patients at 8months of followup, respectively. Nineteen (34.5%) patients did not meet the composite endpoint of treatment success, 56% of whom responded satisfactorily to second-line immunosuppressive tre-

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atment. Recurrence-free survival in patients with treatment success after post-treatment follow-up of 21months (IQR 9.0-35.0months) was 68%. Tamoxifen was well tolerated. Pulmonary embolism occurred in 2 patients receiving tamoxifen and in one patient receiving second-line treatment. CONCLUSION: Tamoxifen is a safe and viable therapeutic option in the treatment of iRPF. PMID: 23246124 [PubMed - indexed for MEDLINE]

Overige publicaties Vergelijkend cohortonderzoek (2007 en 2011) naar prevalentie van iatrogene ziekenhuisopnames op de afdelingen interne geneeskunde, cardiologie en longziekten van een topklinisch ziekenhuis. Hiel DCW, Vendeloo M, Bartels PA, van Bommel EFH, Cleophas AJM, de Vogel EM, Dieleman HG. PW Wetenschappelijk Platform 2013;7:a1308 (pp 6-9).

A rare cause of urinary tract infection: maloplakia. van der Zwan M, van Bommel EFH. Abstract book 25e NIV dagen 2013, Pg 104. ISBN 978-90-8523-153-0.

De REPEAT studie: een fase I en fase II-studie naar de behandeling van het lenalidomide-refractair recidief multiple myeloom met lenalidomide gecombineerd met cyclofosfamide en prednison. Nijhof IS, Zweegman S, Beeker A, Bloem AC, Bos GMJ, Faber LM, van Kessel B, Klein SK, Koene HR, de Kruijf EJFM, Levin MD, Mutis T, van der Spek E, WIttebol S, Sonneveld P, Lokhorst HM en van de Donk NWJC. NTvH 2013; 3: 109-113.

Adherence to the Dutch general practitioner anemia guideline – a retrospective cohort study. Droogendijk J, Berendes PB, Beukers R, van Houten RJ, Sonneveld P, Levin MD. Perfusion 2013; 26: 192-198.

Verminderde nierfunctie: denk aan exogene factoren. van der Meijden WAG, Smak Gregoor PJH. Ned Tijdschr Geneeskd. 2013;157:A5944.

Boek of hoofdstuk in een boek Retroperitoneal Fibrosis. van Bommel EFH. ISBN/EAN: 987-90-820240-0-5. April 2013.

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Voordrachten GLP-1 analogs in Clinical Practice. van Velsen EFS, Lamers J, Blok V, van Leendert RJM and Kiewiet-Kemper RM. 25e Internistendagen, Maastricht, 24 april 2013. Geaccrediteerd door: Nederlandse Internisten Verenging

T-helper cells and fibrosis-associated macrophages dominate the peritoneal inflammatory infiltrate in EPS patients. Habib SM, Abrahams AC, Korte MR, de Vogel L, van Groningen MC,Betjes MGH. Nederlandse Nefrologie Dagen 2013. Veldhoven, The Netherlands.

T-helper cells and fibrosis-associated macrophages dominate the peritoneal inflammatory infiltrate in EPS patients. Habib SM, Abrahams AC, Korte MR, de Vogel L, van Groningen MC,Betjes MGH. European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Congress. Istanbul, Turkey.

Advantages and disadvantages of incorporating C-reactive protein levels, age and Dimer levels in diagnosing pulmonary embolism. Crop MJ, Siemes C, Berendes P, van der Straaten F, Levin MD. Nederlandse hematologiedagen 2013.

Protocollar approach to endoscopic evaluation of the gastrointestinal tract in patients with iron deficiency anemia (IDA) in general practice: a prospective cohort study. Droogendijk J, de Jonge PJ, Beukers R, Berendes PB, van Houten RJ, Sonneveld P, Levin MD. Nederlandse hematologiedagen 2013.

69-jarige vrouw met misselijkheid en diarree. de Jonge PJF, de Vrie W, Levin MD. NVGE Casuistische bespreking 2013.

Advantages and disadvantages of incorporating C-reactive protein levels, age and Dimer levels in diagnosing pulmonary embolism. Crop MJ, Siemes C, Berendes P, van der Straaten F, Levin MD. 25e Internistendagen 2013.

Posters Macrocytic anaemia: causes and prognosis. Stouten K, Riedl JA, Levin M-D. ASH annual meeting and exposition, New Orleans, December 2013.

54

Update on the Dutch Encapsulating peritoneal sclerosis (EPS) registry. Korte MR, Habib SM, Braun N, Abrahams A, Westerhuis R, Struijk D, Heuveling L, Betjes MGH -on behalf of the EPS working group. Nederlandse Nefrologie Dagen 2013. Veldhoven, The Netherlands.

Update on the Dutch Encapsulating peritoneal sclerosis (EPS) registry. Korte MR, Braun N, Habib SM, Goffin E, Summers A, Heuveling L, Betjes MGH - on behalf of the EPS working group. European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Congress. Istanbul, Turkey.

Advantages and disadvantages of incorporating C-reactive protein levels, age and Dimer levels in diagnosing pulmonary embolism. Crop MJ, Siemes C, Berendes P, van der Straaten F, Levin MD. European Hematology Association Congres 2013, Stockholm.

Silence in the intensive care unit? van den Berg BI, Leung E, Kuenen KAJM, Niehof SN, Ponssen HH. Nederlandse Intensivistendagen 2013, 14 februari 2013, Ede.

Correction: Current practices in ICU delirium management: a prospective multicenter study in the Netherlands. Trogrlic Z,Ista E, Slooter A, Ponssen HH, Schoonderbeek J, Schreiner F, Verbrugge S, Duran S, Bakker J and van der Jagt M. Critical Care 2013, 17(Suppl 2):P548 doi:10.1186/cc12703.

Correction: Current perspectives, beliefs and practices concerning delirium in critically ill patients: a multicenter survey among Dutch healthcare professionals. Trogrlic Z, van der Jagt M, van der Voort P, Ponssen HH, Schoonderbeek J, Schreiner F, Verbrugge S, Duran S, Bakker J and Ista E. Critical Care 2013, 17(Suppl 2):P549 doi:10.1186/cc12704.

A psychometric analysis of the Rotterdam renal replacement knowledge-test (r3k-t). Ismail SY, Timmerman L, Timman R, Luchtenburg AE, Smak Gregoor PJH, Nette RW, van den Dorpel RMA, Zuidema WC, Weimar W, Massey EK, and Busschbach JJV. ELPAT congres, 20-23 april 2013.

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Interne geneeskunde

Kindergeneeskunde

PubMed publicaties Long-term effects of previous oxandrolone treatment in adult women with Turner syndrome. Freriks K, Sas TC, Traas MA, Netea-Maier RT, den Heijer M, Hermus AR, Wit JM, van Alfenvan der Velden JA, Otten BJ, de Muinck Keizer-Schrama SM, Gotthardt M, Dejonckere PH, Zandwijken GR, Menke LA, Timmers HJ. Eur J Endocrinol. 2012 Dec 10;168(1):91-9. Print 2013 Jan. OBJECTIVE: Short stature is a prominent feature of Turner syndrome (TS), which is partially overcome by GH treatment. We have previously reported the results of a trial on the effect of oxandrolone (Ox) in girls with TS. Ox in a dose of 0.03 mg/kg per day (Ox 0.03) significantly increased adult height gain, whereas Ox mg/kg per day (0.06) did not, at the cost of deceleration of breast development and mild virilization. The aim of this follow-up study in adult participants of the pediatric trial was to investigate the long-term effects of previous Ox treatment. DESIGN AND METHODS: During the previous randomized controlled trial, 133 girls were treated with GH combined with placebo (Pl), Ox 0.03, or Ox 0.06 from 8 years of age and estrogen from 12 years. Sixty-eight women (Pl, n=23; Ox 0.03, n=27;and Ox 0.06, n=18) participated in the double-blind follow-up study (mean age,24.0 years; mean time since stopping GH, 8.7 years; and mean time of Ox/Pl use,4.9 years). We assessed height, body proportions, breast size, virilization, and body composition. RESULTS: Height gain (final minus predicted adult height) was maintained at follow-up (Ox 0.03 10.2±4.9 cm, Ox 0.06 9.7±4.4 cm vs Pl 8.0±4.6 cm). Breast size, Tanner breast stage, and body composition were not different between groups. Ox-treated women reported more subjective virilization and had a lower voice frequency. CONCLUSION: Ox 0.03 mg/kg per day has a beneficial effect on adult height gain in TS patients. Despite previously reported deceleration of breast development during Ox 0.03 treatment, adult breast size is not affected. Mild virilization persists in only a small minority of patients. The long-term evaluation indicates that Ox 0.03 treatment is effective and safe. PMID: 23076845 [PubMed - indexed for MEDLINE]

Patterns of catch-up growth. de Wit CC, Sas TC, Wit JM, Cutfield WS. J Pediatr. 2013 Feb;162(2):415-20. PMID: 23153864 [PubMed - indexed for MEDLINE]

Cerebral aspects of neonatal extracorporeal membrane oxygenation: a review. de Mol AC, Liem KD, van Heijst AF. Neonatology. 2013;104(2):95-103.

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BACKGROUND: Neonatal extracorporeal membrane oxygenation (ECMO) is a lifesaving therapeutic approach in newborns suffering from severe, but potentially reversible, respiratory insufficiency, mostly complicated by neonatal persistent pulmonary hypertension. However, cerebral damage, intracerebral hemorrhage as well as ischemia belong to the most devastating complications of ECMO. OBJECTIVES: The objectives are to give insights into what is known from the literature concerning cerebral damage related to neonatal ECMO treatment for pulmonary reasons. METHODS: A short introduction to ECMO indications and technical aspects of ECMO are provided for a better understanding of the process. The remainder of this review focuses on outcome and especially on (potential) risk factors for cerebral hemorrhage and ischemia during ECMO treatment. RESULTS: Although neonatal ECMO treatment shows improved outcome compared to conservative treatment in cases of severe respiratory insufficiency, it is related to disturbances in various aspects of neurodevelopmental outcome. Risk factors for cerebral damage are either related to the patient’s disease, EMCO treatment itself, or a combination of both. CONCLUSION: It is of ongoing importance to further understand pathophysiological mechanisms resulting in cerebral hemorrhage and ischemia due to ECMO and to develop neuroprotective strategies and approaches. PMID: 23817232 [PubMed - indexed for MEDLINE]

Novel no-stop FLNA mutation causes multi-organ involvement in males. Oegema R, Hulst JM, Theuns-Valks SD, van Unen LM, Schot R, Mancini GM, Schipper ME, de Wit MC, Sibbles BJ, de Coo IF, Nanninga V, Hofstra RM, Halley DJ,Brooks AS. Am J Med Genet A. 2013 Sep;161(9):2376-84. Mutations in FLNA (Filamin A, OMIM 300017) cause X-linked periventricular nodular heterotopia (XL-PNH). XL-PNH-associated mutations are considered lethal in hemizygous males. However, a few males with unusual mutations (including distal truncating and hypomorphic missense mutations), and somatic mosaicism have been reported to survive past infancy. Two brothers had an atypical presentation with failure to thrive and distinct facial appearance including hypertelorism. Evaluations of these brothers and their affected cousin showed systemic involvement including severe intestinal malfunction, malrotation, congenital short bowel, PNH, pyloric stenosis, wandering spleen, patent ductus arteriosus,atrial septal defect, inguinal hernia, and vesicoureteral reflux. The unanticipated finding of PNH led to FLNA testing and subsequent identification of a novel no-stop FLNA mutation (c.7941_7942delCT, p. (*2648Serext*100)). Western blotting and qRT-PCR of patients’ fibroblasts showed diminished levels of protein and mRNA. This FLNA mutation, the most distal reported so far, causes in females classical XL-PNH, but in males an unusual, multi-organ phenotype, providing a unique insight into the FLNA-associated phenotypes. PMID: 23873601 [PubMed - indexed for MEDLINE]

Urine gonadotropin and estradiol levels in female very-low-birth-weight infants. de Jong M, Rotteveel J, Heijboer AC, Cranendonk A, Twisk JW, van Weissenbruch MM. Early Hum Dev. 2013 Mar;89(3):131-5. BACKGROUND: The postnatal activation of the hypothalamic-pituitary-gonadal axis is more exaggerated in preterm than in full-term born infants and may be important for future repro-

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Kindergeneeskunde

ductive function. AIM: The objective of this study was to investigate the postnatal activation of the hypothalamic-pituitary-gonadal axis in female very-low-birth-weight infants. STUDY DESIGN: We performed serial measurements of gonadotropin and estradiol levels in urine samples of female very-low-birth-weight infants collected at 1 and 4weeks postnatal age, at 32weeks postmenstrual age, at expected date of delivery and at the corrected age of three and six months. SUBJECTS: Twenty-two very-low-birth-weight infants (gestational age 25.4-30.1weeks), participating in the Neonatal Insulin Replacement Therapy in Europe trial, were included in this study. OUTCOME MEASURES: Gonadotropin and estradiol levels were measured in serial urine samples. RESULTS: Longitudinal analysis shows that after birth FSH and LH levels increase until 32weeks postmenstrual age (4weeks postnatal age) and then decrease until 3months corrected age (26weeks postnatal age). Estradiol levels decrease from 28weeks postmenstrual age (1week postnatal age) until 6months corrected age (39weeks postnatal age). CONCLUSIONS: Serial urine sampling for measurement of gonadotropin and estradiol levels provides an accurate description of the postnatal activation of the hypothalamic-pituitarygonadal axis in very-low-birth-weight girls. Levels of FSH and LH peak at a mean postmenstrual age of 32weeks (postnatal age of 4weeks) whereas estradiol levels are highest shortly after birth. PMID: 23041221 [PubMed - indexed for MEDLINE]

Components of the metabolic syndrome in early childhood in very-low-birthweight infants. de Jong M, Lafeber HN, Cranendonk A, van Weissenbruch MM. Horm Res Paediatr. 2013 Nov. [Epub ahead of print]. BACKGROUND/AIMS: Term small-for-gestational-age and preterm born infants have an increased prevalence of metabolic syndrome components already in childhood. Data in verylow-birth-weight (VLBW) children are limited. We investigated the prevalence of metabolic syndrome components in VLBW infants at 2 years of corrected age. METHODS: We included 38 children, participating in the Neonatal Insulin Replacement Therapy in Europe (NIRTURE) trial, a randomized controlled trial of early insulin therapy in VLBW infants. Metabolic syndrome components were defined as: body mass index SDS >2; blood pressure (systolic and/or diastolic) ≥90th percentile; triglycerides ≥0.98 mmol/l; high-density lipoprotein(HDL) cholesterol ≤1.03 mmol/l; glucose ≥5.6 mmol/l. RESULTS: Two children (5%)had three metabolic syndrome components, 13 children (34%) had two components,and 11 children (29%) one component. 63% had raised blood pressure (prevalence higher in boys), 32% low HDL, and 30% high triglycerides (prevalence lower in early insulin group). In children with body mass index SDS <0, insulin-treated children had higher HDL than children with standard care. Systolic blood pressure was correlated with growth between term and 2 years of corrected age. CONCLUSIONS: VLBW infants already have a high prevalence of metabolic syndrome components at 2 years of corrected age. Early insulin treatment could have long-term benefits for some of these components. PMID: 24281139 [PubMed - in process]

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Voordrachten Voedselallergie in het eerste levensjaar. Vriesman W. Careyn CB artsen, 14 januari 2104, Dordrecht.

Klinische Richtlijn Turner syndroom. Sas TCJ. Sectie Endocrinologie Kinderen van de NVK, 8 maart 2014, Utrecht.

Growth and Growth promoting therapies in Turner Syndrome – new avenues. Sas TCJ. Turner syndrome – a European perspective, 11 maart 2014, Aarhus Denemarken.

Hoofdpijn bij kinderen. Carbaat P, Graafland O. Nationaal Congres Praktische Pediatrie, 4 april 2013.

Uitkomst na prematuriteit van 32-37 weken: een literatuuroverzicht. Stoelhorst GMSJ. Eerste Symposium Regionale Neonatologie, 31 mei 2013, Dordrecht, Nederland.

SSRI’s bij moeder: richtlijn vs. Praktijk. Wakker-Deelen JE, de Mol AC. Eerste Symposium Regionale Neonatologie, 31 mei 2013, Dordrecht, Nederland.

Erythrocytentransfusie van literatuur naar Richtlijn. de Mol AC. Eerste Symposium Regionale Neonatologie, 31 mei 2013, Dordrecht, Nederland.

Kind in acute nood. Dekker M, van Puffelen E en Graafland O. Albert Event - Albert Schweizter ziekenhuis, 19 juni 2013, Dordrecht, Nederland.

SSRI’s bij moeder: richtlijn vs. Praktijk. Wakker-Deelen JE, de Mol AC. Wetenschapsdag Albert Schweitzer ziekenhuis, 20 juni 2013, Dordrecht, Nederland.

Diagnostische waarde van prenatale pyelum dilatatie bij SEO voor obstructieve urinewegafwijkingen. de Grauw A, Dekker M, de Mol AC, Rombout-de Weerdt S. Wetenschapsdag Albert Schweitzer ziekenhuis, 20 juni 2013, Dordrecht, Nederland.

Long-term effects of oxandrolone treatment in childhood on neurocognition, wellbeing and social-emotional functioning in young adults with Turner syndrome. Freriks K, Verhaak CM, Sas TCJ, Menke LA, Wit JM, Otten BJ, de Muinck Keizer- Schrama SMPF, Smeets DFCM, Netea-Maier RT, Hermus ARMM, Kessels RPC, Timmers HJLM. 29th Annual Meeting of ESHRE – London, 10 juli 2013.

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Kindergeneeskunde

The importance of using an appropriate dose of GH: case of a girl with Turner syndrome. Sas TCJ. European Society for Pediatric Endocrinology, 19 september 2013, Milaan, Italie.

Posters Frequency of moderate and severe diabetes ketoacidosis in newly diagnosed children with diabetes mellitus a study of the Paediatric Diabetes Registry in the Netherlands (PDR.NL). Sas TCJ, Mul D, Schermer-Rotte J, Veeze HJ on behalf of the Dutch Working Group on Diabetes in Children. Annual Symposium of the International Society for Pediatric and Adolescent Diabetes, 16 October 2013, Gothenborg.

Completeness of immunological testing at diagnosis of diabetes mellitus between 1994 and 2012 in the Paediatric Diabetes Registry in the Netherlands (PDR.NL). Mul D, Sas TCJ, Schermer-Rotte J,Veeze HJ on behalf of the Dutch Working Group on Diabetes in Children. Annual Symposium of the International Society for Pediatric and Adolescent Diabetes, 16 October 2013, Gothenborg.

Volledigheid van immunologische testen bij diagnose van diabetes mellitus type 1 tussen 1994 en 2012 in de pediatrische diabetes registratie in Nederland (PDR.NL). Schermer-Rotte J, Mul D, Sas TCJ, Veeze HJ namens de Landelijke Werkgroep Kinderdiabetes van de SEK. Jaarlijkse symposium van de Nederlandse Vereniging voor Kindergeneeskunde, 6 november 2013, Veldhoven.

Appraisal en assessment bij medisch specialisten: wat gaat goed en wat kan beter?” (nav de ASz enquêtes A&A). Drexhage VR. Nederlandse Vereniging voor Medisch Onderwijs (NVMO), Hotel Zuiderduin, 7 november 2013, Egmond aan zee.

Kinderen met ontwikkelingsstoornissen in de basisschoolleeftijd. Doornbos M. Symposium, 20 november 2013, Havenkwartier (Sliedrecht), Nederland.

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Klinische chemie

PubMed publicaties Extreme elevation of serum angiotensin-converting enzyme (ACE) activity: always consider familial ACE hyperactivity. Stouten K, van de Werken M, Tchetverikov I, Saboerali M, Vermeer HJ, Castel R, Verheijen FM. Ann Clin Biochem. 2014 Mar;51(Pt 2):289-93. Measurement of serum angiotensin-converting enzyme (ACE) activity can be helpful in the diagnosis and disease monitoring of sarcoidosis. Elevated serum ACE activity is found in 60-70% of sarcoidosis patients. Usually, the ACE activity is mildly increased (<3-fold the upper limit of the reference range) in sarcoidosis patients. Extremely elevated ACE activity is suggestive of the benign condition known as ‘familial hyperactivity of ACE’. Familial hyperactivity of ACE is a relatively rare condition and can be confirmed by genetic testing. Considering a genetic cause of strongly elevated serum ACE activity is important to prevent possible overdiagnostics. Here, we highlight the factors that may complicate the interpretation of serum ACE activity measurements, and we present two cases that illustrate the importance of interdisciplinary consultation when extremely elevated serum ACE activity is measured. PMID: 23897103 [PubMed - in process]

Response to: Transferrin/log(ferritin) ratio: a self-fulfilling prophecy when iron deficiency is defined by serum ferritin concentration. Castel R, Berendes PB. Clin Chem Lab Med. 2013 May;51(5):e87-8. Comment on Clin Chem Lab Med. 2012 Aug;50(8):1343-9. Clin Chem Lab Med. 2013 May;51(5):e85-6. PMID: 23454714 [PubMed - in process]

Overige publicaties Application of guidelines as a requirement for accreditation of clinical chemistry Laboratories: the Dutch experience. Verboeket-van de Venne WPHG, Vermeer HJ, Kluiters-deHingh YCM, Thelen MHM, Kleinveld HA, Oosterhuis WP. Euromedlab 2013, Milaan, 19-23 Mei 2013.

