Wetenschappelijk Jaarverslag

Wetenschappelijk Jaarverslag Sint Franciscus Gasthuis | 2012

© Niets uit deze uitgave mag worden gekopieerd zonder toestemming van de uitgever. ISBN (print):978-90-815381-3-8 NUR: 870 Trefwoorden: wetenschappelijk onderzoek; geneeskunde.

Wetenschappelijk Jaarverslag 2012 Sint Franciscus Gasthuis

Blom JHM Cohen Tervaert JW Geerlings CJC van de Geijn GJM de Jongh KA Kerver AJH Rudolphus A

WETENSCHAPPELIJK JAARVERSLAG 2012

Rotterdam, april 2012; Serie Wetenschappelijk Jaarverslag SFG, nr. 4.

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UW ZORG, ONZE PASSIE

INHOUDSOPGAVE


pagina

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Inhoudsopgave Voorwoord Anesthesiologie Apotheek Cardiologie Chirurgie Dermatologie Gynaecologie Intensive Care Interne Geneeskunde Kindergeneeskunde Klinische Chemie Leerhuis Longziekten MDL Neurologie Oogheelkunde Orthopedie Pathologie/ Pathan Psychiatrie Reumatologie Spoedeisende Hulp (SEH) Urologie Verpleegkunde Promoties Abstracts Voordrachten Wetenschapsdag SFG 2012 Abstracts Posters Wetenschapsdag SFG 2012 Artikelenindex Auteursindex

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WOORD VOORAF “One size fits all” De uitgaven voor de gezondheidszorg stijgen ieder jaar. De overheid en ziektekostenverzekeraars maken plannen om de gezondheidszorg betaalbaar te houden.Deze plannen worden, zo mogelijk, gebaseerd op wetenschappelijk onderzoek (evidence-based medicine). Hierbij wordt de patiënt een “gemiddelde” patiënt. In werkelijkheid is de patiënt echter variabel: man óf vrouw, jong óf oud, sterk óf zwak, allochtoon óf autochtoon om een aantal karakteristieken te benoemen. Met patiëntgebonden onderzoek laten wij in het SFG zien hoe evidence-based medicine werkt en waar het “one size fits all” model faalt. In 2012 publiceerden in het Sint Franciscus Gasthuis werkzame medisch specialisten en arts-assistenten een groot aantal artikelen in gezaghebbende internationale tijdschriften. Absolute hoogtepunten zijn de publicatie van de tREACH studie, waarbij onderzocht werd hoe patiënten met reuma het beste behandeld kunnen worden (Annals of the Rheumatic Diseases) en de genetische (GWAS) studie die onderzocht welke genen belangrijk zijn bij het kleiner worden van het volume van de hippocampus (een maat voor vroege dementie) (Nature Genetics). Onderzoek vanuit het Sint Franciscus Gasthuis werd verder gepresenteerd door middel van voordrachten en posters. En twee echte SFG-onderzoekers verdedigden met succes hun proefschrift: dr. A. Alipour en mw. dr. I. Leeuwenburgh. In diverse andere proefschriften werd het Sint Franciscus Gasthuis terug gevonden in het dankwoord, vanwege diverse bijdragen.

De Raad van Bestuur stimuleert het wetenschappelijk klimaat op diverse manieren. In 2012 werd in goed overleg met de Centrale Opleidingscommissie, de Medische Staf en het Leerhuis besloten om prof. dr. Jan Willem Cohen Tervaert aan te trekken als specialist manager wetenschap met als doel het wetenschappelijk onderzoek in de komende jaren op een nog hoger niveau te brengen. Samen met hem wil het Sint Franciscus Gasthuis de wetenschappelijke "size" creëren die past bij patiëntenzorg en opleidingen op top-niveau! Namens de Raad van Bestuur, Karen Kruijthof


Wetenschappelijk onderzoek is belangrijk voor ons topklinisch STZ ziekenhuis. Het levert een belangrijke bijdrage aan de opleiding van medisch specialisten, verpleegkundigen en andere medewerkers in het Sint Franciscus Gasthuis. Daarnaast draagt het bij aan het verder verbeteren van de hoog gespecialiseerde zorg die in het Sint Franciscus Gasthuis aan patiënten wordt geboden.