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Klinische chemie

Early diagnosis of leukemia. Castel R, Riedl JA. CellaVision case report 2013.

The Strange Case of Dr Jekyll and Mr Hyde. Castel R and Riedl JA. CellaVision case report 2013.

Voordrachten Richtlijn NVKC Consultverlening door specialisten laboratoriumgeneeskunde (klinische chemie) – achtergrond, minimum- en streefnormen en vormen van consultverlening. Vermeer HJ. PAOKC Consultverlening, 19 september 2013, Ede.

Patient safety and Laboratory Medicine: to err is human? Vermeer HJ. BioRad Symposium, Into the Future, 10 oktober 2013, Eindhoven.

Een leven lang leren. Vermeer HJ, So R. Nederlandse Vereniging voor Medisch Onderwijs (NVMO), Hotel Zuiderduin, 7 november 2013, Egmond aan Zee.

Posters Macrocytic anaemia: causes and prognosis. Stouten K, Riedl JA, Levin M-D. ASH annual meeting and exposition, New Orleans, December 2013.

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Klinische fysica

Voordrachten Silence in the intensive care unit? van den Berg BI, Leung E, Kuenen KAJM, Niehof SN, Ponssen HH. Nederlandse Intensivistendagen 2013, 14 februari 2013, Ede.

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Klinische fysica

KNO

PubMed publicaties Voordrachten Cholesteatoma in the Zygomatic arch. van der Spek M. Ipswich Temporal Bone Course, 13 juni 2013. Internationaal geaccrediteerde cursus.

Tunnelvisie. van der Spek M. Casuistiek tijdens Cursus KNO Complicatiedagen, 20 september 2013, Oegstgeest. Geaccrediteerde KNO cursus.

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Leerhuis

Voordrachten The importance of feedback in work place based learning [Het belang van feedback bij werkplekleren]. Ridder JMM van de Stagesymposium Opleiding Geneeskunde Universiteit Gent, Ghent Belgium, January 18 & 19, 2013.

Appraisal en Assessment bij medische specialisten: wat gaat goed en wat kan beter? Ridder JMM van de, Hoek B van, Drexhage VR. Paper presented at the Nederlandse Vereniging voor Medisch Onderwijs Congres, Egmond aan Zee, the Netherlands, November 7-8, 2013.

Maatschappelijk Handelen: wat houdt het in en hoe toets je het op de werkvloer? Gardeniers M, Hendriksz TR, Oostenbroek RJ, Ridder JMM van de Round table session presented at the Nederlandse Vereniging voor Medisch Onderwijs Congres, Egmond aan Zee, the Netherlands, November 7-8, 2013.

Perceptieverschillen van feedback bij studenten door impliciete en expliciete feedbackcommunicatie. Ridder JMM van de, Unen E-J van, Meeteren J van. Scientific paper presented at the Nederlandse Vereniging voor Medisch Onderwijs Congres, Egmond aan Zee, the Netherlands, November 7-8, 2013.

Inzicht in ‘boven- en onderstroom’ tijdens evaluatiegesprekken met studenten verpleegkunde. Bart-van der Vorm CJ, Bruijn CN de, Poll E van de, Ridder JMM van de. Poster presented at the Nederlandse Vereniging voor Medisch Onderwijs Congres, Egmond aan Zee, the Netherlands, November 7-8, 2013.

Levenslang leren en ontwikkelen door medische professionals: van ‘competentiegericht’ opleiden naar individuele ‘Appraisal and Assessment’. So RKL, Lemsta A, Ouwerkerk BM van, Ridder JMM van de Workshop presented at the Nederlandse Vereniging voor Medisch Onderwijs Congres, Egmond aan Zee, the Netherlands, November 7-8, 2013.

Hoe geven AIOS-chirurgie en chirurgen feedback: een mixed method studie. Ridder JMM van de, Traas E, Loenhout RB van, Oostenbroek RJ, Plaisier PW.. Paper presented at the Nederlandse Vereniging voor Medisch Onderwijs Congres, Egmond aan Zee, the Netherlands, November 7-8, 2013.

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Kwaliteit, Veiligheid en Innovatie Leerhuis

Het onderwijskwaliteitssysteem en de verbetering van vaardigheden bij supervisie. Oostenbroek RJ, Ridder JMM van de Poster presented at the Nederlandse Vereniging voor Medisch Onderwijs Congres, Egmond aan Zee, the Netherlands, November 7-8, 2013.

Professioneel gedrag en de rol van rolmodellen. Verhoeven BH, Barnhoorn PC on behalf of the NVMO group Professional behavior and Medical Education in Practice.. Symposium NVMO Werkgroep Professioneel Gedrag & NVMO Werkgroep Praktijk van het Medisch Onderwijs. Symposium presented at the Nederlandse Vereniging voor Medisch Onderwijs Congres, Egmond aan Zee, the Netherlands, November 7-8, 2013.

Een goede patiëntenbespreking: zo draag je over! NVMO Werkgroep medische vervolgopleidingen. Baane JA, Witman Y, Oostenbroek RJ, Overeem E.. Workshop presented at the Nederlandse Vereniging voor Medisch Onderwijs Congres, Egmond aan Zee, the Netherlands, November 7-8, 2013.

Kwaliteit van feedback, luistervaardigheid en vertrouwen in eigen kunnen: percepties van AIOS en chirurgen in onze regio. Ridder JMM van de, Molendijk M, Oostenbroek RJ, Plaisier PW. Referaat gehouden op Regionale Refereeravond Regio II, Spaarne Ziekenhuis Hoofddorp, November 6, 2013.

Workshop: Mastery Learning and Deliberate Practice in Medical Education. McGaghie W, Ridder JMM van de Workshop presented at Albert Schweitzer hospital, Dordrecht, Netherlands, August 29, 2013.

Workshop: Mastery Learning and Deliberate Practice in Medical Education. McGaghie W, Ridder JMM van de Workshop presented at the Association for Medical Education in Europe 2013 Conference, Prague, Czech Republic, August 24-28, 2013.

Receiving feedback: How to change a passive listener into an active learner. Ridder JMM van de, Krajic Kachur E, Blatt B, Capello C. Pre-conference Workshop presented at the Association for Medical Education in Europe 2013 Conference, Prague, Czech Republic, August 24-28, 2013.

Workshop: Young medical educator workshop: Problematization and Adaptive Action: Authentic learning for a successful career in Medical Education. Petroni Mennin RH, Mennin S, Huwendiek S, Ringsted C, Amin Z, Ridder JMM van de Workshop presented at the Association for Medical Education in Europe 2013 Conference, Prague, Czech Republic, August 24-28, 2013.

Clerkship feedback content is focused on ‘good points’ and lacks specificity. Ridder JMM van de, Meeteren JM van de, Oostenbroek RJ. Paper presented at the Association for Medical Education in Europe 2013 Conference, Prague, Czech Republic, August 24-28, 2013.

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Educational quality system and the improvement of supervision skills. Oostenbroek RJ, Ridder JMM van de, on behalf of the Programme Committee. Poster presented at the Association for Medical Education in Europe 2013 Conference, Prague, Czech Republic, August 24-28, 2013.

Symposium : Feedback: A fresh look at theories that inform perceptions, acceptance and use. Murdoch-Eaton D, Ridder JMM van de, Sargeant J, Watling C. Symposium presented at the Association for Medical Education in Europe 2013 Conference, Prague, Czech Republic, August 24-28, 2013. http://www.ameelive.org/VOD/Day2_Symposium_Feedback_A_fresh_look_at_theories_that_inform_perceptions_acceptance_and_use_ Video_Archive.php

The use of exit interviews in postgraduate medical education. Verheijen FM, Hollander I den, Bommel EFH van, Oostenbroek RJ, Ridder JMM van de Poster presented at the Association for Medical Education in Europe 2013 Conference, Prague, Czech Republic, August 24-28, 2013.

Exitgesprekken A(N)IOS. Hollander I den, Ridder JMM van de Presentation at the Samenwerkende Topklinische Opleidingsziekenhuizen (STZ)-meeting, Amersfoort, the Netherlands, March 6, 2013.

Maatschappelijk Handelen: wat houdt het in en hoe toets je het op de werkvloer? Maaike Gardeniers M, Hendriksz T, Oostenbroek R, Ridder JMM van de Workshop presented at the STZ OOR-ZWN symposium, Delft, January 23, 2013

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Kwaliteit, Veiligheid en Innovatie Leerhuis

Maag, darm- en levergeneeskunde

PubMed Publicaties Comparing quality, safety, and costs of colonoscopies performed by nurse vs physician trainees. Massl R, van Putten PG, Steyerberg EW, van Tilburg AJ, Lai JY, de Ridder RJ, Brouwer JT, Verburg RJ, Alderliesten J, Schoon EJ, van Leerdam ME, Kuipers EJ. Clin Gastroenterol Hepatol. 2014 Mar;12(3):470-7. doi:0.1016/j.cgh.2013.08.049. Epub 2013 Sep 10. BACKGROUND & AIMS: We evaluated the quality and safety of colonoscopies performed by nurse and physician endoscopy trainees as well as the cost differences. METHODS: We performed a study of 7 nurse and 8 physician (gastroenterology fellows) endoscopy trainees at 2 medical centers in the Netherlands from September 2008 through April 2012. At the beginning of the study, the subjects had no experience in endoscopy; they were trained in gastrointestinal endoscopy according to the regulations of the Dutch Society of Gastroenterology, performing a minimum of 100 colonoscopies. Each trainee then performed 135 consecutive colonoscopies (866 total by nurse trainees and 1080 by physician trainees) under supervision of a gastroenterologist; the colonoscopies were evaluated for quality and safety. We performed statistical analyses of data, assessing multilevel and cost minimization. The mean age of the patients was 57 years, and about half were women in each group. RESULTS: The endoscopic quality and safety were comparable between nurse and physician trainees. Overall rates of cecal intubation were 95% for nurses and 93% for physicians (P = .38), including procedures that required assistance from a supervisor; mean withdrawal times were 10.4 and 9.8 minutes, respectively (P = .44). Each group detected 27% of adenomas and had a 0.5% rate of complication. In both groups, the rates of unassisted cecal intubation gradually increased with the number of colonoscopies performed, from 70% for nurses and 74% for physicians at the beginning to 89% and 86%, respectively, at the end of the assessment period. Using a strategy in which 1 gastroenterologist supervises 3 nurses, the personnel costs decreased from $64.65 to $54.58. CONCLUSIONS: In a supervised setting, nurse endoscopists perform colonoscopies according to quality and safety standards that are comparable with those of physician endoscopist and can substantially reduce costs. PMID: 24036056 [PubMed - in process]

Phenotype of inflammatory bowel disease at diagnosis in the Netherlands: a population- based inception cohort study (the Delta Cohort). Nuij VJ, Zelinkova Z, Rijk MC, Beukers R, Ouwendijk RJ, Quispel R, van Tilburg AJ, Tang TJ, Smalbraak H, Bruin KF, Lindenburg F, Peyrin-Biroulet L, van der Woude CJ; Dutch Delta IBD Group. Inflamm Bowel Dis. 2013 Sep;19(10):2215-22. doi: 10.1097/MIB.0b013e3182961626. BACKGROUND: To describe the clinical characteristics of inflammatory bowel disease (IBD) at

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diagnosis in The Netherlands at the population level in the era of biologics. METHODS: All patients with newly diagnosed IBD (diagnosis made between January 1, 2006 and January 1, 2007) followed in 9 general hospitals in the southwest of the Netherlands were included in this population-based inception cohort study. RESULTS: A total of 413 patients were enrolled, of which 201 Crohn’s disease (CD) (48.7%), 188 ulcerative colitis (UC) (45.5%), and 24 IBD unclassified (5.8%), with a median age of 38 years (range, 14-95). Seventy-eight patients with CD (38.8%) had ileocolonic disease and 73 patients (36.3%) had pure colonic disease. In 8 patients (4.0%), the upper gastrointestinal tract was involved. Nineteen patients with CD (9.5%) had perianal disease. Thirty-nine patients with CD (19.4%) had stricturing phenotype. Of the patients with UC and IBDU, 39 (18.4%) suffered from pancolitis and 61 (29%) from proctitis. Severe endoscopic lesions at diagnosis were seen in 119 patients (28.8%, 68 CD, 49 UC, and 2 IBDU), whereas 98 patients (23.7%) had severe histological disease activity. Thirteen patients (3.1%, 10 CD and 3 UC) had extraintestinal manifestations at diagnosis. Twenty-three patients (5.6%, 20 CD and 3 UC) had fistula at diagnosis. CONCLUSIONS: In this cohort, 31% of the patients with CD had complicated disease at diagnosis, 39% had ileocolonic disease, 9.5% had perianal disease, and in 4% the upper gastrointestinal tract was involved. Most patients with UC suffered from left-sided colitis (51%). Severe endoscopic lesions were reported in 34% of the patients with CD and 26% of the patients with UC. Three percent of the patients with IBD had extraintestinal manifestations. PMID: 23835444 [PubMed - indexed for MEDLINE]

Multiple elevated red spots in a woman with nausea, altered stools, and weight loss. Maas KS, van de Vrie W, Kuizinga MC. Clin Gastroenterol Hepatol. 2014 Jan;12(1):e1. doi: 10.1016/j.cgh.2013.05.022. Epub 2013 Jun 2. PMID: 23735445 [PubMed - in process]

Collaborative authorship Cytotoxic T lymphocyte antigen-4 +49A/G polymorphism does not affect susceptibility to autoimmune hepatitis. van Gerven NM(1), de Boer YS, Zwiers A, van Hoek B, van Erpecum KJ, Beuers U, van Buuren HR, Drenth JP, den Ouden JW, Verdonk RC, Koek GH, Brouwer JT, Guichelaar MM, Vrolijk JM, Kraal G, Mulder CJ, van Nieuwkerk CM, Bouma G; Dutch Autoimmune Hepatitis Study group. … Wolfhagen FH… Liver Int. 2013 Aug;33(7):1039-43. doi: 10.1111/liv.12157. Epub 2013 Mar 31. BACKGROUND & AIMS: Single nucleotide polymorphisms (SNP) in the Cytotoxic T lymphocyte antigen-4 gene (CTLA-4) have been associated with several autoimmune diseases including autoimmune Hepatitis (AIH). In this chronic idiopathic inflammatory liver disease, conflicting results have been reported on the association with a SNP at position +49 in the CTLA-4 gene in small patient cohorts. Here, we established the role of this SNP in a sufficiently large cohort of AIH patients. METHODS: The study population consisted of 672 AIH patients derived from academic and regional hospitals in the Netherlands and was compared with 500 controls selected from the

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Maag-, darm- en levergeneeskunde

‘Genome of the Netherlands’ project cohort. Genotype frequencies were assessed by PCR for patients and by whole genome sequencing for controls. RESULTS: No significant differences in allele frequencies were found between patients and controls (G Allele: 40% vs 39%, P = 0.7). Similarly, no significant differences in genotype frequencies between patients and controls were found. Finally, there was no relation between disease activity and the G allele or AG and GG genotypes. CONCLUSION: The Cytotoxic T Lymphocyte Antigen-4 +49 A/G polymorphism does not represent a major susceptibility risk allele for AIH in Caucasians and is not associated with disease severity at presentation. PMID: 23551963 [PubMed - indexed for MEDLINE]

Relapse is almost universal after withdrawal of immunosuppressive medication in patients with autoimmune hepatitis in remission. van Gerven NM, Verwer BJ, Witte BI, van Hoek B, Coenraad MJ, van Erpecum KJ,Beuers U, van Buuren HR, de Man RA, Drenth JP, den Ouden JW, Verdonk RC, Koek GH,Brouwer JT, Guichelaar MM, Mulder CJ, van Nieuwkerk KM, Bouma G; Dutch Autoimmune Hepatitis Working Group. … Wolfhagen FH… J Hepatol. 2013 Jan;58(1):141-7. doi: 10.1016/j.jhep.2012.09.009. Comment in J Hepatol. 2013 Jan;58(1):5-7. BACKGROUND & AIMS: Current treatment strategies in autoimmune hepatitis (AIH) include long-term treatment with corticosteroids and/or azathioprine. Here we determined the risk of relapse after drug withdrawal in patients in long-term remission and factors associated with such a relapse. METHODS: A total of 131 patients (out of a cohort including 844 patients) from 7 academic and 14 regional centres in the Netherlands were identified in whom treatment was tapered after at least 2 years of clinical and biochemical remission. Relapse was defined as alanine-aminotransferase levels (ALT) three times above the upper limit of normal and loss of remission as a rising ALT necessitating the reinstitution of drug treatment. RESULTS: During follow-up, 61 (47%) patients relapsed and 56 (42%) had a loss of remission. In these 117 patients, 60 patients had fully discontinued medication whereas 57 patients were still on a withdrawal scheme. One year after drug withdrawal, 59% of the patients required retreatment, increasing to 73% and 81% after 2 and 3 years, respectively. Previous combination therapy of corticosteroids and azathioprine, a concomitant autoimmune disease and younger age at time of drug withdrawal were associated with an increased risk of relapse. Subsequent attempts for discontinuation after initial failure in 32 patients inevitably resulted in a new relapse. CONCLUSIONS: This retrospective analysis indicates that loss of remission or relapse occurs in virtually all patients with AIH in long-term remission when immunosuppressive therapy is discontinued. These findings indicate a reluctant attitude towards discontinuation of immunosuppressive treatment in AIH patients. PMID: 22989569 [PubMed - indexed for MEDLINE]

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PubMed Publicaties Indigenous Infection with Francisella tularensis holarctica in The Netherlands. Maraha B, Hajer G, Sjödin A, Forsman M, Paauw A, Roeselers G, Verspui E, Frenay I, Notermans D, de Vries M, Reubsaet F. Case Rep Infect Dis. 2013;2013:916985. We report here the first case of indigenous tularemia detected in The Netherlands, a nonendemic country, since 1953. Whole genome DNA sequence analysis assigned the isolate BD11-00177 to the genomic group B.FTNF002-00, which previously has been exclusively reported from Spain, France, Italy, Switzerland, and Germany. The patient had not been abroad for years, which implies that this is an indigenous infection. The current case might predict an upcoming distribution of Francisella tularensis holarctica genomic group. PMCID: PMC3775396 PMID: 24078889 [PubMed]

Draft genome sequence of Francisella tularensis subsp. holarctica BD11-00177. Coolen JP, Sjödin A, Maraha B, Hajer GF, Forsman M, Verspui E, Frenay HM, Notermans DW, de Vries MC, Reubsaet FA, Paauw A, Roeselers G. Stand Genomic Sci. 2013 Aug 10;8(3):539-47. Francisella tularensis is a facultative intracellular bacterium in the class Gammaproteobacteria. This strain is of interest because it is the etiologic agent of tularemia and a highly virulent category A biothreat agent. Here we describe the draft genome sequence and annotation of Francisella tularensis subsp. holarctica BD11-00177, isolated from the first case of indigenous tularemia detected in The Netherlands since 1953. Whole genome DNA sequence analysis assigned this isolate to the genomic group B.FTNF002-00, which previously has been exclusively reported from Spain, France, Italy, Switzerland and Germany. Automatic annotation of the 1,813,372 bp draft genome revealed 2,103 protein-coding and 46 RNA genes. PMCID: PMC3910693 PMID: 24501637 [PubMed]

Evaluation of yield of currently available diagnostics by sample type to optimize detection of respiratory pathogens in patients with a community-acquired pneumonia. Huijskens EG, Rossen JW, Kluytmans JA, van der Zanden AG, Koopmans M. Influenza Other Respir Viruses. 2014 Mar;8(2):243-9. BACKGROUND: For the detection of respiratory pathogens, the sampling strategy may influence the diagnostic yield. Ideally, samples from the lower respiratory tract are collected, but they are difficult to obtain.

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Kwaliteit, microbiologie Medische Veiligheid en Innovatie

OBJECTIVES: In this study, we compared the diagnostic yield in sputum and oropharyngeal samples (OPS) for the detection of respiratory pathogens in patients with community-acquired pneumonia (CAP), with the objective to optimize our diagnostic testing algorithm. METHODS: Matched sputum samples, OPS, blood cultures, serum, and urine samples were taken from patients (>18 years) with CAP and tested for the presence of possible respiratory pathogens using bacterial cultures, PCR for 17 viruses and five bacteria and urinary antigen testing. RESULTS: When using only conventional methods, that is, blood cultures, sputum culture, urinary antigen tests, a pathogen was detected in 49·6% of patients (n = 57). Adding molecular detection assays increased the yield to 80%. A pathogen was detected in 77 of the 115 patients in OPS or sputum samples by PCR. The sensitivity of the OPS was lower than that of the sputum samples (57% versus 74%). In particular, bacterial pathogens were more often detected in sputum samples. The sensitivity of OPS for the detection of most viruses was higher than in sputum samples (72% versus 66%), except for human rhinovirus and respiratory syncytial virus. CONCLUSION: Addition of PCR on both OPS and sputum samples significantly increased the diagnostic yield. For molecular detection of bacterial pathogens, a sputum sample is imperative, but for detection of most viral pathogens, an OPS is sufficient. PMID: 23957707 [PubMed - in process]

The value of signs and symptoms in differentiating between bacterial, viral and mixed aetiology in patients with community-acquired pneumonia. Huijskens EG, Koopmans M, Palmen FM, van Erkel AJ, Mulder PG, Rossen JW. J Med Microbiol. 2014 Mar;63(Pt 3):441-52. Current diagnostics for community-acquired pneumonia (CAP) include testing for a wide range of pathogens, which is costly and not always informative. We compared clinical and laboratory parameters of patients with CAP caused by different groups of pathogens to evaluate the potential for targeted diagnostics and directed treatment. In a prospective study, conducted between April 2008 and April 2009, adult patients with CAP were tested for the presence of a broad range of possible respiratory pathogens using bacterial cultures, PCR, urinary antigen testing and serology. Of 408 patients with CAP, pathogens were detected in 263 patients (64.5%). Streptococcus pneumoniae and influenza A virus were the most frequently identified bacterial and viral pathogens, respectively. Age had a significant effect on the prediction of aetiology (P = 0.054), with an increase in the relative contribution of viruses with advancing age. Multivariate analyses further showed that the presence of cough increased the likelihood of detecting a viral pathogen [odds ratio (OR) 5.536, 95% confidence interval (CI) 2.130-14.390], the presence of immunodeficiency decreased the likelihood of detecting a bacterial pathogen (OR 0.595, 95% CI 0.246-1.437) and an increase in pneumonia severity index score increased the likelihood of detecting a pathogen in general. Although several variables were independently associated with the detection of a pathogen group, substantial overlap meant there were no reliable clinical predictors to distinguish aetiologies. Therefore, testing for common respiratory pathogens is still necessary to optimize treatment. PMID: 24344207 [PubMed - in process]

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Difficulties in diagnosing terminal ileitis due to Yersinia pseudotuberculosis. Wunderink HF, Oostvogel PM, Frénay IH, Notermans DW, Fruth A, Kuijper EJ. Eur J Clin Microbiol Infect Dis. 2014 Feb;33(2):197-200. doi: 10.1007/s10096-013-1943-4. Epub 2013 Aug 8. We report three patients with terminal ileitis and positive fecal cultures with Yersinia pseudotuberculosis. From one patient, a virulence plasmid (pYV)-negative Y. pseudotuberculosis was isolated, which represents the second finding of a pYV-negative isolate associated with human disease. All patients were treated with ciprofloxacin and fully recovered. Since conventional culture methods for yersiniosis are gradually replaced with molecular tests not recognizing Y. pseudotuberculosis, we recommend to include a specific culture medium or to apply a specific polymerase chain reaction (PCR) assay on fecal samples from patients suspected of terminal ileitis. PMID: 23925588 [PubMed - in process]

Collaborative authorship Selective decontamination of the oropharynx and the digestive tract, and antimicrobial resistance: a 4 year ecological study in 38 intensive care units in the Netherlands. Houben AJ, Oostdijk EA, van der Voort PH, Monen JC, Bonten MJ, van der Bij AK; ISIS-AR Study Group. … Frénay I… J Antimicrob Chemother. 2014 Mar;69(3):797-804. doi: 10.1093/jac/dkt416. Epub 2013 Oct 21. Comment in J Antimicrob Chemother. 2014 Mar;69(3):861. J Antimicrob Chemother. 2014 Mar;69(3):860. OBJECTIVES: Selective oropharyngeal decontamination (SOD) and selective decontamination of the digestive tract (SDD) are associated with improved outcomes among patients in intensive care units (ICUs), but uncertainty remains about their long-term effects on resistance levels. We determined trends in antibiotic resistance among Gram-negative bacteria in 38 Dutch ICUs using and not using SOD/SDD. METHODS: The Infectious Disease Surveillance Information System-Antibiotic Resistance (ISIS-AR) was used to identify all Enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter spp. isolates from blood and respiratory tract specimens from ICUs between January 2008 and April 2012. Per patient, the last isolate per species per specimen per month was selected to determine cumulative resistance rates (per 100 beds/month) for colistin, tobramycin, ciprofloxacin, ceftazidime and cefotaxime/ceftriaxone in ICUs that continuously used or did not use SOD/SDD, and ICUs that introduced SOD/SDD. Time trends were analysed by multilevel Poisson regression. RESULTS: Seventeen ICUs continuously used SOD/SDD (859 months), 13 did not use SOD/ SDD (663 months) and 8 introduced SOD/SDD (223 and 117 months before and after introduction). There were no discernible trends in antibiotic resistance among 637 blood isolates. For the 8353 respiratory isolates, resistance to cefotaxime/ceftriaxone increased in ICUs that

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did not use SOD/SDD (P < 0.001) and decreased in those that continuously used SOD/SDD (P = 0.04), as did resistance to ciprofloxacin (P < 0.001). The introduction of SOD/SDD was followed by statistically significant reductions in resistance rates for all antimicrobial agents. CONCLUSIONS: Continuous use of SOD/SDD was associated with decreasing trends for resistance to cefotaxime/ceftriaxone and ciprofloxacin. The introduction of SOD/SDD was associated with reductions in resistance rates for all antimicrobial agents included. PMID: 24144922 [PubMed - in process]

Selective decontamination of the digestive tract and selective oropharyngeal decontamination in intensive care unit patients: a cost-effectiveness analysis. Oostdijk EA, de Wit GA, Bakker M, de Smet AM, Bonten MJ; Dutch SOD-SDD trialists group. … Frénay I… BMJ Open. 2013 Mar 5;3(3). pii: e002529. doi: 10.1136/bmjopen-2012-002529. OBJECTIVE: To determine costs and effects of selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) as compared with standard care (ie, no SDD/SOD (SC)) from a healthcare perspective in Dutch Intensive Care Units (ICUs). DESIGN: A post hoc analysis of a previously performed cluster-randomised trial (NEJM 2009;360:20). SETTING: 13 Dutch ICUs. PARTICIPANTS: Patients with ICU-stay of >48 h that received SDD (n=2045), SOD (n=1904) or SC (n=1990). INTERVENTIONS: SDD or SOD. PRIMARY AND SECONDARY OUTCOME MEASURES: Effects were based on hospital survival, expressed as crude Life Years Gained (cLYG). The incremental cost-effectiveness ratio (ICER) was calculated, with corresponding cost acceptability curves. Sensitivity analyses were performed for discount rates, costs of SDD, SOD and mechanical ventilation. RESULTS: Total costs per patient were €41 941 for SC (95% CI €40 184 to €43 698), €40 433 for SOD (95% CI €38 838 to €42 029) and €41 183 for SOD (95% CI €39 408 to €42 958). SOD and SDD resulted in crude LYG of +0.04 and +0.25, respectively, as compared with SC, implying that both SDD and SOD are dominant (ie, cheaper and more beneficial) over SC. In cost-effectiveness acceptability curves probabilities for cost-effectiveness, compared with standard care, ranged from 89% to 93% for SOD and from 63% to 72% for SDD, for acceptable costs for 1 LYG ranging from €0 to €20 000. Sensitivity analysis for mechanical ventilation and discount rates did not change interpretation. Yet, if costs of the topical component of SDD and SOD would increase 40-fold to €400/day and €40/day (maximum values based on free market prices in 2012), the estimated ICER as compared with SC for SDD would be €21 590 per LYG. SOD would remain cost-saving. CONCLUSIONS: SDD and SOD were both effective and cost-saving in Dutch ICUs. PMCID: PMC3612803 PMID: 23468472 [PubMed]

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Consequences of switching from a fixed 2 : 1 ratio of oxicillin/clavulanate (CLSI) to a fixed concentration of clavulanate (EUCAST) for susceptibility testing of Escherichia coli. Leverstein-van Hall MA(1), Waar K, Muilwijk J, Cohen Stuart J; ISIS-AR Study Group. … Frénay I… J Antimicrob Chemother. 2013 Nov;68(11):2636-40. doi: 10.1093/jac/dkt218. Epub 2013 Jun 13. OBJECTIVES: The CLSI recommends a fixed 2 : 1 ratio of co-amoxiclav for broth microdilution susceptibility testing of Enterobacteriaceae, while EUCAST recommends a fixed 2 mg/L clavulanate concentration. The aims of this study were: (i) to determine the influence of a switch from CLSI to EUCAST methodology on Escherichia coli susceptibility rates; (ii) to compare susceptibility results obtained using EUCAST-compliant microdilution with those from disc diffusion and the Etest; and (iii) to evaluate the clinical outcome of patients with E. coli sepsis treated with co-amoxiclav in relation to the susceptibility results obtained using either method. METHODS: Resistance rates were determined in three laboratories that switched from CLSI to EUCAST cards with the Phoenix system (Becton Dickinson) as well as in 17 laboratories that continued to use CLSI cards with the VITEK 2 system (bioMérieux). In one laboratory, isolates were simultaneously tested by both the Phoenix system and either disc diffusion (n = 471) or the Etest (n = 113). Medical and laboratory records were reviewed for E. coli sepsis patients treated with co-amoxiclav monotherapy. RESULTS: Only laboratories that switched methodology showed an increase in resistance rates - from 19% in 2010 to 31% in 2011 (P < 0.0001). All isolates that tested susceptible by microdilution were also susceptible by disc diffusion or the Etest, but of 326 isolates that tested resistant by microdilution, 43% and 59% tested susceptible by disc diffusion and the Etest, respectively. Among the 89 patients included there was a better correlation between clinical response and measured MICs using the Phoenix system than the Etest. CONCLUSIONS: EUCAST methodology resulted in higher co-amoxiclav E. coli resistance rates than CLSI methodology, but correlated better with clinical outcome. EUCAST-compliant microdilution and disc diffusion provided discrepant results. PMID: 23766488 [PubMed - indexed for MEDLINE]

Overige publicaties Antimicrobiële resistentie bij urineweginfecties bij (kwetsbare) ouderen > 70 jaar. Frénay I, van der Bij A. Tijdschr. Ouderengeneeskunde, 2013 (01): 18-19.

Voordrachten Yersinia pseudotuberculosisas cause of terminal ileitis without diarrhea in three patients. Wunderink HF, Oostvogel PM, Frénay HME, Noterman DW, Furth A, Kuiper EJ. (www.nvvm-online.nl/modules/2013-program).

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Three cases of terminal ileitis due to Yersinia pseudotuberculosis. Wunderink HF, Oostvogel PM, Frénay HME, Noterman DW, Furth A, Kuiper EJ. In: http://eccmid.insideguidance.com/programme2013/p.2484.

Outbreaks of Clostridium difficile type 027 infections in nursing homes: tip of the iceberg? van Dorp S, Kuiper EJ, Verspui EA, van der Zwet WC, Frénay I, Notermans DW. (www.nvvm-online.nl/modules/2013 -program).

Urineweginfecties (UWI’s): Antibiotica en resistentie bij micro-organismen in verpleeghuizen. Frénay HME. (SNIV, Regioavond Verenso Den Haag e.o. January 30, 2013).

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Neurologie

PubMed publicaties Clinical Aspects of Co-Morbid Schizophrenia and Idiopathic Parkinson’s Disease. de Jong MH, Zemel D, Van Gool AR. Clin Schizophr Relat Psychoses. 2013 Feb 21:1-13. [Epub ahead of print] The co-morbidity of schizophrenia and idiopathic Parkinson’s disease (IPD) is illustrated by a case description of a schizophrenic patient, who develops motor symptoms finally diagnosed and treated as co-morbid IPD. Several aspects of the clinical challenges of this comorbidity are discussed and an overview of earlier reported cases is presented. IPD must be distinguished from neuroleptic induced parkinsonism by clinical course and characteristics. A SPECT scan is helpful for diagnosis. We recommend antiparkinsonian treatment to be prescribed only with the protection of antipsychotic agents of which clozapine and quetiapine are the best choices. PMID: 23428786 [PubMed - as supplied by publisher]

Novel no-stop FLNA mutation causes multi-organ involvement in males. Oegema R, Hulst JM, Theuns-Valks SD, van Unen LM, Schot R, Mancini GM, Schipper ME, de Wit MC, Sibbles BJ, de Coo IF, Nanninga V, Hofstra RM, Halley DJ, Brooks AS. Am J Med Genet A. 2013 Sep;161(9):2376-84. doi: 10.1002/ajmg.a.36109. Epub 2013 Jul 19. Mutations in FLNA (Filamin A, OMIM 300017) cause X-linked periventricular nodular heterotopia (XL-PNH). XL-PNH-associated mutations are considered lethal in hemizygous males. However, a few males with unusual mutations (including distal truncating and hypomorphic missense mutations), and somatic mosaicism have been reported to survive past infancy. Two brothers had an atypical presentation with failure to thrive and distinct facial appearance including hypertelorism. Evaluations of these brothers and their affected cousin showed systemic involvement including severe intestinal malfunction, malrotation, congenital short bowel, PNH, pyloric stenosis, wandering spleen, patent ductus arteriosus, atrial septal defect, inguinal hernia, and vesicoureteral reflux. The unanticipated finding of PNH led to FLNA testing and subsequent identification of a novel no-stop FLNA mutation (c.7941_7942delCT, p.(*2648Serext*100)). Western blotting and qRT-PCR of patients’ fibroblasts showed diminished levels of protein and mRNA. This FLNA mutation, the most distal reported so far, causes in females classical XL-PNH, but in males an unusual, multi-organ phenotype, providing a unique insight into the FLNA-associated phenotypes. PMID: 23873601 [PubMed - indexed for MEDLINE]

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Kwaliteit, Veiligheid en Innovatie Neurologie

Efficacy of intrathecal baclofen on different pain qualities in complex regional pain syndrome. van der Plas AA, van Rijn MA, Marinus J, Putter H, van Hilten JJ. Anesth Analg. 2013 Jan;116(1):211-5. doi: 10.1213/ANE.0b013e31826f0a2e. Epub 2012 Dec 7. BACKGROUND: Complex regional pain syndrome (CRPS) is characterized by severe debilitating chronic pain. Patients with CRPS may experience various pain sensations, which likely embody different pathophysiologic mechanisms. In this study, we evaluated the differential effects of central γ-aminobutyric acid (B) receptor stimulation on the different pain qualities in CRPS patients with dystonia. METHODS: The 10 pain qualities of the neuropathic pain scale, dystonia severity, and changes in use of antinociceptive drugs were evaluated every 3 months for a period of 1 year in 42 CRPS patients with dystonia receiving titrated doses of intrathecal baclofen (ITB) treatment in an open design. RESULTS: Using a linear mixed model analysis and controlling for global dystonia severity and the use of supplemental analgesics, we found a significant improvement in global intense pain, sharp pain, dull pain, and deep pain during the first 6 months. After this period, the scores leveled off despite further improvement of dystonia and continued ITB dose escalation. CONCLUSIONS: γ-Aminobutyric acid (B) receptor stimulation by ITB exerts differential antinociceptive effects on specific pain qualities in CRPS patients with dystonia. PMID: 23223108 [PubMed - indexed for MEDLINE]

Voordrachten Beleid en diagnostiek bij hersenmetastasen. de Beukelaar JWK. Rotterdamse Regionale Neurologen Bijeenkomst, Dordrecht, 10 juni 2013. Geaccrediteerd door Nederlandse Vereniging voor Neurologie.

De les is de vraag. Herseninfarct bij KHAT gebruik. de Beukelaar JWK. Regionale Neurologen Nascholing Zuidwest Nederland, Groningen, 26 januari 2014. Geaccrediteerd door de Nederlandse Vereniging voor Neurologie.

Ritme monitoring op de stroke unit. Zinvol of toch niet? Zock E. Regionale refereeravond Neurologie, Dordrecht, 10 juni 2013. Geaccrediteerd door de NVN.

Dealy in acute stroke treatment. Zock E. Wetenschappelijke neurovasculaire nascholing. Amsterdam, 12.09.2013. Geaccrediteerd door de NVN.

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Neurochirurgie

PubMed publicaties A randomised trial of high and low pressure level settings on an adjustable ventriculoperitoneal shunt valve for idiopathic normal pressure hydrocephalus: results of the Dutch evaluation programme Strata shunt (DEPSS) trial. Delwel EJ, de Jong DA, Dammers R, Kurt E, van den Brink W, Dirven CM. J Neurol Neurosurg Psychiatry. 2013 Jul;84(7):813-7. BACKGROUND: In treating idiopathic normal pressure hydrocephalus (INPH) with a shunt there is always a risk of underdrainage or overdrainage. The hypothesis is tested whether patients treated using an adjustable valve preset at the highest opening pressure leads to comparable good clinical results with less subdural effusions than in a control group with an opening pressure preset at a low pressure level. METHODS: A multicentre prospective randomised trial was performed on a total of 58 patients suspected of INPH. Thirty patients were assigned to (control) group 1 and received a Strata shunt (Medtronic, Goleta, USA) with the valve preset at a performance level (PL) of 1.0, while 28 patients were assigned to group 2 and received a Strata shunt with the valve preset at PL 2.5. In this group the PL was allowed to be lowered until improvement or radiological signs of overdrainage were met. RESULTS: Significantly more subdural effusions were observed in the improved patients of group 1. There was no statistically significant difference in improvement between both groups overall. CONCLUSIONS: On the basis of this multicentre prospective randomised trial it is to be recommended to treat patients with INPH with a shunt with an adjustable valve, preset at the highest opening pressure and lowered until clinical improvement or radiological signs of overdrainage occur although slower improvement and more shunt adjustments might be the consequence. PMID: 23408069 [PubMed - indexed for MEDLINE]

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Kwaliteit, Veiligheid en Innovatie Neurochirurgie

Oogheelkunde

PubMed publicaties Clinical presentation and morbidity of contact lens-associated microbial keratitis: a retrospective study. Hoddenbach JG, Boekhoorn SS, Wubbels R, Vreugdenhil W, Van Rooij J, Geerards AJ. Graefes Arch Clin Exp Ophthalmol. 2014 Feb;252(2):299-306. doi: 10.1007/s00417-013-2514-1. Epub 2013 Nov 27. PURPOSE: To investigate the clinical presentation, isolated organism, treatment, and morbidity of contact lens-associated microbial keratitis needing hospitalization. METHODS: This retrospective study included all consecutive patients with contact lens-associated microbial keratitis hospitalized in the Rotterdam Eye Hospital from January 1, 2005, to December 31, 2009. All data regarding epidemiological characteristics, clinical presentation, isolated organism, and treatment were collected from medical records. RESULTS: There were 109 cases (108 patients) of contact lens-associated microbial keratitis hospitalized during the study period. Mean age was 33.3 ± 15.4 (SD) years. Pseudomonas aeruginosa was the most frequently isolated microorganism (68.8%), with minor resistance to gentamicin (2.7%) and ofloxacin (1.3%). At time of presentation, best corrected visual acuity (BCVA) was very poor, with the largest proportion of patients (65.1%) seeing worse than 0.05 Snellen. After intensive treatment, the visual outcome improved considerably, with the largest proportion (67.0%) achieving a BCVA ≥ 0.7 Snellen. Low BCVA at admission was significantly associated with a worse final BCVA. A total of 22 patients (20.2%) required corneal transplantation (three emergency cases). Larger size of stromal infiltrate was significantly associated with the need for corneal transplantation. CONCLUSION: Microbial keratitis is a serious complication of contact lens wear, with approximately one out of five hospitalized cases requiring corneal transplantation. Ofloxacin, or a combination of gentamicin and cephazolin, still appear to be excellent first-choice therapies in the Netherlands, as little resistance has developed to these antibiotics. PMID: 24281783 [PubMed - in process]

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Orthopedie

Voordrachten A relatively easy and cost effective treatment for femoral bone stock problems in –revision- hip arthroplasty. Van Koeveringe AJ. World orthopedic congres te Bejing, 7-10 nov 2013. AIMS: In order to achieve a good primary stability a long femoral stem (MP-stem, Link, Germany)is used to bridge bone defects, which usually results in a long lasting hip replacement. Many systems are available to achieve this goal. We describe a cost effective system with good functionality and few accessory components, which is besides this, easy to use without too many parts in stock. PATIENTS AND METHODS: The Link-MP stem has four different lengths (18-21-25-30 cm) and reaches from 12-20 mm (2 mm steps) diameter for the distal part. The distal diafyseal fixing stem is introduced using a special handpiece with the advantage that the proximal part can be placed after introduction of the distal stem into the bone. For construction of the proximal part an elongation of three centimeters is still possible as two different offsets can be chosen. For cases of very poor bone quality or a lack of a diafyseal isthmus to support the stem, two sizes of cemented distal stems are available. Between 2009 and 2012, 18 patients were treated with the Link MP long stem. In 13 cases the stem was placed in revision cases, once in tumor and 4 times after a fracture (1 periprosthetic). In 5 patients, the distal part of the MP-stem was cemented due to either limited bone strength distally, or in cases of revision of a previous long stem. In the remaining 13 cases, an uncemented distal part was chosen. To ascertain a good primary stability in 11 of the cases, we used cables and cable plates to prevent collateral fractures during sledging-in the distal stem, as well as providing accessory rotational and longitudinal stability of the proximal part. In 10 cases, a double mobility cup (Advantage, Biomet) was placed, with additional reinforcement in 3 cases. The Oxford hip score was determined and radiographs were evaluated before operation and after one year follow up. RESULTS: Quality of life was significantly increased in all patients according to the Oxford hip score. An average improvement of 22 points on a total scale of 48 points was achieved. The procedure was complicated in one case by a subsidence of 4mm. One sciatic nerve palsy and one chronic luxation was seen additionally. One superficial infection was documented and no deep infections took place. Conclusion: Using the relatively cheap MP-stem with accessory cables and plates, only one case of a slight subsidence was seen during the follow up period. Notwithstanding the limited number of sizes and offset options, we detected a satisfactory result with a stable and well weight loadable implant with a significant increase in quality of life in all patients.