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ANESTHESIOLOGIE

ANESTHESIOLOGIE

ANESTHESIOLOGIE

Overige artikelen Vetemboliesyndroom na een totale knie arthroplastiek.

van Bergeijk H, van Velzen C, de Quelerij M, Doornaar M, van der Klooster J, de Feiter PW, den Heijer T, Verbrugge SJC. Nederlands Tijdschrift voor Anesthesiologie 2012; 25 (4): 31-35.

Prevalence and determinants of complications in a bariatric ICU population. de Queleri j M, van Velzen C, Luitwieler R, Meijer N, Gadiot RPM, van der Voet J, van der Klooster J, de Feiter P, Mannaerts GHH, Verbrugge SJC. Nederlands Tijdschrift voor Anesthesiologie 2012; 25 (5): 16-21.

Voordrachten Pijnstilling op de afdeling.

Quist RJ. Rotterdam: Sint Franciscus Gasthuis, Wetenschappelijk café, 1 februari 2012.

Anesthesiologische aspecten van bariatrische chirurgie.

Verbrugge SJC. Dordrecht: Albert Schweitzer Ziekenhuis, Schakels in de zorg, 20 en 29 maart 2012.

Comorbiditeit en complicaties bij de bariatrische patient: De waarde IC opname criteria. Verbrugge SJC. Rotterdam: Sint Franciscus Gasthuis, Wetenschapsdag, 13 april 2012.

Comorbidity and complications in patients undergoing bariatric surgery: the value of the ICU admission criteria.

Pijnbestrijding bij kanker.

Quist RJ. Rotterdam: Sint Franciscus Gasthuis, Oncologie aan de Bergse Plas. Workshop voor huisartsen, 10 oktober 2012.

Obesity, Bariatric Surgery and Anesthesia.

De Quelerij M. Rotterdam: Sint Franciscus Gasthuis. Advanced course in Laparoscopic Sleeve Gastrectomy and Logistics, 6 november 2012.

Workshop NIV- interfaces en tracheacannules.

Verbrugge SJC, Brouwers AJBW. Ede: Congrescentrum de Reehorst, NVIC Mechanische beademingsdagen 2012, 22 en 23 november 2012.


Meijer N, de Quelerij M, van Velzen C, Luitwieler R, Gadiot RPM, van der Voet J, van der Klooster J, de Feiter PW, Mannaerts GHH, Verbrugge SJC. Maastricht: MECC Congrescentrum, Anesthesiologendagen 2012, vrijdag 11 mei 2012.

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Cursief: werkzaam in het Sint Franciscus Gasthuis

UW ZORG, ONZE PASSIE

APOTHEEK

APOTHEEK

APOTHEEK

Overige artikelen Twee medicatiedistributiesystemen in het zorghotel, locatie Sint Franciscus Gasthuis; een observationele vergelijking. Soema LM, Van Dijck-van Boetzelaer CWT, Heetman-Meijer CFM, Birnie E, Robijn RH, Schouten JP. Pharm Weekbl 2012;6:a1227.

Voordracht Van leidingwater tot steriele substitutievloeistof. Kwaliteitsborging van water voor on-line HDF.

Geerlings CJC. Utrecht: Cursus interne geneeskunde voor 2e/3e jaars ziekenhuisapothekers in opleiding, 15 februari 2012.

Nierfunctiestoornissen en dialyse.

Van den Oever FJ. Utrecht: Nascholing apothekers Nierfunctiestoornissen en dialyse, 29 november 2012.

Poster Therapeutic drug monitoring of caffeine in preterm neonates.

Bosma MS, Van Tuijl SGL, Mooij MG, Kamerbeek A, Geerlings CJC. Milaan: Congres European Association of Hospital Pharmacy, 20 tot 23 maart 2012.

A practical thrice weekly ertapenem dosing regime for chronic hemodialysis patients.

A practical thrice weekly ertapenem dosing regime for chronic hemodialysis patients. Bosma MS, Geerlings CJC, De Man P, Touw DJ, Rietveld AP. Nunspeet: Nederlandse Ziekenhuisfarmaciedagen, 10 en 11 mei 2012.


Bosma MS, Geerlings CJC, De Man P, Touw DJ, Rietveld AP. Veldhoven: Nederlandse Nefrologiedagen 2012,3 en 4 april 2012.