Management of acetabular bone loss in Type III acetabular defects. Van Koeveringe AJ. International symposium on revision hip and knee joint arthroplasty te Hamburg, 18 en 19 nov 2013.

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Orthopedie

Pathologie

PubMed publicaties Non-pheochromocytoma (PCC)/paraganglioma (PGL) tumors in patients with succinate dehydrogenase-related PCC-PGL syndromes: a clinicopathological and molecular analysis. Papathomas TG, Gaal J, Corssmit EP, Oudijk L, Korpershoek E, Heimdal K, Bayley JP, Morreau H, van Dooren M, Papaspyrou K, Schreiner T, Hansen T, Andresen PA,Restuccia DF, van Kessel I, van Leenders GJ, Kros JM, Looijenga LH, Hofland LJ,Mann W, van Nederveen FH, Mete O, Asa SL, de Krijger RR, Dinjens WN. Eur J Endocrinol. 2013 Nov 22;170(1):1-12. doi: 10.1530/EJE-13-0623. Print 2014 Jan. OBJECTIVE: Although the succinate dehydrogenase (SDH)-related tumor spectrum has been recently expanded, there are only rare reports of non-pheochromocytoma/paraganglioma tumors in SDHx-mutated patients. Therefore, questions still remain unresolved concerning the aforementioned tumors with regard to their pathogenesis, clinicopathological phenotype, and even causal relatedness to SDHx mutations. Absence of SDHB expression in tumors derived from tissues susceptible to SDH deficiency is not fully elucidated. DESIGN AND METHODS: Three unrelated SDHD patients, two with pituitary adenoma (PA) and one with papillary thyroid carcinoma (PTC), and three SDHB patients affected by renal cell carcinomas (RCCs) were identified from four European centers. SDHA/SDHB immunohistochemistry (IHC), SDHx mutation analysis, and loss of heterozygosity analysis of the involved SDHx gene were performed on all tumors. A cohort of 348 tumors of unknown SDHx mutational status, including renal tumors, PTCs, PAs, neuroblastic tumors, seminomas, and adenomatoid tumors, was investigated by SDHB IHC. RESULTS: Of the six index patients, all RCCs and one PA displayed SDHB immunonegativity in contrast to the other PA and PTC. All immunonegative tumors demonstrated loss of the WT allele, indicating bi-allelic inactivation of the germline mutated gene. Of 348 tumors, one clear cell RCC exhibited partial loss of SDHB expression. CONCLUSIONS: These findings strengthen the etiological association of SDHx genes with pituitary neoplasia and provide evidence against a link between PTC and SDHx mutations. Somatic deletions seem to constitute the second hit in SDHB-related renal neoplasia, while SDHx alterations do not appear to be primary drivers in sporadic tumorigenesis from tissues affected by SDH deficiency. PMID: 24096523 [PubMed - indexed for MEDLINE]

ACTH-independent macronodular adrenocortical hyperplasia reveals prevalent aberrant in vivo and in vitro responses to hormonal stimuli and coupling of arginine-vasopressin type 1a receptor to 11β-hydroxylase. Hofland J(1), Hofland LJ, van Koetsveld PM, Steenbergen J, de Herder WW, van Eijck CH, de Krijger RR, van Nederveen FH, van Aken MO, de Groot JW, Links TP, de Jong FH, Feelders RA. Orphanet J Rare Dis. 2013 Sep 13;8:142. doi: 10.1186/1750-1172-8-142.

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BACKGROUND: Adrenal Cushing’s syndrome caused by ACTH-independent macronodular adrenocortical hyperplasia (AIMAH) can be accompanied by aberrant responses to hormonal stimuli. We investigated the prevalence of adrenocortical reactions to these stimuli in a large cohort of AIMAH patients, both in vivo and in vitro. METHODS: In vivo cortisol responses to hormonal stimuli were studied in 35 patients with ACTH-independent bilateral adrenal enlargement and (sub-)clinical hypercortisolism. In vitro, the effects of these stimuli on cortisol secretion and steroidogenic enzyme mRNA expression were evaluated in cultured AIMAH and other adrenocortical cells. Arginine-vasopressin (AVP) receptor mRNA levels were determined in the adrenal tissues. RESULTS: Positive serum cortisol responses to stimuli were detected in 27/35 AIMAH patients tested, with multiple responses within individual patients occurring for up to four stimuli. AVP and metoclopramide were the most prevalent hormonal stimuli triggering positive responses in vivo. Catecholamines induced short-term cortisol production more often in AIMAH cultures compared to other adrenal cells. Short- and long-term incubation with AVP increased cortisol secretion in cultures of AIMAH cells. AVP also increased steroidogenic enzyme mRNA expression, among which an aberrant induction of CYP11B1. AVP type 1a receptor was the only AVPR expressed and levels were high in the AIMAH tissues. AVPR1A expression was related to the AVP-induced stimulation of CYP11B1. CONCLUSIONS: Multiple hormonal signals can simultaneously induce hypercortisolism in AIMAH. AVP is the most prevalent eutopic signal and expression of its type 1a receptor was aberrantly linked to CYP11B1 expression. PMCID: PMC3847204 PMID: 24034279 [PubMed - in process]

Genetics of hereditary head and neck paragangliomas. Boedeker CC, Hensen EF, Neumann HP, Maier W, van Nederveen FH, Suárez C, Kunst HP, Rodrigo JP, Takes RP, Pellitteri PK, Rinaldo A, Ferlito A. Head Neck. 2013 Aug 3. doi: 10.1002/hed.23436. [Epub ahead of print] BACKGROUND: The purpose of this study was to give an overview on hereditary syndromes associated with head and neck paragangliomas (HNPGs). METHODS: Our methods were the review and discussion of the pertinent literature. RESULTS: About one third of all patients with HNPGs are carriers of germline mutations. Hereditary HNPGs have been described in association with mutations of 10 different genes. Mutations of the genes succinate dehydrogenase subunit D (SDHD), succinate dehydrogenase complex assembly factor 2 gene (SDHAF2), succinate dehydrogenase subunit C (SDHC), and succinate dehydrogenase subunit B (SDHB) are the cause of paraganglioma syndromes (PGLs) 1, 2, 3, and 4. Succinate dehydrogenase subunit A (SDHA), von Hippel-Lindau (VHL), and transmembrane protein 127 (TMEM127) gene mutations also harbor the risk for HNPG development. HNPGs in patients with rearranged during transfection (RET), neurofibromatosis type 1 (NF1), and MYC-associated factor X (MAX) gene mutations have been described very infrequently. CONCLUSION: All patients with HNPGs should be offered a molecular genetic screening. This screening may usually be restricted to mutations of the genes SDHD, SDHB, and SDHC. Certain clinical parameters can help to set up the order in which those genes should be tested. PMID: 23913591 [PubMed - as supplied by publisher]

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Pathologie

Protein kinase C-induced activin A switches adrenocortical steroidogenesis to aldosterone by suppressing CYP17A1 expression. Hofland J, Steenbergen J, Hofland LJ, van Koetsveld PM, Eijken M, van Nederveen FH, Kazemier G, de Herder WW, Feelders RA, de Jong FH. Am J Physiol Endocrinol Metab. 2013 Sep 15;305(6):E736-44. doi: 10.1152/ ajpendo.00034.2013. Epub 2013 Jul 30. Functional zonation of the adrenal cortex is a consequence of the zone-specific expression of P450c17 (CYP17A1) and its cofactors. Activin and inhibin peptides are differentially produced within the zones of the adrenal cortex and have been implicated in steroidogenic control. In this study, we investigated whether activin and inhibin can function as intermediates in functional zonation of the human adrenal cortex. Activin A suppressed CYP17A1 expression and P450c17 function in adrenocortical cell lines as well as in primary adrenal cell cultures. Inhibin βA-subunit mRNA and activin A protein levels were found to be increased up to 1,900-fold and 49-fold, respectively, after protein kinase C (PKC) stimulation through PMA or angiotensin II in H295R adrenocortical carcinoma cells. This was confirmed in HAC15 cells and for PMA in primary adrenal cell cultures. Both PMA and Ang II decreased CYP17A1 expression in the adrenocortical cell lines, whereas PMA concurrently suppressed CYP17A1 levels in the primary cultures. Inhibition of activin signaling during PKC stimulation through silencing of the inhibin βA-subunit or blocking of the activin type I receptor opposed the PMA-induced downregulation of CYP17A1 expression and P450c17 function. In contrast, PKA stimulation through adrenocorticotrophin or forskolin increased expression of the inhibin α-subunit and betaglycan, both of which are antagonists of activin action. These data indicate that activin A acts as a PKC-induced paracrine factor involved in the suppression of CYP17A1 in the zona glomerulosa and can thereby contribute to functional adrenocortical zonation. PMID: 23900415 [PubMed - indexed for MEDLINE]

SDHA mutations in adult and pediatric wild-type gastrointestinal stromal tumors. Oudijk L, Gaal J, Korpershoek E, van Nederveen FH, Kelly L, Schiavon G, Verweij J, Mathijssen RH, den Bakker MA, Oldenburg RA, van Loon RL, O’Sullivan MJ, de Krijger RR, Dinjens WN. Mod Pathol. 2013 Mar;26(3):456-63. doi: 10.1038/modpathol.2012.186. Most gastrointestinal stromal tumors (GISTs) harbor oncogenic mutations in KIT or platelet-derived growth factor receptor-α. However, a small subset of GISTs lacks such mutations and is termed ‘wild-type GISTs’. Germline mutation in any of the subunits of succinate dehydrogenase (SDH) predisposes individuals to hereditary paragangliomas and pheochromocytomas. However, germline mutations of the genes encoding SDH subunits A, B, C or D (SDHA, SDHB, SDHC or SDHD; collectively SDHx) are also identified in GISTs. SDHA and SDHB immunohistochemistry are reliable techniques to identify pheochromocytomas and paragangliomas with mutations in SDHA, SDHB, SDHC and SDHD. In this study, we investigated if SDHA immunohistochemistry could also identify SDHA-mutated GISTs. Twenty-four adult wild-type GISTs and nine pediatric/adolescent wild-type GISTs were analyzed with SDHB, and where this was negative, then with SDHA immunohistochemistry. If SDHA immunohistochemistry was negative, sequencing analysis of the entire SDHA coding sequence was performed. All nine pediatric/adolescent GISTs and seven adult wild-type GISTs were negative for SDHB immunohistochemistry. One pediatric GIST and three

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SDHB-immunonegative adult wild-type GISTs were negative for SDHA immunohistochemistry. In all four SDHA-negative GISTs, a germline SDHA c.91C>T transition was found leading to a nonsense p.Arg31X mutation. Our results demonstrate that SDHA immunohistochemistry on GISTs can identify the presence of an SDHA germline mutation. Identifying GISTs with deficient SDH activity warrants additional genetic testing, evaluation and follow-up for inherited disorders and paragangliomas. PMID: 23174939 [PubMed - indexed for MEDLINE]

High prevalence of oncogenic MYD88 and CD79B mutations in primary testicular diffuse large B-cell lymphoma. Kraan W, van Keimpema M, Horlings HM, Schilder-Tol EJ, Oud ME, Noorduyn LA, Kluin PM, Kersten MJ, Spaargaren M, Pals ST. Leukemia. 2014 Mar;28(3):719-20. doi: 10.1038/leu.2013.348. Epub 2013 Nov 20. PMID: 24253023 [PubMed - in process]

Prognosis of women with primary breast cancer diagnosed during pregnancy: results from an international collaborative study. Amant F, von Minckwitz G, Han SN, Bontenbal M, Ring AE, Giermek J, Wildiers H,Fehm T, Linn SC, Schlehe B, Neven P, Westenend PJ, Müller V, Van Calsteren K,Rack B, Nekljudova V, Harbeck N, Untch M, Witteveen PO, Schwedler K, Thomssen C, Van Calster B, Loibl S. J Clin Oncol. 2013 Jul 10;31(20):2532-9. doi: 10.1200/JCO.2012.45.6335. Epub 2013 Apr 22. PURPOSE: We aimed to determine the prognosis of patients with breast cancer diagnosed during pregnancy (BCP). PATIENTS AND METHODS: In this cohort study, a multicentric registry of patients with BCP (from Cancer in Pregnancy, Leuven, Belgium, and GBG 29/BIG 02-03) compiled pro- and retrospectively between 2003 and 2011 was compared with patients who did not have associated pregnancies, using an age limit of 45 years. Patients with a diagnosis postpartum were excluded. The main analysis was performed using Cox proportional hazards regression of disease-free survival (DFS) and overall survival (OS) on exposure (pregnant or not), adjusting for age, stage, grade, hormone receptor status, human epidermal growth factor 2 status, histology, type of chemotherapy, use of trastuzumab, radiotherapy, and hormone therapy. RESULTS: The registry contained 447 women with BCP, mainly originating from Germany and Belgium, of whom 311 (69.6%) were eligible for analysis. The nonpregnant group consisted of 865 women. Median age was 33 years for the pregnant and 41 years for the nonpregnant patients. Median follow-up was 61 months. The hazard ratio of pregnancy was 1.34 (95% CI, 0.93 to 1.91; P = .14) for DFS and 1.19 (95% CI, 0.73 to 1.93; P = .51) for OS. Cox regression estimated that the 5-year DFS rate for pregnant patients would have increased from 65% to 71% if these patients had not been pregnant. Likewise, the 5-year OS rate would have increased from 78% to 81%. CONCLUSION: The results show similar OS for patients diagnosed with BCP compared with nonpregnant patients. This information is important when patients are counseled and supports the option to start treatment with continuation of pregnancy. PMID: 23610117 [PubMed - indexed for MEDLINE]

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Pathologie

Loss of E-cadherin is not a necessity for epithelial to mesenchymal transition in human breast cancer. Hollestelle A, Peeters JK, Smid M, Timmermans M, Verhoog LC, Westenend PJ,Heine AA, Chan A, Sieuwerts AM, Wiemer EA, Klijn JG, van der Spek PJ, Foekens JA,Schutte M, den Bakker MA, Martens JW. Breast Cancer Res Treat. 2013 Feb;138(1):47-57. doi: 10.1007/s10549-013-2415-3. Epub 2013 Jan 22. Epithelial to mesenchymal transition (EMT) is typically defined by the acquisition of a spindle cell morphology in combination with loss of E-cadherin and upregulation of mesenchymal markers. However, by studying E-cadherin inactivation in 38 human breast cancer cell lines, we noted that not all cell lines that had undergone EMT had concomitantly lost E-cadherin expression. We further investigated this discrepancy functionally and in clinical breast cancer specimens. Interestingly, reconstitution of wild-type E-cadherin cDNA in a E-cadherin negative cell line that had undergone EMT (MDA-MB-231) did not revert the spindle morphology back to an epithelial morphology. Neither were changes observed in the expression of several markers known to be involved in the EMT process. Similarly, upregulation of E-cadherin via global DNA demethylation in eleven cell lines that had undergone EMT did not induce a change in cell morphology, nor did it alter the expression of EMT markers in these cells. Next, we extracted genes differentially expressed between cell lines that had undergone EMT versus cell lines that had not undergone EMT. Caveolin-1 was identified to be an excellent marker for EMT, irrespective of E-cadherin status (specificity and sensitivity of 100%). Consistent with our observations in the breast cancer cell lines, expression of Caveolin-1 identified a subset of basal breast cancers, particularly of metaplastic pathology, and only 50% of these lacked E-cadherin expression. The discrepancy between E-cadherin loss and EMT was thus reproduced in clinical samples. Together, these results indicate that in human breast cancer loss of E-cadherin is not causal for EMT and even not a necessity. PMID: 23338761 [PubMed - indexed for MEDLINE]

Collaborative authorship Discordance in ERα, PR and HER2 receptor status across different distant breast cancer metastases within the same patient. Hoefnagel LD(1), van der Groep P, van de Vijver MJ, Boers JE, Wesseling P, Wesseling J; Dutch Distant Breast Cancer Metastases Consortium, van der Wall E,van Diest PJ. … Westenend PJ… Ann Oncol. 2013 Dec;24(12):3017-23. doi: 10.1093/annonc/mdt390. Epub 2013 Oct 10. BACKGROUND: We studied discordance in estrogen receptor alpha (ERα), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status between multiple distant metastases from the same breast cancer patient. MATERIAL AND METHODS: Multiple distant metastases from 55 female patients were stained for ERα, PR and HER2 by immunohistochemistry and in situ hybridization for confirmation of the HER2 status. RESULTS: Different metastatic sites within the same patient showed discordance in ERα receptor status in 7.3% or 10.9% of patients (using a 10% or 1% threshold for positivity, respectively). For PR, 29.1% or 30.9% of patients showed discordance. Taking ERα and PR

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together, 36.4% of cases (both thresholds) showed discrepancy between metastases. In 10.9% (10% threshold) or 14.5% of patients (1% threshold), such discordance could have clinical consequences with regard to hormonal treatment. For HER2, there was 3.6% discordance on the immunohistochemical level but 0% on the gene level. CONCLUSION: In a significant proportion of metastatic breast cancer patients, discordance in ERα and PR receptor status between different metastatic sites was observed. This implies that multiple metastases may need to be biopsied to optimally reassess receptors. PMID: 24114857 [PubMed - in process]

Overige publicaties Quality improvement in surgical breast cancer care: A decrease in positive surgical margins after first breast conserving surgery. van Bommel ACM, van Dalen T, Snijders HS,Westenend PJ, Siesling S, Wouters MWJM, van der Heiden - van der Loo M. European Cancer Congress 2013 Abstract Book in the European Journal of Cancer, Volume 49 Supplement 2, September 2013. http://eccamsterdam2013.ecco-org.eu/Scientific-Programme/Abstract- search.aspx?abstractid=5007.

Breast cancer pathology differences between hospitals in the Netherlands – Results from the NABON breast cancer audit. van Bommel ACM, Westenend PJ, van der Heiden M, Siesling S, van Dalen T, Tjan-Heijnen VCG on behalf of the scientific committee of the NABON breast cancer audit. Abstracts NVVP april 2013.

The virtual thymoma panel, the first year experience. van Nederveen FH, Nicholson A, Blaauwgeers H, Timens W, Weissferdt A, Thunnissen E, Strobel P, Marx A, den Bakker M. Abstracts NVVP april 2013.

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Kwaliteit, Veiligheid en Innovatie Pathologie

Psychiatrie

Voordrachten Fibromyalgie en psychiatrische stoornissen. Derksen M. Nascholing “Licht en Donker “ voor psychiaters, 30 januari 2013, Zermatt, Zwitserland. Geaccrediteerd door de Nederlandse Vereniging voor psychiatrie.

Competentiegericht werken en het voorkomen van disfunctioneren: tips voor aios, supervisoren en opleiders. Derksen M. Wetenschapsdag Yulius, Alblasserdam, 25-3-2013. Geaccrediteerd door de Nederlandse Vereniging voor psychiatrie.

Competentiegericht opleiden. Wat zijn de voordelen? Derksen M. Mini-symposium Modernisering Medische Vervolgopleidingen, Erasmus Universiteit 5-2-2013. Geaccrediteerd.

Fibromyalgie ADHD, angst- en stemmingsstoornissen. Derksen M. Presentatie op de Wetenschapsdag Yulius, Alblasserdam, 25-3-2013. Geaccrediteerd door de Nederlandse Vereniging voor psychiatrie.

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Poliklinische apotheken

Posters De mate van therapietrouw bij orale oncolytica patiënten, voor en na een toegepaste interventie. Bervoets AC, Boot M. Wetenschapsdag ASz, 20 juni 2013, Dordrecht.

LEAN: Verbeteren vanuit het perspectief van de patiënt. Spapens M, Tarrahi F. Wetenschapsdag ASz, 20 juni 2013, Dordrecht.