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CARDIOLOGIE

CARDIOLOGIE

CARDIOLOGIE

Pubmed artikelen Intrinsic versus laser-induced fluorescence spectroscopy for coronary atherosclerosis: a generational comparison model for testing diagnostic accuracy.

van de Poll SW, Angheloiu GO, Georgakoudi I, Motz JT, Haka AS, Podrez E, Fitzmaurice M, Dasari RR, Feld MS, Kramer JR. Appl Spectrosc. 2012 Dec;66(12):1403-10 doi: 10.1366/11-06566. PMID: 23231902.

Abstract Laser-induced fluorescence (LIF) and intrinsic fluorescence spectroscopy (IFS) have been used experimentally for diagnosing coronary atherosclerosis. In this study, we demonstrated the diagnostic superiority of IFS at 342-nm excitation (IFS(342)) versus LIF (LIF(342)) and described a protocol for head-to-head comparison of old (LIF) versus new (IFS) generations of similar diagnostic methods, labeled as “generational comparison model”. IFS(342) and LIF(342) were modeled with basis spectra of media, fibrous caps, and superficial foam cells and of their correspondent chemicals (elastin, collagen, and lipoproteins). The average accuracy and receiver operating characteristic area under the curve of IFS(342) in single-, double-, and triple-parameter diagnostic algorithm iterations, geared toward identifying 84 atherosclerotic specimens from a group of 117 coronary segments, was 90% ± 1% and 0.87 ± 0.025, superior to LIF(342) (84% ± 3% and 0.84 ± 0.016; P = 0.0002 and 0.02, respectively) in a generational comparison model.

A somnolent man found in the park – rhythm puzzle.

Pieters C, van de Poll SW. Neth Heart J. 2012 Sep;20(9):382-3. doi: 10.1007/s12471-012-0316-4. PMID: 22890620. Geen abstract. PMC: 3430765. Free PMC article.

Onion-like masses in the left ventricle.

Overige artikelen A somnolent man found in the park – answer.

Pieters C, van de Poll SW. Neth Heart J. 2012 Sep;20(9):379. doi: 10.1007/s12471-012-0315-5.


Baars JE, Edward Visser W, Hoedemaeker R, Pieters C, van Miltenburg AJ. Eur Heart J Cardiovasc Imaging. 2012 Oct 2. [Epub ahead of print] PMID: 23034993. Geen abstract

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CHIRURGIE

CHIRURGIE

Pubmed artikel Treatment outcome in breast cancer patients with ipsilateral supraclaviculair lymph node metastasis at time of diagnosis: A review of the literature. Grotenhuis BA, Klem TMAL, Vrijland WW. Eur J Surg Oncol. 2012 Dec 8. doi:pii: S0748-7983(12)01304-2. 10.1016. PMID: 23232205.

CHIRURGIE

CHIRURGIE

In the revised 6th edition of the AJCC-TNM staging system for breast cancer, metastasis in ipsilateral supraclavicular lymph node(s) is considered as a locoregional disease and classified as N3c rather than M1 distant disease. The aim of this review was to search the recent literature in order to investigate whether the reported treatment outcome of patients with ipsilateral supraclavicular metastases in breast cancer patients justifies this revision. A review of the recent English-language literature (January 2001-June 2012) concerning breast cancer with supraclavicular involvement was performed. A total number of six studies were included in the current review. All reported comparable data with regard to treatment outcome after multimodality treatment, despite considerable heterogeneity in study populations. Patients with ipsilateral supraclavicular lymph node involvement showed outcomes more similar to locally advanced breast cancer patients rather than patients with distant tumor spread. It seems that the 2002 revision of the AJCC-TNM staging system for breast cancer has appropriately reclassified patients with supraclavicular disease to a new category (N3c).

Re-diplacement of stable both-bone forearm fractures in children: A randomised controlled multicentre trial.

INTRODUCTION: Displaced metaphyseal both-bone fractures of the distal forearm are generally reduced and stabilised by an above-elbow cast (AEC) with or without additional pinning. The purpose of this study was to find out if re-displacement of a reduced stable metaphyseal both-bone fracture of the distal forearm in a child could be prevented by stabilisation with Kirschner wires. METHODS: Consecutive children aged <16 years with a displaced metaphyseal both-bone fracture of the distal forearm (n=128) that was stable after reduction were randomised to AEC with or without percutaneous fixation with Kirschner wires. The primary outcome was re-displacement of the fracture. RESULTS: A total of 67 children were allocated to fracture reduction and AEC and 61 to reduction of the fracture, fixation with Kirschner wires and AEC. The follow-up rate was 96% with a mean follow-up of 7.1 months. Fractures treated with additional pinning showed less re-displacement (8% vs. 45%), less limitation of pronation and supination (mean limitation 6.9 (±9.4)° vs. 14.3 (±13.6)°) but more complications (14 vs. 1). CONCLUSIONS: Pinning of apparent stable both-bone fractures of the distal forearm in children might reduce fracture re-displacement. The frequently seen complications of pinning might be reduced by a proper surgical technique.