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Poliklinische apotheken

Radiologie

PubMed publicaties Randomized trial of Legflow(®) paclitaxel eluting balloon and stenting versus standard percutaneous transluminal angioplasty and stenting for the treatment of intermediate and long lesions of the superficial femoral artery (RAPID trial): study protocol for a randomized controlled trial. Karimi A, de Boer SW, van den Heuvel DA, Fioole B, Vroegindeweij D, Heyligers JM, Lohle PN, Elgersma O, Nolthenius RP, Vos JA, de Vries JP. Trials. 2013 Mar 28;14:87. BACKGROUND: Restenosis after percutaneous transluminal angioplasty (PTA) of the superficial femoral artery (SFA) may occur in 45% of patients at 2 years follow-up. Paclitaxel-coated balloons have been found to reduce neointimal hyperplasia, and thus reduce restenosis. Recently, the Legflow(®)paclitaxel-coated balloon (Cardionovum Sp.z.o.o., Warsaw, Poland) (LPEB) has been introduced. This balloon is covered with shellac, a Food and Drug Administration (FDA) approved natural resin, to obtain an equally distributed tissue concentration of paclitaxel. The RAPID trial is designed to assess restenosis after PTA using the Legflow balloon combined with nitinol stenting versus uncoated balloons with nitinol stenting in SFA lesions >5 cm. METHODS/DESIGN: A total of 176 adult patients with Rutherford class 2 to class 6 symptoms due to intermediate (5-15 cm) or long (>15 cm) atherosclerotic lesions in the SFA will be randomly allocated for treatment with LPEB with nitinol stenting or uncoated balloon angioplasty with stenting. Stenting will be performed using the Supera(®) stent in both groups (IDEV Technologies Inc., Webster, TX). The primary endpoint is the absence of binary restenosis of the treated SFA segment. Secondary outcomes are target lesion revascularization (TLR), clinical and hemodynamic outcome, amputation rate, mortality rate, adverse events, and device-specific adverse events. Follow up consists of four visits in which ankle-brachial indices (ABI), toe pressure measurements, and duplex ultrasound (DUS) will be performed. Furthermore, a peripheral artery questionnaire (PAQ) will be completed by the patients at each follow-up. In the event that DUS reveals a symptomatic >50% restenosis, or a >75% asymptomatic restenosis, additional digital subtraction angiography will be performed with any necessary re-intervention. DISCUSSION: The RAPID trial is a multicenter randomized controlled patient blind trial that will provide evidence concerning whether the use of the Legflow paclitaxel/shellac coated balloons with nitinol stenting significantly reduces the frequency of restenosis in intermediate and long SFA lesions compared to standard PTA and stenting. TRIAL REGISTRATION: ISRCTN47846578. PMCID: PMC3651710 PMID: 23537403 [PubMed - in process]

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Hyaline fibromatosis of Hoffa’s fat pad in a patient with a mild type of hyaline fibromatosis syndrome. Van Raak SM, Meuffels DE, Van Leenders GJ, Oei EH. Skeletal Radiol. 2014 Apr;43(4):531-4. doi: 10.1007/s00256-013-1746-9. Epub 2013 Oct 17. Hyaline fibromatosis syndrome (HFS) is a rare, homozygous, autosomal recessive disease, characterized by deposition of hyaline material in skin and other organs, resulting in esthetic problems, disability, and potential life-threatening complications. Most patients become clinically apparent in the first few years of life, and the disorder typically progresses with the appearance of new lesions. We describe a rare case of a 20-year-old patient with juvenile-onset mild HFS who presented with a history of progressive anterior knee pain. Detailed magnetic resonance (MR) imaging findings with histopathological correlation are presented of hyaline fibromatosis of Hoffa’s fat pad, including differential diagnosis. The diagnosis of HFS is generally made on basis of clinical and histopathological findings. Imaging findings, however, may contribute to the correct diagnosis in patients who present with a less typical clinical course of HFS. PMID: 24132693 [PubMed - in process]


Long-term safety and efficacy of a tamoxifen-based treatment strategy for idiopathic retroperitoneal fibrosis. van Bommel EF, Pelkmans LG, van Damme H, Hendriksz TR. Eur J Intern Med. 2013; 24(5): 444-50.

Sagittal spinal profile and spinopelvic balance in parents of scoliotic children. Janssen MM1, Vincken KL, van Raak SM, Vrtovec T, Kemp B, Viergever MA, Bartels LW, Castelein RM. Spine J. 2013;13(12):1789-800.|

Reduced neonatal lung function and wheezing illnesses during the first 5 years of life. van der Gugten AC1, Uiterwaal CS, van Putte-Katier N, Koopman M, Verheij TJ, van der Ent CK. Eur Respir J. 2013 Jul;42(1):107-115.

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Radiologie

Voordrachten Angiography for the diagnosis of brain death; which vessels may still enhance? Bakker J. First joint meeting Belgian and Dutch sections Neuroradiology, 1 februari 2013, Antwerpen.

Extradurale afwijkingen van de wervelkolom. Bakker J. Sandwichcursus (6x), Neuroradiologie, 21-22 juni 2013.

Effectiveness and Reproducibility of Radiological Signs on Digital Chest X-ray in Heart Failure. Bruijnzeel-Koster IM,Visser P, Herfkens HF, Kofflard MJM,Kock MCJM. Wetenschapsdag ASz, 20 juni 2013, Dordrecht.

Beeldvormende diagnostiek bij dementie; inventarisatie van de praktijk binnen de Nederlandse geheugenklinieken. Gardeniers M, Bakker J, Meulen EFJ, Wattjes MP, Barkhof F. Wetenschapsdag ASz, 20 juni 2013, Dordrecht.

Geen MRI maken bij bloederige tepelvloed indien conventionele diagnostiek niet afwijkend is! van Gelder L, Bisschops R, Pennings J. Nederlandse vereniging voor Chirurgie, mei 2013.

Preoperatieve MRI voor lobulair carcinoom: nuttig? Pennings J, van Gelder L. Nederlandse vereniging voor Chirurgie, mei 2013.

Beeldvormende diagnostiek bij dementie: inventarisatie van de praktijk binnen de Nederlandse geheugenklinieken. Gardeniers M, Bakker J, Watjes . Nederlandse vereniging voor Radiologie, september 2013.

De toegevoegde waarde van de MRI mammografie bij patiënten met bloederige tepeluitvloed. van Gelder L, Bisschops R, Pennings J. Nederlandse vereniging voor Radiologie, september 2013.

Magnetic resonance imaging findings after lateral ankle trauma in injured and contralateral ankles. van Putte-Katier N, Oei E. Nederlandse vereniging voor Radiologie, september 2013.

CT Coronary Angiography: Effect of Iodine CONcentration on Vascular Attenuation: The CT-CON Multicentric Study. Preliminary Results. Rengo M. Dharampal AS, Das M, Kock MC, Niezen A; vanTilborg F, Caruso D, Nieman K,Krestin GP. Radiology Society of North America (RSNA), december 2013.

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Radiological Manifestations of the SMAD3-related Aneurysms-osteoarthritis Syndrome. van Raak S, van De Laar IM,Moelker A,Devos AS, Bertolli-Avella AM; Oei EH. Radiology Society of North America (RSNA), december 2013.

Hypertrophic cardiomyopathy the presence of edema is associated with a more advanced stage of disease. Gommans DHF, Cramer GE, Bakker J, Fouraux M, Michels M, ten Cate FJ, Verheugt FWH, Brouwer MA, Kofflard MJM. American Heart 2013.

In hypertrophic cardiomyopathy the presence of edema is associated with a more advanced stage of disease. Gommans DHF, Cramer GE, Bakker J, Fouraux M, Michels M, ten Cate FJ, Verheugt FWH, Brouwer MA, Kofflard MJM. AHA Scientific Sessions, November 2013.

Elevated highly-sensitive cardiac troponin T is associated with hypertrophy and fibrosis in patients with hypertrophic cardiomyopathy. Gommans DHF, Cramer GE, Bakker J, Fouraux M, Michels M, ten Cate FJ, Verheugt FWH, Brouwer MA, Kofflard MJM. Nederlandse Vereniging voor Cardiologie, najaarscongres 2013.

Angiography for the diagnosis of brain death; which vessels may still enhance? Plaisier A, Bakker J. First joint meeting Belgian and Dutch sections Neuroradiology, Antwerpen, Februari 2013.

Posters Echografische cerebrale ventrikelgrootte-metingen; verschillende meetmethoden vergeleken. Adbenabbi O, Bakker J, Smit-Kleinlugtenbeld. Wetenschapsdag ASz, 20 juni 2013, Dordrecht.

Coronary CTA in Pediatric Cardiac Transplants. Galuzina J, Ouhlous M, Moelker A. European Congress of Radiology, maart 2013.

Imaging and Endovascular Treatment of Chronic Iliofemoral Venous Obstruction. Galuzina J, Ouhlous M, Moelker A. Radiology Society of North America (RSNA), december 2013.

Technical and Radiological Image Quality Comparison of Different Liquid Crystal Displays for Radiology. Dams I, Kock M, van der Valk P. European Congress of Radiology 2013.

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Radiologie

Elevated high-sensitivity cardiac troponin is associated with hypertrophy and fibrosis assessed with CMR in patients with hypertrophic cardiomyopathy. Gommans DHF, Bakker J, Cramer GE, Fouraux MA, Kurvers MJ, Verheugt FWA, Brouwer MA, Kofflard MJM. SCMR Scientific Sessions, februari 2013.

Stress-induced troponin rise in patients with hypertrophic cardiomyopathy: associations with sarcomere mutation and MRI characteristics. Cramer GE, Gommans DHF, Michels M, Fouraux M, Bakker J, Verheugt FWA, ten Cate FJ, Brouwer MA, Kofflard MJM. European Muscle Conference, september 2013.

Echografische cerebrale ventrikelgrootte-metingen; verschillende meetmethoden vergeleken. Abdennabi O, Bakker J. Nederlandse vereniging voor Radiologie, september 2013.

Non-diagnostic results of fine needle aspiration cytology of thyroid nodules. Jacobs S. European Thyroid Association (ETA), Leiden, september 2013.

Bloody nipple discharge and conventional diagnostic imaging negative for malignancy: limited additional value of MRI. Gelder van L, Pennings PJ, Menke-Pluymers MBE, Bisschops RHC, Plaisier PW. International Surgery Week 2013, Helsinki.

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Reumatologie

PubMed publicaties Methotrexate polyglutamates in erythrocytes are associated with lower disease activity in patients with rheumatoid arthritis. de Rotte MC, den Boer E, de Jong PH, Pluijm SM, Bulatovic Calasan M, Weel AE, Huisman AM, Gerards AH, van Schaeybroeck B, Wulffraat NM, Lindemans J, Hazes JM, de Jonge R. Ann Rheum Dis. 2013 Dec 5. doi: 10.1136/annrheumdis-2013-203725. [Epub ahead of print] OBJECTIVE: To investigate if erythrocyte-methotrexate-polyglutamate (MTX-PG)concentrations in patients with rheumatoid arthritis (RA) are associated with disease activity or adverse events. METHODS: We used a longitudinal study design with two cohorts. The derivation cohort included 102 and the validation cohort included 285 patients with RA on MTX. We measured erythrocyte-MTX-PG with 1-5 glutamate residues at 3 months, 6 months and 9 months after MTX start with a liquid chromatography (LC)-mass spectrometry (MS)/MS assay. Outcomes were disease activity score in 28 joints (DAS28) and adverse events. Longitudinal associations of MTX-PG concentrations after 3 months, 6 months and 9 months with DAS28 were tested with a linear mixed model adjusted for age, gender, baseline DAS28, MTX dose and comedication. RESULTS: In the derivation cohort, mean DAS28 decreased from 4.26 (SE=0.14) at baseline to 2.72 (SE=0.13) after 9 months. Thirty per cent of patients in the derivation cohort experienced more than three adverse events after 3 months,which decreased to 18% after 9 months. In the validation cohort, DAS28 and adverse events were comparable with the derivation cohort. In the derivation cohort, MTX-PG1 (ß=-0.005), MTX-PG2 (ß=-0.022), MTX-PG3 (β=-0.007) and total MTX-PG (ß=-0.004) were associated (p<0.05) with lower DAS28 over 9 months. In the validation cohort, MTX-PG2 (ß=-0.015), MTX-PG3 (ß=-0.010), MTX-PG4 (ß=0.008) and total MTX-PG (ß=-0.003) were associated with lower DAS28 over 9 months. None of the MTX-PGs was associated with adverse events. CONCLUSIONS: In this first longitudinal study, we showed that an increase in erythrocyte-MTX-PG concentration was associated with a decreased DAS28 over 9 months in two cohorts, and is therefore a potential tool for therapeutic drug monitoring of MTX in RA. PMID: 24297383 [PubMed - as supplied by publisher]

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Reumatologie

Spoedeisende geneeskunde

PubMed publicaties A prospective validation of the HEART score for chest pain patients at the emergency department. Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SH, van Tooren R, Mast TP, van den Akker F, Cramer MJ, Poldervaart JM, Hoes AW, Doevendans PA. Int J Cardiol. 2013 Feb 25. BACKGROUND: The focus of the diagnostic process in chest pain patients at the emergency department is to identify both low and high risk patients for an acute coronary syndrome (ACS). The HEART score was designed to facilitate this process. This study is a prospective validation of the HEART score. METHODS: A total of 2440 unselected patients presented with chest pain at the cardiac emergency department of ten participating hospitals in The Netherlands. The HEART score was assessed as soon as the first lab results and ECG were obtained. Primary endpoint was the occurrence of major adverse cardiac events (MACE) within 6weeks. Secondary endpoints were (i) the occurrence of AMI and death, (ii) ACS and (iii) the performance of a coronary angiogram. The performance of the HEART score was compared with the TIMI and GRACE scores. RESULTS: Low HEART scores (values 0-3)were calculated in 36.4% of the patients. MACE occurred in 1.7%. In patients with HEART scores 4-6, MACE was diagnosed in 16.6%. In patients with high HEART scores(values 7-10), MACE occurred in 50.1%. The c-statistic of the HEART score (0.83)is significantly higher than the c-statistic of TIMI (0.75)and GRACE (0.70)respectively (p<0.0001). CONCLUSION: The HEART score provides the clinician with a quick and reliable predictor of outcome, without computer-required calculating. Low HEART scores (0-3), exclude short-term MACE with >98% certainty. In these patients one might consider reserved policies. In patients with high HEART scores (7-10) the high risk of MACE may indicate more aggressive policies. PMID: 23465250 [PubMed - as supplied by publisher]

Posters Pericardial fat necrosis: a rare cause of chest pain. Bink MHC, van der Velden AM, Oskam E. VIIth Mediterranean Emergency Medicine Congress, Marseille - Frankrijk (sept 2013).

Hashimoto encephalopathy - a rare cause of altered mental state. van der Velden AM, Stuart PA. VIIth Mediterranean Emergency Medicine Congress, Marseille - Frankrijk (sept 2013).

Asymptomatic coin ingestion in children. Spruyt C, Hagens R. 7th Dutch North Sea Emergency medicine congress. 96

Urologie

Voordrachten Robotchirurgie in de urologie. Dé toekomst? Zeegers AGM. Wetenschapsdag ASz, 20 juni 2013, Dordrecht.

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Kwaliteit, Veiligheid en Innovatie Urologie

Ziekenhuisapotheek

PubMed publicaties Detection and correct handling of prescribing errors in Dutch hospital pharmacies using test patients. Beex-Oosterhuis MM, de Vogel EM, van der Sijs H, Dieleman HG, van den Bemt PM. Int J Clin Pharm. 2013 Dec;35(6):1188-202. BACKGROUND: Hospital pharmacists and pharmacy technicians play a major role in detecting prescribing errors by medication surveillance. At present the frequency of detected and correctly handled prescribing errors is unclear, as are factors associated with correct handling. OBJECTIVE: To examine the frequency of detection of prescribing errors and the frequency of correct handling, as well as factors associated with correct handling of prescribing errors by hospital pharmacists and pharmacy technicians. SETTING: This study was conducted in 57 Dutch hospital pharmacies. METHOD: Prospective observational study with test patients, using a case-control design to identify factors associated with correct handling. A questionnaire was used to collect the potential factors. Test patients containing prescribing errors were developed by an expert panel of hospital pharmacists (a total of 40 errors in nine medication records divided among three test patients; each test patient was used in 3 rounds; on average 4.5 prescribing error per patient per round). Prescribing errors were defined as dosing errors or therapeutic errors (contra-indication, drug-drug interaction, (pseudo)duplicate medication). The errors were selected on relevance and unequivocalness. The panel also defined how the errors should be handled in practice using national guidelines and this was defined as ‘correct handling’. The test patients had to be treated as real patients while conducting medication surveillance. The pharmacists and technicians were asked to report detected errors to the investigator. MAIN OUTCOME MEASURE: The percentages of detected and correctly handled prescribing errors were the main outcome measures. Factors associated with correct handling were determined, using multivariate logistic regression analysis. RESULTS: Fifty-nine percent of the total number of intentionally added prescribing errors were detected and 57% were handled correctly by the hospital pharmacists and technicians. The use of a computer system for medication surveillance compared to no computer system was independently associated with correct handling [odds ratio (OR) 15.39 (95% confidence interval (CI) 3.62-65.50] for computerized physician order entry system; OR 15.40 (95% CI 3.61-65.70) for order entry by pharmacy technicians), but because the reference category contained only one hospital these results can’t be interpreted. Furthermore, manual screening of dosages in children with or without computerized surveillance compared to no dosage checks for children [OR 2.02 (95% CI 1.06-3.84)], qualified pharmacy technicians compared to no qualified pharmacy technicians [OR 1.32 (95% CI 1.03-1.67)] and pharmacy technicians using protocols compared to ones not using protocols [OR 1.30 (95% CI 1.04-1.61)] were independently associated with correct handling.

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CONCLUSION: This study showed that the quality of medication surveillance in Dutch hospital pharmacies can be subject to improvement and the identified factors may give direction to such improvements. PMID: 24062191 [PubMed - in process]

Overige publicaties Rifaxamine houdt ammoniakspiegel in toom. Reserveplek bij hepatische encefalopathie. de Vos-Koppelaar NCM, de Vogel EM, Beukers R, Dieleman HG. Pharmaceutisch Weekblad 2013;1

Vergelijkend cohortondersoek (2007 en 2011) naar prevalentie van iatrogene ziekenhuiopnames op de afdelingen interne geneeskunde, cardiologie en longziekten van een topklinisch opleidingsziekenhuis. Hiel DCW, Vendeloo M, Bartels PA, van Bommel EFH, Cleophas AJM, de Vogel EM, Dieleman HG. PW Wetenschappelijk Platform. 2013;7:a1308.

Voordrachten The effect of a slower than standard dose escalation scheme for dipyridamole on headaches in secondary prevention therapy of stroke. A randomised, prospective, open label study (DOSE). de Vos-Koppelaar NCM. CWZO. Utrecht 5 maart 2013. Geaccrediteerd door: Nederlandsche vereniging van Ziekenhuisapothekers.

Zorgvuldig, zorgveilig. Veenbaas T. Openingssymposium bereidingsfaciliteit Albert Schweitzer ziekenhuis. Dordrecht 26 maart 2013 Geaccrediteerd door: Nederlandsche vereniging van Ziekenhuisapothekers.

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Kwaliteit, Veiligheid en Innovatie Ziekenhuisapotheek

Promoties ASz 2013

Determinants of postoperative mortality after cancer surgery. Damhuis RAM. Erasmus Universiteit Rotterdam 17 oktober 2013. Promotor: Prof. dr J.J.B. van Lanschot Co-promotor: dr PW Plaisier

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Wetenschapsdag ASz 2013

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Mondelinge presentaties Cardiologie Sexuality of patients with CHF and their spouses and the need for information regarding sexuality. A.G. van Driel1, M.J.J. de Hosson2, C. Gamel3 1

Cardiology, Albert Schweitzer ziekenhuis, Dordrecht

2

Cardiology, Ghent, Belgium

3

University of Utrecht

Reference publication: Eur J Cardiovasc Nurs. 2013 Apr 10. [Epub ahead of print] Background / Achtergrond Psychological and physiological effects of CHF can influence sexuality. Both CHF patients and their partners may experience changes and have questions about sexuality. Despite this, healthcare professionals give little information regarding sexuality. Objective / Doel The aims of this study were to describe the sexuality of patients and their partners and to describe their needs for information regarding sexuality. Methods / Methoden A prospective, descriptive cross-sectional design. A convenienvce sample was obtained in three hospitals. Patients and partners completed two questionnaires: SAS and the NSCS-CHF. Results / Resultaten There were 52 patients and 32 partners who participated in the study. No or slight disturbance was seen in sexual discussion and intimicy. Marked or serious disturbance was reported in sexual activity. A mixed profile was seen in sexual performance, sexual interest and sexual pleasure. The majority of patients with CHF and their partners want information regarding sexuality. The NSCS-CHF clearly identified the information needs of patients and partners and most needs concerned the areas of symptoms, the relationship and relaxation. Conclusion / Conclusie The questionnaires were easy to complete and changes in sexuality and information needs were identified. The NSCS-CHF needs further validation as a research instrument. Healthcare professionals can use both questionnairres to bring u the topic of sexuality and to identify further counseling topics.

Gynaecologie De risicoselectie beter bekeken. Het vergelijken van de incidentie van perinatale mortaliteit en ernstige morbiditeit tussen de 1e en 2e lijn. C. Adriaanse-Hartog, S. Rombout-de Weerd Afdeling gynaecologie en verloskunde, Albert Schweitzer Ziekenhuis

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Background / Achtergrond Uit recent onderzoek is gebleken dat risico selectie voor start baring niet adequaat is in Nederland. Is er in onze regio en ASZ een zelfde zorgelijk verschil in perinatale uitkomsten bij vrouwen die in de 1e lijn starten, 2e lijn starten, en diegene die worden overgedragen durante partu? Objective / Doel Het doel van het onderzoek is het bestuderen van de effectiviteit van de risicoselectie in de regio Dordrecht. Dit wordt gedaan door te onderzoeken of er een verschil is in de incidentie van perinatale sterfte en ernstige perinatale morbiditeit tussen de eerste en de tweede lijn. Methods / Methoden Tussen 1 januari 2008 en 1 januari 2011 worden de gegevens van alle vrouwen die in de regio Dordrecht bevielen vanuit de landelijke database de Perinatale Registratie Nederland (PRN) geanalyseerd. Hierbij wordt het verschil in perinatale sterfte en ernsitge morbiditeit per verwijscategorie bepaald. Results / Resultaten Te verkrijgen in april/mei 2013, bezoek aan PRN gepland medio april (pas na toekenning stipendium, eerder geen inzage gekregen) Conclusion / Conclusie Volgt

Interne geneeskunde GLP-1 analogs in Clinical Practice. E.F.S. van Velsen¹, J. Lamers², V. Blok², R.J.M. van Leendert¹, R.M. Kiewiet-Kemper¹ ¹ Interne Geneeskunde, Albert Schweitzer Ziekenhuis ² Interne Geneeskunde / Diabetes Centrum, Albert Schweitzer Ziekenhuis Background / Achtergrond Glucagon-like-peptide-1 (GLP-1) analogs are since 2009 approved in The Netherlands for the treatment of type 2 diabetes patients with a BMI larger than 35kg/m2 and inadequate glycaemic control with oral glucose-lowering medication. Literature shows a significant reduction in HbA1c and body weight. Objective / Doel To determine the effect of GLP-1 analogs on glycaemic control and body weight in clinical practice. Methods / Methoden From April 2010 until May 2012 we included all patients starting GLP-1 analogs (liraglutide/exenatide). At inclusion, all patients were diagnosed with type 2 diabetes. HbA1c, body weight, medication (oral medication, insulin) and side effects were registered at baseline, after 3 and after 6 months. Results / Resultaten We included 238 patients. Mean age was 57.0 years, and 109 (46%) subjects were women. At baseline, mean HbA1c was 67.8mmol/mol, while mean body weight was 117.7kg. Furthermore, 162 patients (68%) used any form of insulin therapy (101 ± 66 IE on average), 32% oral glucose-lowering medication only. 229 patients (96%) started liraglutide, while 9 (4%) started exenatide. HbA1c decreased 5.7mmol/mol (±13.7) and 7.2mmol/mol (±14.7) after 3 and 6 months respectively (both p<0.001 compared to baseline). Furthermore, a weight reduction of 7.7kg (±6.2) and 10.8kg (±8.6) was observed after 3 and 6 months respectively (both p<0.001 compared to baseline). At six months, 48 of 162 patients (30%) had stopped using any form of insulin therapy, while 52 (32%) using 4 or 2 times insulin therapy a day at baseline decreased towards once daily. Additionally, there was a significant decrease in total daily dose of insulin; both in patients who discontinued and in those who continued using insulin. During the study, 20 patients (8%) discontinued GLP-1 analogs due to lack of effect on glycaemic control, while 7 (3%)

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stopped due to intolerable side effects. No pancreatitis was observed. Conclusion / Conclusie GLP-1 analogs induce a significant reduction in HbA1c and body weight. Additionally, we have demonstrated that patients already on insulin therapy benefit from GLP-1 analogs as well: despite significant reduction or discontinuation of insulin dose, HbA1c levels and body weight decreased.

Kindergeneeskunde De diagnostische waarde van screenend antenataal onderzoek naar obstruerende afwijkingen aan nieren en urinewegen. H.T. den Dekker¹, A.M. de Grauw¹, A.C. de Mol¹, S. Rombout-de Weerd² ¹ afdeling Kindergeneeskunde, Albert Schweitzer ziekenhuis ² afdeling Gynaecologie, Albert Schweitzer ziekenhuis Background / Achtergrond Urineweginfecties (UWI’s) predisponeren voor hypertensie en nierlijden. Obstruerende afwijkingen aan nieren en urinewegen en (ernstige) vesico-urethrale reflux zijn risicofactoren voor UWI. Bij structureel echografisch onderzoek (SEO) bij 20 weken zwangerschapsduur wordt gekeken naar antenatale hydronefrose (AHN) als teken van nieren urinewegafwijkingen. In geval van AHN volgt diagnostiek in een vroeg stadium post nataal. Objective / Doel Het bepalen van de sensitiviteit, specificiteit en positief- en negatief voorspellende waarde (PVW en NVW) van structureel echografisch onderzoek (SEO) voor afwijkingen aan nieren en urinewegen. Methods / Methoden Retrospectief onderzoek over de periode 2007-2011. Alle SEO’s met AHN in het Albert Schweitzer ziekenhuis (ASZ) werden vergeleken met de bevindingen post partum. Tevens werden bij kinderen, geboren na 2007 en tot de leeftijd van 1 jaar, die zich presenteerden met een UWI in het ASZ, de antenatale bevindingen bij echografie geëvalueerd. Results / Resultaten Bij 7,000 kinderen werd een SEO verricht. Bij n=47 (0,7%) werd AHN vastgesteld. Hiervan bleken 43 kinderen nier-/urinewegafwijkinen te hebben bij post nataal onderzoek [PVW = 0.91 (91%)]. Echografisch werden bij n=58 van de kinderen die zich presenteerden met een UWI nierafwijkingen gevonden. Bij n=11 was dit antenataal niet vastgesteld. [NVW = 0,998 (bijna 100%)]. Van alle kinderen met nierafwijkingen (n=58) werd dit bij SEO bij 19% niet gezien. De sensitiviteit en specificiteit van SEO voor de diagnose van AHN/ nierafwijkingen bedroegen respectievelijk 0.80 en 0.999. Conclusion / Conclusie De NVW van bijna 100% toont dat een SEO bij 20 weken zwangerschapsduur in principe een goed screeningsinstrument is. Bij 11 kinderen over een periode van 4 jaar (3 per jaar) werden nieren urinewegafwijkingen antenataal niet vastgesteld, terwijl die er waarschijnlijk wel waren. Het is interessant te onderzoeken of dit aantal lager wordt als de SEO bij een latere zwangerschapsduur herhaald zou worden. Bij 1 op de 10 kinderen met AHN bleek er post partum geen sprake van nier-/urinewegafwijkingen. Dit dient meegenomen te worden in de counseling van de ouders.

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Longgeneeskunde Ademhalingsondersteuning (thuis) bij patiënten met zeer ernstig COPD in de palliatieve fase. Leidt dit tot minder ziektelast; hogere kwaliteit van leven en minder ziekenhuisopnames? N. de Graaf1, C. Theunisse2, D. Cheung3, H. Ponssen4, R. van Uffelen3, E. Jordens1, M. Le Grand2 1

verpleegkundig specialist Longgeneeskunde, Albert Schweitzer ziekenhuis

2

ventilation practitioner / IC verpleegkundige, Albert Schweitzer ziekenhuis

3

longarts, Albert Schweitzer ziekenhuis

4

intensivist, Albert Schweitzer ziekenhuis

Background / Achtergrond In het Albert Schweitzer ziekenhuis is begin 2012 een project gestart om patiënten met zeer ernstig COPD niet-invasieve beademing thuis te geven middels bipap. Dit project is een gezamenlijk initiatief vanuit de specialismen Longgeneeskunde en Intensive / Medium Care. Objective / Doel Doel is om te kijken of behandeling met NIB in de thuissituatie deze patiënten verlichting geeft van hun zeer zware ziektelast; verbetering in kwaliteit van leven; en vermindering van ziekenhuisopnames. Deze behandeling wordt nog niet aangeboden aan deze patiëntengroep in Nederland. Methods / Methoden Patiënten met een forse ziektelast en / of frequente ziekenhuisopnames (waaronder IC opnames) worden 24 uur opgenomen op de Medium Care voor het instellen van de NIB. Er vindt een 0-meting plaats, na 6 weken, 3 maanden en 1 jaar. Parameters: o.a KvL, ZH opnames, ervaren klachten. Results / Resultaten In totaal zijn er 18 patiënten gestart waarbij sinds februari 2012 meetmomenten plaatsvinden om het effect te evalueren. De 1e resultaten zijn bekend, de komende maanden zullen deze resultaten worden aangevuld met nieuwe data. Gemiddelde leeftijd van deze groep is 55 jaar (met een spreiding van 46 tot 64). Alle patiënten hebben een COPD stadium 4; 11 van hen zitten in het longtransplantatietraject (al dan niet al op de wachtlijst); 4 zijn hiervoor afgewezen; 2 zijn niet bekend in het longtransplantatietraject; en 1 is tijdens dit onderzoek getransplanteerd. Van de 18 patiënten zijn 2 gestopt vanwege o.a. angst voor het NIB-apparaat. De overige 16 zijn deels geëvalueerd. Van 7 patiënten is het aantal opnames 1 jaar voor en 1 jaar na start NIB reeds bekend. Het gaat hier om een totale afname van > 50%: 19 opnames vóór start NIB t.o.v. 9 opames ná start NIB. Van 12 patiënten is geëvalueerd welke ervaren klachten zijn verminderd: minder exacerbaties (4); makkelijker ADL ondernemen (7); beter uitgerust (11); minder opstartproblemen (7); beter ademhalen (5). Ervaring van NIB in het algemeen is ook onder 12 patiënten geëvalueerd: negatief (0); neutraal (0); positief (5); zeer positief (7). Conclusion / Conclusie Behandeling met NIB thuis bij patiënten met zeer ernstig COPD met zware ziektelast, lijkt te leiden tot minder ziekenhuisopnames en minder ervaren ziektelast. Het gaat om een kleine doelgroep, de komende jaren zullen de data verder aangevuld moeten worden om het effect daadwerkelijk aan te tonen.

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Radiologie Effectiveness and Reproducibility of Radiological Signs on Digital Chest X-ray in Heart Failure. I.M. Bruijnzeel-Koster¹, P. Visser¹, H.F. Herfkens¹, M.J.M. Kofflard², M.C.J.M. Kock¹ ¹ Radiologie, Albert Schweitzer ziekenhuis ² Cardiologie, Albert Schweitzer ziekenhuis Objective / Doel Detection of heart failure (HF) is still a major challenge, but can most likely be improved if a validated prediction model of chest X-ray (CXR) is used. The aim of this retrospective study is to evaluate the Effectiveness and reproducibility of CXR for detecting HF. Methods / Methoden 61 patients with cardiac complaints referred to the radiology department for CXR were studied retrospective. All chest x-rays were independently double blind scored for radiographic signs of HF by two radiologists. Predictive values of CXR and individuals signs were calculated. Results / Resultaten Of 61 patients, 16 were diagnosed with heart failure. Sensitivity for CXR is 40%-42% with a specificity of 92%-94% respectively for radiologist one and two. Test performance of radiographic signs varied with a sensitivity of 14.4%- 86.8%, and a specificity of 46.7%-97.8%. Subjective cardiomegaly and subjective large vascular pedicle are the most sensitive radiographic signs. Kappa score for agreement between the two radiologists overall interpretation and between stages of heart failure was 0.629 and 0.747 respectively Conclusion / Conclusie Digital CXR has a high specificity in the diagnosis of heart failure. Of all radiographic signs cardiomegaly and large vascular pedicle are the most sensitive. Unfortunate not every radiographic sign can be reliably detected on every digital CXR.

Radiologie Beeldvormende diagnostiek bij dementie: inventarisatie van de praktijk binnen de Nederlandse geheugenklinieken. M. Gardeniers¹, J. Bakker¹, E.F.J. Meulen², M.P. Wattjes³, F. Barkhof³ ¹ Radiologie, Albert Schweitzer ziekenhuis ² Geriatrie, Albert Schweitzer ziekenhuis ³ Radiologie, VU Reference publications: Radiology 2009;253(1):174-83 (dit is van het in de “background” geciteerde artikel) Background / Achtergrond Dementie is een snel groeiend probleem binnen ons zorgsysteem. Diagnostiek van dementie, waaronder beeldvorming, is hierdoor van toenemend belang. Wattjes et al. beschreven dat, in de klinische setting, CT-cerebrum vergelijkbare informatie oplevert als MRI. Objective / Doel Heeft de bevinding van Wattjes et al. ook zijn weg gevonden in de praktijk? Wij onderzochten het gebruik van MRI en CT bij dementiediagnostiek binnen de Neder-

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landse geheugenklinieken. Methods / Methoden Per e-mail werd een enquête voorgelegd aan alle specialisten verbonden aan een Nederlandse geheugenkliniek. Results / Resultaten 63% (151/240) respondeerde, waaronder 84% geriaters, 13% neurologen en 3% anders (totaal 69 klinieken). 89% werkt in een perifeer ziekenhuis of GGZ-instelling, 11% academisch. 53% vraagt altijd beeldvorming aan, 47% doet dit bij selecte patiënten niet. 40% kiest wisselend CT of MRI, 37% kiest MRI, 19% CT, 4% CT én MRI. Belangrijkste keuzefactoren hierbij zijn: contra-indicaties voor MRI, lichamelijke beperkingen, leeftijd, vasculaire of oncologische voorgeschiedenis en wachttijd. Met alleen CT meent 87% informatie te missen: vasculaire schade/witte stofafwijkingen, (hippocampus)atrofie en specifieke pathologie (o.a. metastasen, amyloïd-angiopathie). Daarnaast wordt betere eigen vaardigheid in het beoordelen van MRI genoemd. Bij 66% zijn er afdelingsbrede afspraken omtrent het aanvraagbeleid, 34% beslist individueel. Volgens 52% bevat het CT-protocol coronale reconstructies, maar worden deze inconsequent bijgeleverd. Beelden worden in 5% met scoringsschalen beschreven, 68% zegt dat er geen uniforme beoordeling plaatsvindt. Conclusion / Conclusie Bij de diagnostiek van dementie heeft men een duidelijke voorkeur voor MRI boven CT. Onbekendheid met (de mogelijkheden van) CT, het ontbreken van coronale reconstructies bij CT en het niet uniform beschrijven van de beelden zijn hier debet aan.

Urologie Robotchirurgie, dé toekomst? A.G.M. (Toine) Zeegers¹, O.S.(Sjoerd) Klaver² ¹ Afdeling Urologie, Albert Schweitzer ziekenhuis, Dordrecht ² Afdeling Urologie Maasstad ziekenhuis, Rotterdam Background / Achtergrond Sinds 10 jaar worden er operaties uitgevoerd met de Da Vinci operatierobot. De laatste jaren is er een enorme vooruitgang geboekt in het aantal indicatiegebieden en nieuwe technieken. Vooral urologische ingrepen worden uitgevoerd, zoals de prostatectomie, partële nefrectomie en cystectomie. Objective / Doel Sinds 3 jaar opereren urologen uit Albert Schweitzer pt met prostaatcarcinoom en niercelcarcinoom in Robotcentrumin Rotterdam met Da Vinci robot. Methods / Methoden De techniek wordt besproken. Pre- en postoperatieve oncologische parameters, functionele en oncologische resultaten werden prospectief in een database verzameld. PSA-stijging (PSA > 0,2) werd gebruikt als surrogaateindpunt voor progressie. Continentie en potentie werden geëvalueerd . Results / Resultaten De Rotterdamse resultaten van de RALP( Robot geassisteerde Laparoscopische Prostatectomie) worden besproken. Zowel de oncologische als de functionele resultaten. Na 12 maanden follow-up werd PSA-progressie vastgesteld bij 13,1% van de patiënten, was 90,2% van de patiënten continent en 60,7% van de preoperatief potente patiënten potent. Conclusion / Conclusie RALP uitgevoerd in een hoogvolumekliniek gaat gepaard met zeer acceptabele morbiditeit en mortaliteit en met goede oncologische en functionele resultaten in een groep met een hoog percentage oncologisch intermediaire en hoogrisico patiënten.

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Poster presentaties Anesthesiologie Early Goal Directed Therapy with Vigileo cardiac output measurements. B. Postema- van der Heijde¹, B. van der Leeuw¹, G. Kuijpers¹, M. Frank² ¹ afdeling Anesthesiologie, Albert Schweitzer ziekenhuis ² afdeling Intensive Care, Albert Schweitzer ziekenhuis Background / Achtergrond In april 2012 we started with the Early Goal Directed Therapy study in Albert Schweitzer Hospital. This study aimes at optimizing cardiac output by arterial waveform analysis with the Vigileo. Treatment is described in a well defined protocol. Objective / Doel To determine the degree of protocol adherence in de studypopulation and to present preliminary results concerning patientcharacteristics. Methods / Methoden Multi-center, randomized controlled, clinical study Results / Resultaten We will describe patient characteristics of the studypopulation and the adherence to the protocol after one year of study

Pulse transit time as a quick predictor of a successful axillary brachial plexus block. M.C. Kortekaas, S.P. Niehof, M.H.N. van Velzen, E.M. Galvin, F.J.P.M. Huygen, R.J. Stolker ¹Department of Anesthesiology, Erasmus University Medical Center Rotterdam Reference publication: Acta Anaesthesiol Scand 2012; 56: 1228–1233 Background / Achtergrond It can take up to 30 min to determine whether or not an axillary block (AB) has been successful. Pulse transit time (PTT) is the time between the R-wave on ECG and the arrival of the resulting pressure pulse wave in the fingertip measured with PPG. It provides information about arterial resistance. Objective / doel AB affects vasomotor tone causing loss of sympathetic vasoconstriction resulting in an increased PTT. Early objective assessment of a block can improve efficacy of operating room time This study explores whether PTT can objectively, reliably and quickly predict a successful AB. Methods / Methoden Forty patients undergoing handsurgery under AB were included. A 3-lead ECG and PPG-sensors were placed on both index fingers. Measurements were made from 2 min before until 30 min after induction of the block . Afterwards, the PTT was calculated of both arms. Results / Resultaten To assess the change in PTT caused by the block, the PTT difference between the control and blocked arm was calculated. Sensitivity and specificity of PTT difference were calculated using receiver operating characteristic analysis. In a successful block, the mean PTT difference significantly increased after 3 min by 12 (standard error of the mean 3.9) ms, sensitivity 87% and specificity 71% (area under the curve 0.87, P = 0.004).

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Conclusion / Conclusie PTT is a reliable, quick and objective method to assess whether axillary block is going to be successful or not.

De POP-i-studie: Het gebruik van intraveneus ijzer om het pre-operatief Hb-gehalte te verhogen. J. van Nordennen1, A.W.M.M. Koopman-van Gemert1, C. So-Osman2, J.J. Zwaginga3, R.G.H.H. Nelissen4 1

Afdeling Anesthesiologie Albert Schweitzer ziekenhuis

2

Sanquin

3

Afdeling immunohaematology LUMC

4

Afdeling Orthopedie LUMC

Background / Achtergrond Een risicofactor voor een bloedtransfusie is anaemie pre-operatief. Preventief kan erythropoietine gebruikt worden met effectief resultaat, echter tegen zeer hoge kostprijs. Een mogelijk goed alternatief is intraveneuze ijzer therapie. Objective / Doel Primaire doel: Is i.v. ijzer een effectief alternatief voor de erythropoietine om het pre-operatief haemoglobine getal te laten stijgen. Secundaire doelen: indicatie gebied i.v. ijzer, reductie van behandelkosten en de veiligheid in ambulante setting. Methods / Methoden Een gerandomiseerde multi-center studie waarbij intraveneus ijzer wordt vergeleken met erythropoietine en een controle groep. In deze studie gaat het om 1.170 patienten gepland voor een THP of TKP operatie. Inclusie criterium is een Hb-getal tussen 6.2-8.2 mmol/L. Results / Resultaten De Medisch Ethische Commissie heeft deze studie goedgekeurd en zal starten in de lente/zomer van 2013. Conclusion / Conclusie Een gerandomiseerde multi-center studie naar het gebruik van intraveneus ijzer als effectief en goedkoper alternatief voor erythropoietine.

Cardiologie Elevated High-Sensitivity Cardiac Troponin is Associated with Hypertrophy and Fibrosis Assessed with CMR in Patients with Hypertrophic Cardiomyopathy. D.H.F. Gommans1, J. Bakker2, G.E. Cramer1, M. Fouraux3, M. Kurvers4, F.W.A. Verheugt1, M.A. Brouwer1, M.J.M. Kofflard4 1

Cardiologie, UMC St Radboud Nijmegen

2

Radiologie, Albert Schweitzer Ziekenhuis Dordrecht

3

Klinische Chemie, Albert Schweitzer Ziekenhuis Dordrecht

4

Cardiologie, Albert Schweitzer Ziekenhuis Dordrecht

Background / Achtergrond High-sensitivity(hs) cardiac troponin is a valuable biomarker of myocardial injury and frequently elevated in patients with hypertrophic cardiomyopathy (HCM). Using cardiovascular magnetic resonance (CMR) the HCM phenotype can be characterized with fibrosis as a finding with prognostic significance. Objective / Doel To investigate whether hs-troponin levels in patients with clinical HCM are associated with LV hypertrophy and fibrosis as assessed with CMR. Methods / Methoden Study population: 62 outpatient clinic patients with the HCM pheno-

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Poster presentaties

type (36 males, mean age 51 ± 15 years). Hs-troponin T was determined with a hs-assay (Roche Diagnostics). CMR with late gadolinium enhancement (LGE) was performed (Philips Achieva 1.5T). Results / Resultaten Hs-troponin T was elevated in 16 HCM patients (26%). Both the median LV MI and MWT were higher in HCM patients with an elevated hs-troponin T. In HCM patients with an elevated hs-troponin T fibrosis was more common, but it did not reach statistical significance. Considering only those patients with fibrosis (n = 31), the extent of fibrosis was higher in HCM patients with an elevated hs-troponin T. Conclusion / Conclusie Elevated hs-troponin T levels are common in HCM patients and associated with specific features of HCM such as hypertrophy and fibrosis. Our findings indicate that an elevated hs-troponin T might be a potential surrogate marker of fibrosis in patients with HCM.

GKCL Causes of macrocytic anemia in patients with newly diagnosed anemia. K.Stouten¹, J. Riedl¹, M-D Levin² ¹ GKCL, Albert Schweitzer ziekenhuis ² Internist-hematoloog, Albert Schweitzer ziekenhuis Background / Achtergrond The causes of macrocytic anemia in general practice remain to be established. Most frequently vitamin B12 or folic acid deficiency, myelodysplastic syndrome (MDS) or hemolysis is found in this population. Objective / Doel The objective is to determine the cause of anemia in patients with newly discovered macrocytic anemia. In what percentage of patients can a cause be establised and in what percentage of patients is that cause vitamin B12 deficiency, folic acid deficiency, MDS or hemolysis? Methods / Methoden Patients who presented with a newly discovered macrocytic anemia between January 2007 and February 2013 were included. Female patients had to be 50 years or older to be included, male patients 17 years or older. Vitamin B12 and folic acid levels and hemolysis parameters were determined. Results / Resultaten n/a Conclusion / Conclusie n/a

Intensive care Eerste resultaten IC na-zorg poli. G. Craane, A. Lekkerkerker, A. de Haan, J. Bronk, M. Frank Afdeling intensive care Albert Schweitzer ziekenhuis

Journal submitted / in press. Nehterlands journal of intensive care

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Background / Achtergrond Patienten die op de ic gelegen hebben kunnen specifieke klachten daaraan overhouden. Deze zijn niet het gevolg van de ziekte of verwondingen waarmee de patiënt was opgenomen, maar van het lange liggen, in een ongemakkelijke positie, veelal buiten bewustzijn en met beademing. Methods / Methoden We bezoeken alle patiënten die ≥5 dagen op IC gelegen hebben wekelijks op de afdeling. Na 6 weken van ontslag uit het ziekenhuis sturen we een uitnodiging voor een nazorggesprek op de poli, en vragen we een vragenlijst in te vullen. Results / Resultaten 239 bezoeken op de afdeling. 150 patiënten geincludeerd. 87 uitnodigingen verstuurd voor het invullen van een vragenlijst (48 vragenlijsten retour). 25 patiënten hebben nog gebruik gemaakt van de nazorggesprekken (16%). Meest voorkomende klachten: Verminderde lichamelijke conditie. Spier- en gewrichtsklachten, zenuwbeschadiging. Slikklachten, smaakverandering, gehoor- en visus stoornissen. Slaapproblemen, dromen, concentratiestoornissen, angst. Moeite met doorgemaakt delier. Conclusion / Conclusie De terug koppeling naar de intensive care, van de resultaten van gesprekken op verpleegafdeling als op de vragenlijst zal kwaliteitsverbetering geven op de intensive care. De IC nazorggesprekken op verpleegafdeling zijn nuttig voor herstel en verwerking ic opname.

Interne geneeskunde Plasmawaterconcentratie in een groot perifeer ziekenhuis. D.P. Boer¹, J.A. Riedl², H.J. Vermeer², G.M.T. de Jong¹ ¹ Afdeling Interne Geneeskunde, Albert Schweitzer ziekenhuis ² Afdeling Klinische Chemie, Albert Schweitzer ziekenhuis Background / Achtergrond De plasmawaterconcentratie (PWC) wordt verondersteld minimaal te variëren rond de 93%. De PWC kan berekend worden als simultaan een Natrium met de volbloed-methode (directe ion-selectieve electrode (DSE)) en met de plasmamethode (indirecte ion-selectieve electrode (ISE)) worden bepaald [1]. Objective / Doel Sinds november 2012 wordt PWC in ons ziekenhuis automatisch gerapporteerd als beide bepalingen verricht zijn. Het doel van ons onderzoek is inzicht verkrijgen in de plasmawaterwaarden in ons ziekenhuis. Methods / Methoden De PWC waarden van november 2012 tot april 2013 werden ver zameld. Bij waarden die buiten het 95% interval lagen, werd in het ziekenhuisinformatiesysyteem gezocht naar een verklaring voor de afwijkende waarde. Tevens werd gekeken wat de spreiding kon zijn van meerdere bepalingen bij een patiënt. Results / Resultaten Tussen november en april 2013 is 143 keer een PWC bepaald in 87 unieke patiënten. Gemiddelde PWC was 0.93 L/L (spreiding 0.86-0.98 L/L; 95% interval: 0.89-0.97 L/L). 7 waarden vielen buiten het 95% interval. Er waren 5 lage waarden (bij 4 unieke patiënten). Als verklaring hiervoor kon bij 1 patiënt start hemodialysebehandeling worden gevonden, bij de overige 3 patiënten was er sprake van dehydratie waarvan een met diabetes insipidus. Bij de 2 hogere waarden was sprake van vasopressinegebruik op de ICU ivm septische shock. Bij 27 patiënten werd meer dan twee keer het plasmawater bepaald. De gemiddelde interindividuële spreiding was 0.02 L/L. De sterkste interindividuële spreiding was 0.07 L/L (0.87 tot 0.94 L/L. De patiënt met de grootste spreiding was tevens één van de patiënten met een waarde onder de -2SD (bij hemodialyse). In PWC is een duidelijk

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Poster presentaties

spreiding aanwezig: de laagste waarde is 88% van de hoogste. Onze waarden liggen hoger dan eerder gevonden referentiewaarden [2]. Ook valt op dat de gevonden Na-waarden soms dicht bij elkaar liggen, terwijl er toch een variatie is in plasmawater. Conclusion / Conclusie Ons onderzoek geeft inzicht in de PWC in ons ziekenhuis. Laboratoriumbepalingen, die uitgaan van een vast PWC, zullen bij variatie van de PWC aangepast moeten worden. Nader onderzoek is nodig naar de afwijking van eerdere waarden en de kleine variatie van de natriumwaarden in verschillende methoden.

Het sepsis-protocol op de SEH; hoeveel patiënten hebben daadwerkelijk een bacteriële infectie? T.C. Minderhoud¹, C. Spruyt², S. Huisman², M. Lomax², H. Ponssen¹ ¹ Afdeling interne geneeskunde, Albert Schweitzer ziekenhuis ² Afdeling Spoed Eisende Hulp, Albert Schweitzer ziekenhuis Background / Achtergrond Vroege behandeling van sepsis kan de mortaliteit reduceren. Sinds december 2009 worden patiënten op de SEH van het ASZ gescreend voor mogelijke sepsis met behulp van de SIRS criteria. Als er een positieve score is wordt direct overlegd over antibioticatoediening. Objective / Doel Vaststellen hoeveel patiënten, die geïncludeerd worden in het lokale sepsis-protocol, daadwerkelijk een bacteriële infectie doormaakten, en hoeveel mensen antibiotica kregen zonder dat er een bacteriële ziekte was. Methods / Methoden Van januari tot mei 2011 werden 178 patiënten geïncludeerd in het sepsisprotocol. Retrospectief werd statusonderzoek verricht naar de ontslagdiagnose. Tevens werden microbiologie en radiologie uitslagen beoordeeld om aan/ afwezigheid van een infectie te beoordelen met tevoren vastgestelde criteria. Results / Resultaten Van alle patiënten op de SEH bij wie het surviving sepsis protocol werd ingevuld had 33% van de patiënten een bewezen bacteriële infectie, en nog een 31,5% een sterke verdenking op een bacteriële infectie. Een kleine groep (4,5%) had een bewezen virale infectie, en nog enkelen (8,9%) hadden verdenking op een virale infectie. Van de totale groep virale infecties kreeg 1/4 geen antibiotica op de SEH omdat er klinisch ook een virale infectie vermoed werd. Bij 30 patiënten was er achteraf een alternatieve diagnose of géén hard argument vóor een bacteriële infectie (22% van de gehele groep). Van de totale groep zonder infectie kregen 7 patiënten geen antibiotica op de SEH toegediend, op klinische gronden. Achteraf gezien kregen 41 patiënten (22,9 ) zonder bacteriële aandoening antibiotica toegediend. Het betreft een zeer heterogene groep, waarbij er soms in eerste instantie wel een goede índicatie was voor de antbiotica, maar uiteindelijk geen bacteriële infectie werd aangetoond (bijvoorbeeld neutropene koorts). Conclusion / Conclusie In dit cohort was in bijna 2/3 van de geïncludeerde patiënten inderdaad sprake van een bacteriële infectie. In ongeveer 1/5 van het cohort was er in retrospectie geen bacteriële infectie, maar werden er wel antibiotica toegediend op de SEH.

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Gynaecologie Koelen na episiotomie. T.J. Ligthart, L. van de Velde Afdeling A1 verloskunde Albert Schweitzer ziekenhuis Background / Achtergrond Dit praktijkonderzoek is gedaan In het kader van de opleiding tot obstetrievpk. Bij veel vrouwen wordt er tijdens de partus een episiotomie gezet en daar ondervinden de meeste vrouwen post partum hinder van. Objective / Doel vraagstelling: Heeft het koelen met een ijskompres bij patiënten met een episiotomie effect op de pijnbeleving tijdens de wondgenezing dan wanneer er niet gebruik gemaakt wordt van een ijskompres om te koelen? Methods / Methoden Literatuuronderzoek en benchmarking werd gedaan om ervaringen en evidence based onderbouwing te vinden rondom het koelen van een episotomie. Results / Resultaten Uit onderzoeken is gebleken dat het koelen van een episiotomie wond/ ruptuur een positief effect heeft op de pijnverlichting van de patiënten. Uit het artikel van M. Petersen uit 2011 “Revieuw of Interventions to relieve postpartum pain from perineal trauma” kwam naar voren dat het daadwerkelijk pijnverlichtend is om een episiotomie te koelen en dat dit helpt infecties te voorkomen.Ook uit het artikel van Ramler uit 1986 “A comparison of cold and warmd sitz baths for relief of postpartum perineal pain” is te zien, dat vrouwen na het nemen van een koud bad onmiddellijke pijnverlichting aangeven (in vergelijking met een warm bad waarbij het effect op de pijnverlichting continue wat lager was). In de aanleiding gaven wij aan dat veel vrouwen hinder ervaren van een episiotomie. In 2 ziekenhuizen wordt gebruik gemaakt van ijskompressen om de pijn te verlichting. Er was in de praktijk geen duidelijkheid of dit de beste en evidence-based practice oplossing was. In de verschillende onderzoeken die tijdens het onderzoek naar voren kwamen is hier een duidelijk antwoord op gekomen. Het koelen van een episiotomie heeft inderdaad effect op de pijn beleving van de patiënten. Conclusion / Conclusie Conclusie is dat het advies naar de beroepspraktijk is om iedereen aan te bevelen een ijspack of koude therapie toe te passen na een episiotomie wond. De koude therapie werkt pijnverlichtend en voorkomt grote oedeem vorming, wat ook pijnklachten kan gaan geven.

Obstructive sleep apnea and pregnancy. drs. I. Vlot¹, dr. S. Rombout-de Weerd¹, dr. J. Tan² ¹ Afdeling Obstetrie en Gynaecolgie, Albert Schweitzer ziekenhuis ² Afdeling KNO, Sint Lucas Andreas ziekenhuis Background / Achtergrond Obstructive sleep apnea (OSA) is one of the most prevalent sleep breathing disorders. Prevalence of OSA during pregnancy remains unclear. It may lead to adverse pregnancy and neonatal outcome. There are no validated screening tools for OSA in pregnant women. Objective / Doel To perform a prospective study using screening tools (questionnaires) and overnight polysomnography to identify the prevalence of OSA during pregnancy and to examine multiple outcomes in relationship to OSA during pregancy.

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Kwaliteit, Poster presentaties Veiligheid en Innovatie

Methods / Methoden A mutlicentre prospective study will be performed. Inclusions at outpatient clinic in first trimester of pregnancy. Screening tools and overnight polysomnography (golden standard for diagnosing OSA) combined with cardiotocography will be performed. Data will be analyzed using SPSS. Results / Resultaten Primairy outcome is the prevalence of OSA, pregnancy and neonatal outcome (defined as pregnancy related morbidity, delivery mode, Apgar-scores, umbilical cord gas at birth and birthweight). Analysis will be performed by comparing different groups: those who screened positive and negative for being at risk for OSA in the questionnaires, and those who screened positive and negative for OSA in the overnight polysomnography. A relationship between questionnaires and polysomnography will be explored. A secondary outcome is to identify predisposing factors for OSA preconceptional or at the first trimester of pregnancy. Conclusion / Conclusie This study will be performed to estimate the prevalence of OSA in pregnancy as also understanding OSA during pregnancy. This may lead to more research for better and frequent screening of patients at risk as also treatment of OSA during pregnancy.

Leerhuis Appraisal en Assessment bij medische specialisten: Wat gaat goed en wat kan beter? B. van Hoek¹, J. M. M. van de Ridder¹, V. R. Drexhage², M. de Ridder³ ¹ Afdeling Leerhuis, Albert Schweitzer ziekenhuis ² Afdeling Kindergeneeskunde, Albert Schweitzer ziekenhuis ³ Statisticus, Albert Schweitzer ziekenhuis Background / Achtergrond Appraisal & Assessment (A&A) is een kwaliteitsinstrument voor en door medisch specialisten. Het gaat hierbij om zelfreflectie door de medisch specialist en om 360 graden feedback organisatiebreed. Hierbij is de appraisee degene wie de A&Acyclus ondergaat en de appraisor leidt het A&A-gesprek. Objective / Doel Sinds 2007 is A&A in het ASz ingevoerd. Inmiddels hebben alle deelnemende specialisten een eerste gesprek gehad, dit is dus het moment om de methodiek te evalueren. De centrale vraag bij evaluatie is: Wat zijn de ervaringen van appraisors en appraisees met A&A? Methods / Methoden De commissie A&A ontwikkelde twee digitale enquêtes, één voor appraisors (N=30) en één voor appraisees (N=175). De resultaten zijn inzichtelijk gemaakt door middel van beschrijvende statistieken. Daarnaast zijn verbanden getoetst met Fisher’s exact toets, trendanalyse en Spearman’s.correlatie Results / Resultaten Alle appraisors vulden de enquête in. Appraisors zijn positief over de thema’s scholing en intervisie, motivatie, veiligheid en privacy en zij waarderen A&A. Zij staan sceptisch tegenover het thema efficientie. De respons bij de appraisees betrof 70% (N=123). Het POP is bij 29% van de appraisees richtinggevend voor hun persoonlijke ontwikkeling en slechts 12% bespreekt het na in de vakgroep. Men verwachtte dat A&A meer inzicht in het eigen functioneren zou geven (47%), dat hun persoonlijke ontwikkeling zou zijn gebaat bij de tips (69%) en dat het hun ontwikkeling zou beïnvloeden (41%). Wanneer appraisees het gesprek als positief ervaren, dan ervaren ze hun POP als effectiever r = .44 p < 0.001.

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Conclusion / Conclusie Zowel appraisors als appraisees zien de waarde van A&A. Appraisors geven aan dat de uitvoering van A&A nog efficiënter kan. Daarnaast moet worden nagegaan hoe de rol van het POP vergroot kan worden in de professionele ontwikkeling van de appraisee.

Het gebruik van exitgesprekken in postacademisch medisch onderwijs in STZ-ziekenhuizen. M. M. C. den Hollander¹, F. M. Verheijen², E. F. M. van Bommel³, R. J. Oostenbroek¹, J. M. M. van de Ridder¹ ¹ Afdeling Leerhuis, Albert Schweitzer Ziekenhuis ² Afdeling Klinische Chemie, Albert Schweitzer Ziekenhuis ³ Afdeling Interne Geneeskunde, Albert Schweitzer Ziekenhuis Background / Achtergrond Exitgesprekken worden gebruikt als kwaliteitsinstrument. Exitgesprekken kunnen de perceptie van een vertrekkende arts-assistent van het pedagogische klimaat, de faciliteiten en de kwaliteit van patiëntenzorg verkennen en zijn zo een unieke bron van informatie. Objective / Doel Informatie over het gebruik, effectiviteit en waardering van exitgesprekken in het medisch onderwijs in ziekenhuizen is beperkt. Hoe worden exitgesprekken gebruikt in postacademisch onderwijs in de Nederlandse STZ-ziekenhuizen? Methods / Methoden Alle 28 STZ-ziekenhuizen zijn telefonisch geinterviewd aan de hand van een semi-gestructureerde vragenlijst. Deze vragenlijst bestond uit tien vragen, met onderwerpen zoals de doelgroep en de procedure van terugkoppeling van resultaten. De resultaten zijn kwantitatief en kwalitatief geanalyseerd. Results / Resultaten Alle 28 STZ-ziekenhuizen hebben meegewerkt aan dit onderzoek. 4 ziekenhuizen (14%) zijn bezig met de ontwikkeling en implementatie van exitgesprekken en 16 ziekenhuizen (57%) gebruiken exitgesprekken. De doelgroep bestaat uit AIOS, maar 5 ziekenhuizen interviewen ook ANIOS. Het aantal exitgesprekken loopt uiteen van 2 tot 60 per jaar en deze gesprekken duren tussen de 15 en 60 minuten. De meeste ziekenhuizen gebruiken een eigen format voor het gesprek. De onderwerpen die het meest aan bod komen zijn: leerklimaat, kwaliteit van het opleidingsprogramma en verbeterpunten. De procedure van terugkoppeling van de resultaten varieert van een volledig anonieme verwerking tot een gebundelde of geheel open terugkoppeling. Exitgesprekken worden positief gewaardeerd door de ziekenhuizen. Er zijn echter ook enkele bedreigingen aanwezig zoals de grote tijdsinvestering die exitgesprekken vergen en een gebrek aan motivatie bij A(N)IOS. Conclusion / Conclusie Exitgesprekken bieden rijke informatie en zijn zo erg bruikbaar om het leerklimaat op de werkvloer te verbeteren. De beste resultaten kunnen worden behaald wanneer anonimiteit gegarandeerd kan worden. Exitgesprekken worden veelal zeer gewaardeerd door de STZ-ziekenhuizen en door de A(N)IOS zelf.

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Poster presentaties

2-days introduction program Albert Schweitzer ziekenhuis. I.C. Juliana¹, A.W.M.M. Koopman¹, G.S. Kooi² ¹ Afdeling Leerhuis, Albert Schweitzer ziekenhuis ² Afdeling Gynaecologie, Albert Schweitzer ziekenhuis Journal submitted / in press: Quality & Safety in Healthcare/ Congres London 2013 Background / Achtergrond This was a joint initiative of the educational department and the doctors. In our hospital we have 250 medical specialists and yearly about 100 residents. Objective / Doel We organize a two-day introduction program every month for approximately 65 new doctors a year. The attendance and interest was very low. Methods / Methoden Improving the content of the introduction program, with the help of the PDCA method and the given feedback Results / Resultaten We managed to get a turnout of almost 100% by refreshing and improving the program and by making it more tailor-made and interesting. Conclusion / Conclusie - For implementation of a new program you need the collaboration of all parties. - Focus on content and not on attendance - Evaluate yearly: if necessary adapt the program based on feedback and new regulations.

Introducties coassistenten in Samenwerkende Top-klinische Ziekenhuizen. Janneke de Kloe Afdeling Leerhuis, Albert Schweitzer ziekenhuis Background / Achtergrond Door de Nederlandse Federatie van Universitair Medische Centra (NFU, 2009) wordt genoemd dat een gezondheidsinstelling een introductie dient te regelen voor coassistenten. Binnen het Leerhuis van het ASz wordt nagedacht over de ontwikkeling van een centrale introductie voor nieuwe coassistenten. Objective / Doel Het doel van dit onderzoek is om een overzicht te verkrijgen van 1) de inhoud van de centrale introducties voor coassistenten in andere ziekenhuizen inclusief tijdstip, lengte en vorm, 2) de doelen die nagestreefd worden en 3) de evaluaties op de introducties. Methods / Methoden Alle 27 STZ ziekenhuizen zijn telefonisch benaderd. Er is gevraagd naar iemand die iets kan vertellen over een introductie voor coassistenten. Alle geïnterviewden werken op een opleidingsafdeling, maar zij hebben diverse functies, bijvoorbeeld onderwijskundigen, of coördinatoren coassistenten. Results / Resultaten Van de 27 STZ ziekenhuizen bieden 19 ziekenhuizen een centraal introductieprograma aan. De meeste introducties bestaan uit drie delen, namelijk 1) het geven van uitleg, presentaties of trainingen, 2) een rondleiding door het ziekenhuis met uitleg, waarbij de bibliotheek altijd bezocht wordt, 3) het regelen van de praktische zaken, zoals pasjes en jassen. De inhoud van de uitleg, presentaties of trainingen varieert. De uitleg gaat bijvoorbeeld in op de verwachtingen van het ziekenhuis, of is een kennismaking met het ziekenhuis. Verder worden presentaties gegeven door bijvoorbeeld het laboratorium, of er is een workshop gastvrijheid. Er worden specfieke trainingen gegeven, zoals prikinstructie, of hechten of knopen, en algemene trainingen, zoals een E-learning module over het patiën-

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tensysteem. De lengte van een introducties varieert van een half uur aan het begin van de dag tot volle twee dagen. De introductie wordt meestal gedaan door één medewerker, of er is een digitale introductie. Er worden verschillende doelen nagestreefd, bijvoorbeeld het veilig en welkom voelen, of het regelen van de praktische zaken. Zowel de opleiders als de coassistenten waarderen de introducties positief. Conclusion / Conclusie Van de zevenentwintig STZ ziekenhuizen biedt 70% een centrale introductie aan voor nieuwe coassistenten. De lengte, inhoud en het tijdstip verschilt sterk en is mede afhankelijk van de duur van het coschap. De introducties worden positief gewaardeerd door zowel opleiders als coassistenten.

Longgeneeskunde Uitweg uit een negatieve spiraal. Ontwikkeling en implementatie Actie plan COPD. E. Jordens, Netty de Graaf, René van Uffelen Afdeling Longgeneeskunde, Albert Schweitzer ziekenhuis Background / Achtergrond Dit ontwerpproject is geschreven in het kader van het afstuderen aan de opleiding Master Advanced Nursing Practice aan de Hoge School Utrecht. Het ontwerpproject is een praktijkonderzoek, gericht op het ontwikkelen van interventie om de gevolgen van exacerbaties van patienten met copd te beperken. Objective / Doel Patiënten met Chronische Obstructive Pulmonary Disease maken gemiddeld twee maal per jaar een excerbatie door. Ten gevolge van deze exacerbaties gaat de longfunctie, conditie en de kwaliteit van leven achteruit. Methods / Methoden Voor het praktijkonderzoek is dossier onderzoek gedaan en zijn interviews met patiënten en zorgverleners afgenomen om de probleemstelling goed in beeld te krijgen. Vervolgens is literatuur onderzoek en benchmark onderzoek verricht om de best mogelijk interventie voor de probleemstelling te vinden. Results / Resultaten De uitkomsten van dit onderzoek zijn dat zowel een actieplan als telemonitoring en het gebruik van de CCQ-lijst bijdraagt aan het vroegtijdig herkennen van symptomen van een exacerbatie. In het literatuuronderzoek is een trend zichtbaar dat een actieplan de achteruitgang van kwaliteit van leven beperkt. De resultaten zijn echter niet significant. De respondenten van het benchmarkonderzoek bevestigen deze trend en geven aan wel degelijk de indruk te hebben dat een actieplan positief effect heeft op de kwaliteit van leven van patiënten. Naar effecten van de interventie telemonitoring bij COPD is nog geen gerandomiseerd onderzoek met een controle groep gedaan. Het bewijs van de uitkomsten is van een lager niveau dan van het actieplan. De ervaringen uit het benchmarkonderzoek over telezorg zijn positief. Het vergroot de kennis omtrent ziekte inzicht en het vergroot het vertrouwen van de patiënt. De CCQ-vragenlijst is een lijst die ingezet kan worden om zicht te krijgen niet gerapporteerde exacerbaties. Conclusion / Conclusie Gekozen is voor het gebruik van een actieplan met begeleiding van een longverpleegkundige. De infrastructuur voor zelfmanagement, contacten tussen eerste en tweede lijn zijn aanwezig. Dit zijn belangrijke voorwaarden zijn om de interventie succesvol te laten zijn.

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Poster presentaties

Orthopedie Indicaties voor pre-operatieve bloedgroep bepaling bij Totale Heup Prothese chirurgie. R.T.T. Bartels1, A.V. Boeddha2, dr. A.J. van Koeveringe2, dr. W. van Gelder3, dr. L.T.M. Breimer4 1

Heelkunde, Albert Schweitzer ziekenhuis

2

Orthopedie, Albert Schweitzer ziekenhuis

3

Klinische Chemie, Albert Schweitzer ziekenhuis

4

Anesthesiologie, Albert Schweitzer ziekenhuis

Background / Achtergrond In het ASz wordt bij Totale Heup Prothese (THP) chirurgie preoperatief op twee momenten een bloedgroepbepaling gedaan in het kader van een mogelijke bloedtransfusie per- of postoperatief. Bij deze studie willen we onderzoeken welke factoren van invloed zijn op de noodzaak van bloedtransfusie Objective / Doel Aantonen dat het niet zinvol is bij alle THP patiënten 2x pre-operatief een bloedgroep bepaling te doen, en alleen de patiënten met een verhoogd risico 2x pre-operatief te laten langskomen voor bloedgroepbepalingen. Methods / Methoden Hiertoe hebben we een retrospectief cohort onderzoek uitgevoerd. Alle patiënten die tussen 1 januari 2010 en 31 december 2011 in het ASz primaire THP chirurgie hebben ondergaan, werden geïncludeerd. Patiënten die een bloedtransfusie ondergingen, werden nader geanalyseerd. Results / Resultaten In totaal vonden er 774 primaire THP operaties plaats in bovenstaande periode, die allen werden geïncludeerd. Hiervan ondergingen 85 patiënten per- of postoperatief een bloedtransfusie (11%). Van deze patiënten kregen 21 patiënten op de dag van de operatie een bloedtransfusie (2.7% van 774 patiënten). Dit was nooit in een acute situatie en altijd post-operatief na Hb bepaling. Ook waren er 6 patiënten met een uitgangs Hb van onder de 7.0 welke allen een bloedtransfusie hebben gekregen op dag 0 of dag 1. Conclusion / Conclusie Bij THP chirurgie is niet bij alle patiënten 2x preoperatieve bloedgroep bepaling geïndiceerd. Er wordt aangeraden patiënten met een preoperatieve anemie voor de operatie te behandelen. Ook is de aanbeveling alleen patiënten met grotere kans op bloeding (bijv ascal gebruik) 2x bloedgroep te bepalen.

Pathologie Pheochromocytoma: not exclusively on TV! A.H.A.G. Ooms, P.J. Westenend, F.H. van Nederveen Pathologie, PAL Dordrecht Background / Achtergrond Pheochromocytomas usually present with hypertension, tachycardia and sweating, sometimes these symptoms are paroxysmal. Acute cardiovascular damage due to this hypertension can lead to sudden death. Pheochromocytomas are associated in 30% with an inheritable tumor syndrome. Objective / Doel To establish how many pheochromocytomas have been diagnosed in our facility (PAL Dordrecht) in the last 15 years, emphasizing the clinical presentation.

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In addition we looked for additional signs indicating the possibility of an inheritable syndrome. Methods / Methoden In the Pathology Department we use the national coding database PALGA, in which the codes reflect the organ and disease. We searched PALGA for pheochromocytomas during the last 15 years. We extracted more information on the cases from PALGA as well as from the hospital information system. Results / Resultaten Using PALGA we found 3 autopsy cases and 6 adrenal resections with pheochromocytomas. Five pheochromocytomas occurred in men and 4 in women. There was a preference for the right adrenal, with 6 occurring in the right adrenal, 1 in the left and 1 unknown. The mean age of diagnosis was 57 years (40-63yr). The mean tumor diameter was 5.5cm (2-7.5cm) and all tumors were unilateral. All tumors appeared to be benign with no metastasis during follow-up. All autopsy cases were patients who presented with sudden death. Two patients had been examined for unexplained cardiological symptoms. Information on 5 patients of the resection specimens was present. In 2 patients, the pheochromocytoma was an incidental finding. Clinical presentations included hypertension (5/5), nausea (3/5), abdominal pain (3/5), fear (3/5), sweating (2/5) and tachycardia (1/5). In one case the symptoms were paroxysmal. In one autopsy case c-celhyperplasia was found in the thyroid, combined with pheochromocytoma suggestive of Multiple Endocrine Neoplasia (MEN) 2 syndrome. One patient with an adrenal resection was diagnosed with Neurofibromatosis-1. Conclusion / Conclusie In a patient presenting with hypertension, tachycardia, sweating or abdominal pain, the physician should include pheochromocytoma in the differential diagnosis. When a pheochromocytoma has been diagnosed, an inheritable syndrome should be investigated.

Poliklinische apotheek A study to examine the degree of adherence to oral antineoplastic therapy, before and after a patient-preference based intervention to increase treatment compliance is applied. A.C. Bervoets¹, M. Boot¹, J.C. Verster² ¹ Poliklinische apotheek, Albert Schweitzer ziekenhuis ² Farmacologie afdeling, Universiteit Utrecht Background / Achtergrond In modern oncology treatment, patients frequently use oral anticancer drugs. In contrast to intravenous therapy that could be closely monitored for compliance, non-adherence to oral drugs have been reported. Since this may negatively influence clinical outcome, patient adherence is very important. Objective / Doel In this study the degree of patient adherence to oral antineoplastic therapy is measured and an intervention to improve the patient adherence is being applied. In the end, the patient adherence will be measured again to determine the efficacy of the intervention. Methods / Methoden A cross-over study in 50 oral antineoplastic agent users, registered at the Albert Schweitzer hospital. Patients will be interviewed twice by phone: 1st interview determines the patient adherence before the intervention, 2nd interview determines the adherence after intervention.

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Poster presentaties

Results / Resultaten Since the investigation is still on going, not available yet. Conclusion / Conclusie Since the investigation is still on going, not available yet.

‘’Een slimme meid let op de tijd.’’ Onderzoek naar de toepasbaarheid van de lean methode om de efficiëntie in de poliklinische apotheek te verbeteren. Maryse Spapens, Faiza Tarrahi Poliklinische apotheek, Albert Schweitzer ziekenhuis Background / Achtergrond De lean methode is nog nauwelijks toegepast in ASZ en in de farmacie en is zeker uniek voor een poliklinische apotheek. Door lean te werken wordt de zorg veiliger en efficienter en dit komt de patiënt ten goede. Objective / Doel Onderzoeken of de lean methode toepasbaar is in de poliklinische apotheek. Methods / Methoden Participerend, kwalitatief onderzoek m.b.v. workflowanalyses/ observaties, diepte-interviews en een bedrijfsvergelijking in poliklin. apotheek Zwijndrecht & Hilversum. Benoemen van de belangrijkste (deel)processen in de apotheek die bijdragen aan de wachttijden van de patient. Results / Resultaten LEAN maakt onderscheid in 7 vormen van verspillingen ( wachten, extra verwerking, beweging, overproductie, transport, defect & voorraad), niet-onnodige verspillingen en waarde - toevoegende activiteiten. Er is een processchema gemaakt aan de hand van observationele gegevens, waarin deze verspillingen zijn aangegeven. Met behulp van dit processchema en de diepte-interviews is een inventarisatie gedaan van de huidige processen in de politheek en zijn de knelpunten per proces beschreven. Het oplossen van de knelpunten op zowel lange als korte termijn kan bijdragen aan een efficiëntere bedrijfsvoering en verlaging van de wachttijd van de patiënt. Er zijn knelpunten benoemd m.b.t. het systeem, de communicatie en de organisatie. De lean methode is uitstekend geschikt gebleken als methode om efficienter en veilger te werken in de poliklinische apotheek. Conclusion / Conclusie De processen in de poliapotheek zijn complex en divers. Elk proces bestaat uit meerdere handelingen, waarbij soms de directe waarde voor de patiënt ontbreek (bijv. administratie). De lean methode is geschikt om de processen door te lichten en om efficientieverbeteringen in de apotheek in te voeren.

Psychiatrie Vitamine D en de PAAZ. H.M. Bronzwaer, M. Derksen Afdeling Psychiatrie Albert Schweitzer Ziekenhuis Background / Achtergrond Naast de klassieke functie van vitamine D op de calciumhomeostase zijn er aanwijzingen voor niet-calciëmische effecten. Er is een niet ontrafeld verband tussen vit d deficiëntie en psychische klachten. Bovendien hoort een deel van de psychiatrische patienten tot een risicogroep.

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Objective / Doel Wat is de prevalentie van vitamine D gebrek op een psychiatrie afdeling van een algemeen ziekenhuis. Kan de dokter vit D–deficiëntie voorspellen bij deze groep? Methods / Methoden In zomer en najaar werden vitamine D spiegels bepaald bij 54 patiënten en bij 20 personeelsleden. De waarden werden vergeleken met een controlegroep. De door de arts van tevoren gemaakte inschatting werd getoetst. Results / Resultaten In het totaal had 70% van de patienten bij opname een vitamine D tekort. De prevalentie van vit D-def bij pat>65 was 85%; significant hoger dan in de populatie. Dit wordt in een grafiek toegelicht. Bij ouderen die geen suppletie slikten was dit zelfs 100%. De prevalentie van vit-D def bij (blanke) volwassenen bleek 49% en lager dan die van het personeel. Dit wordt in een grafiek toegelicht. Artsen bleken aan de hand van bekende risico factoren geen betrouwbare voorspelling te kunnen doen bij deze populatie. Dit wordt in een tabel toegelicht. Conclusion / Conclusie Het advies is de vitamine D status op de PAAZ in principe mee te nemen bij het routine bloedonderzoek bij volwassenen en zo nodig te suppleren. Ouderen kunnen ook standaard gesuppleerd worden met minimaal 800E p.d. Ook binnen de geriatrie is er overigens nog geen concrete richtlijn.

Radiologie Echografische cerebrale ventrikelgrootte-metingen; verschillende meetmethoden vergeleken. I. Oulad Abdennabi¹, J. Bakker¹, E. Smit-Kleinlugtenbeld² ¹ Radiologie, Albert Schweitzer ziekenhuis ² Kindergeneeskunde, Albert Schweitzer ziekenhuis Background / Achtergrond Ventrikelgrootte-metingen middels echografie is belangrijk om vroegtijdig dilatatie te diagnosticeren. Ventrikeldilatatie is meestal een complicatie van bloeding bij prematuren en kan leiden tot verhoogde intra-craniële druk. Aangezien klinische symptomen zich laat manifesteren is betrouwbare meting. Objective / Doel Echografische cerebrale ventrikelgrootte-metingen: uitleg van beschikbare meetmethoden, correcte uitvoering, reproduceerbaarheid en sensitiviteit. Results / Resultaten De ventrikelindex (VI, Levene) is de afstand van de falx naar de laterale begrenzing van de zijventrikel, beiderzijds gemeten in het coronale vlak net posterieur of op het niveau van het foramen van Monro. Het is de meest beschreven methode en heeft de grootste database aan referentiewaarden. De VI toont echter pas een duidelijke toename bij ernstige hydrocephalus. De term VI wordt vaak verward met ventrikel-hemisferic ratio, de breedte van de voorhoornen als ratio t.o.v. de biparietale afstand, die minder gevoelig is voor ventrikeltoename in de eerste paar weken post-partum. De Anterior horn width (AHW, Davies); de maximale diagonale wijdte van de voorhoorn, wordt in hetzelfde vlak gemeten als de VI en is sensitiever voor milde ventrikeldilatatie. De Thalamo-occipitale distance wordt verricht in het sagitale vlak, is de lengte van de thalamus tot de punt van de achterhoorn. Deze meting is het gevoeligst voor milde dilatatie omdat ventrikeldilatatie zich als eerste manifesteert in de achterhoornen, maar is moeilijk reproduceerbaar. Conclusion / Conclusie Van de beschikbare ventrikelgrootte-metingen heeft de AHW een goede sensitiviteit en reproduceerbaarheid. VI heeft een lagere sensitiviteit voor milde dilatatie maar heeft de meest uitgebreide referentiewaarden.

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Safe transportation of clinical patients within the Albert Schweitzer Hospital. J.D. van Weereld-de Vos, C. Ritmeester Background / Achtergrond In the ASz patients are transported form ward to radiology by nurse or department assistant (following the procedure for internal transportation. There’s no communication about the patients condition between the ward and radiology. Objective / Doel Clinical patienttransport from general ward to the radiology department resulted in the occurrence of severe incidents.The problem was quantified by using our voluntary incident reporting system. Methods / Methoden Intervention: - Process analysis of the entire transport process including risk assessment In the process, the roles and responsibilities of relevant disciplines are described - 3 month pilot 4 wards in + evaluation - 6 month phased implementation Results / Resultaten - Decision tree patient transport + explanation: risk assessment based on stability, cognitive conditions and technical operations. Based decision tree there are 3 options; patient should not be transported / transport only under supervision nurse / transportation department assistant - Patientstransfer form: nursing and radiologic technologist fill pondered form (pondered guaranteed 1. No more serious adverse events since introduction of the procedure 2. Increased Situational Awareness (SA) by involved staff members 3. No unattended instable patients in radiology waiting area 4. Staff act appropriately due to “information transfer” of the patients condition

1. From ward to radiology

2. From radiology to ward

5. Proactive acting on things that can happen such as;

no more beeping infusions pumps, full urine bags, oxygen cylinders empty etc.

Conclusion / Conclusie 1. Never accept the existing procedure 2. Always run a m.d. process analysis including a risk assessment 3. M.d process analysis provides insight into the multidisciplinairy process and associated risks and creates wider acceptance of intervention 4. Standardisation ensures patient safety

Verpleegkundige Advies Raad (VAR) Empowerment of nurses in hospital policy by implemtation of a nursing advisory board. A.G. van Driel, N. de Graaf, C. Fingal, J. Taks Background / Achtergrond Around 95.00 nurses work in Dutch hospitals. Despite this large number of nurses, their influence in hospital policy is often insignificant. Among 1400 nurses work in the ASh. Although they have a great responsibility in Quality and Safety, they had no offical organ to influence hospital policy. Objective / Doel Empowerment of nurses in the ASh to improve quality and safety.

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Methods / Methoden Implementation of an advisory board in the Ash. Results / Resultaten Eleven nurses participated in the NAB. The NAB gave thirtheen policy advices to the executives of the Ash. Twenty-nine nurses participated in the NAB platform. All the nurses of the ASh are familiair with the existence and aims of the NAB. Conclusion / Conclusie By the intervention of the NAB, nurses have significantly more influence in healthcare policy of the Ash.

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Verantwoording

De data ten behoeve van het wetenschappelijk jaaroverzicht 2013 zijn verzameld via de leden van de Wetenschapscommissie en via de vakgroepen. Daarnaast is er door het DB Wetenschapscommissie actief gezocht in Google Scholar en PubMed. In het wetenschappelijk jaaroverzicht zijn de publicaties opgenomen die zijn terug te vinden op PubMed. PubMed Publications die al “collaborative authorship” gepubliceerd staan, zijn apart onder PubMed publicaties vermeld onder “PubMed collaborative authorship publicaties. Onder ‘overige publicaties’ zijn internationale/nationale publicaties opgenomen die niet in PubMed zijn terug te vinden en verschenen zijn in tijdschriften die geen impactfactor hebben. Naast PubMed publicaties zijn wetenschappelijke bijdrages in de vorm van een ‘boek of hoofdstuk van een boek’ opgenomen. Voor de genoemde publicaties geldt dat de (co) auteur en tijde van dataverzameling, dataverwerking of opschrijven van de resultaten een aanzienlijk deel van de werkzaamheden moet hebben verricht in het Albert Schweitzer ziekenhuis en daar werkzaam moet zijn (geweest). Het ASz dient dan ook bij de affiliatie vermeld te staan. 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 2013 zijn zoveel als mogelijk meegenomen in het jaaroverzicht 2013. Voor ‘voordrachten’ en ‘posters’ geldt dat deze in het wetenschappelijk jaaroverzicht opgenomen worden indien het geaccrediteerde wetenschappelijke symposia, congressen nationaal of internationaal betreft waar een abstract is gepubliceerd. Hierbij geldt dat de (co) auteur ten tijde van de voordracht werkzaam moet zijn (geweest) in het Albert Schweitzer ziekenhuis. Het wetenschappelijk jaaroverzicht is opgesteld volgens de regels voor bio medische tijdschriften, de Vancouverregels. De auteursnamen zijn alfabetisch gerangschikt op naam van de eerste betrokken auteur werkzaam in het Albert Schweitzer ziekenhuis en zijn vet gedrukt. Bij meerdere ASz auteurs is de referentie bij de betreffende vakgroepen opgenomen. De gehele lijst wordt zoveel mogelijk met links naar full text te zijner tijd geplaatst op de intranet - en internetsite van het Leerhuis/ Wetenschapscommissie.

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Dit wetenschappelijk jaarverslag van het Albert Schweitzer ziekenhuis wordt uitgegeven door het Leerhuis. De redactie is Claudia van Waardhuizen zeer erkentelijk voor haar standvastige en doortastende wijze van werken om de benodigde informatie bij elkaar te krijgen en waar nodig te corrigeren. Uitgave: Wetenschappelijk jaarverslag 2013 Redactie Drs. C.N. (Claudia) van Waardhuizen (beleidsadviseur wetenschapscommissie) dr. M.D. (Mark-David) Levin (hematoloog / secretaris wetenschapscommissie) dr. J. (Joke) Bosch (wetenschapscoördinator / klinisch epidemioloog) E.Y. (Esther) de Kruyf (secretariaat wetenschapscommissie) A.D.. (Agnes) Klaren (manager Leerhuis ASz) dr. M.C.J.M. (Marc) Kock (radioloog / voorzitter wetenschapscommissie)

Fotografie Frederike Slieker Vormgeving Elan Strategie en Creatie, Rijswijk Productie en contact C.N. van Waardhuizen, beleidsadviseur ASz Oplage: digitaal © Alle rechten voorbehouden. Niets uit deze uitgave mag worden verveelvoudigd, opgeslagen in een automatisch gegevensbestand of openbaar gemaakt, in enige vorm of op enige wijze, hetzij elektronisch, mechanisch, door foto- kopieën, opnamen, of enige andere manier, zonder voorafgaande schriftelijke toestemming van de uitgever. Uitgever en auteurs verklaren dat deze uitgave op zorgvuldige wijze en naar beste weten is samengesteld. Evenwel kunnen uitgever en auteurs op geen enkele wijze instaan voor de juistheid of volledigheid van deinformatie. Uitgever en auteurs aanvaarden geen enkele aansprakelijkheid voor schade, van welke aard dan ook,die het gevolg is van handelingen en of beslissingen die gebaseerd zijn op bedoelde informatie.

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Wetenschappelijk jaaroverzicht 2013

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