Colaris JW, Allema JH, Biter LU, de Vries MR, van der Ven CP, Bloem RM, Kerver AJH, Reijman M, Verhaar JAN. Injury.2012 Dec 3.doi:pii:S0020-1383(12)00488-3.10.1016/j.injury.2012.11.001 PMID: 23217981.

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Below-elbow cast for metaphyseal both-bone fractures of the distal forearm in children: a randomised multicentre study. Colaris JW, Biter LU, Allema JH, Bloem RM, van der Ven CP, de Vries MR, Kerver AJH, Reijman M, Verhaar JAN. Injury.2012 Jul;43(7):1107-11.doi:10.1016/j.injury.2012.02.020.Epub 2012 Apr 6. PMID: 22483541.

INTRODUCTION: Minimally displaced metaphyseal both-bone fractures of the distal forearm in children are often treated with an above-elbow cast (AEC). Treatment with a below-elbow cast (BEC) could give more comfort, but might lead to fracture displacement reducing pronation and supination. Because this has not been systematically investigated, we set up a randomised multicentre study. The purpose of this study was to find out whether BEC causes equal limitation of pronation and supination but with higher comfort level, compared with AEC. PATIENTS AND METHODS: In four hospitals, consecutive children aged<16 (mean 7.1) years with a minimally displaced metaphyseal both-bone fracture of the distal forearm were randomised to 4 weeks BEC (n=35) or 4 weeks AEC (n=31). Primary outcome was limitation of pronation and supination 6 months after initial trauma. The secondary outcomes were cast comfort, limitation of flexion/extension of wrist/elbow, complications, cosmetics, complaints, and radiological assessment. RESULTS: A group of 35 children received BEC and 31 children received AEC. All children attended for the final examination at a mean follow-up of 7.0 months (range 5.0-11.6 months). Limitation of pronation and supination 6 months after initial trauma showed no significant difference between the two groups [4.4° (± 5.8) for BEC and 5.8° (± 9.8) for AEC]. Children treated with BEC had significantly higher cast comfort on a visual analogue scale [5.6 (± 2.7) vs. 8.4 (± 1.4)] and needed significantly less help with dressing (8.2 days vs. 15.1 days). Six complications occurred in the BEC group and 14 in the AEC group. Other secondary outcomes were similar between the two groups.

Laparoscopic sleeve gastrectomy with an extensive posterior mobilization: technique and preliminary results.


Gadiot RPM, Biter LU, Zengerink HJ, de Vos tot Nederveen Cappel RJ, Elte JWF, Castro Cabezas M, Mannaerts GHH. Obes Surg. 2012 Feb;22(2):320-9.doi:10.1007/s11695-011-0488-9 PMID: 21826582.

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BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is becoming increasingly popular as a stand-alone procedure for the treatment of morbidly obese patients. A direct posterior approach to the angle of His was developed at our department to improve visualization of the difficult dissection of the short gastric vessels and to facilitate proper mobilization of the stomach around the left crus enabling safe realization of a tight sleeve. The technique and its preliminary results are described. METHODS: LSG by posterior approach was performed in a consecutive series of 445 (110 male/335 female, age 18-63 years, mean body mass index 46 kg/m(2) (range 35-76)) patients between 2007 and 2010. RESULTS: Weight loss defined as mean percent excess weight loss (%EWL) was 71% (±26%) at 1 year, 69% (±25%) at 2 years, and 55% (±27%) at 3 years. Sixteen patients (4%) developed postoperative intra-abdominal hematoma, 8 patients (2%) anastomotic leakage, and 6 patients intra-abdominal abscess (1%), requiring reoperation in 20 patients (4%). Five patients (1%) had pulmonary embolism. Thirty-day mortality rate was 0.2%.

CHIRURGIE

CONCLUSIONS: LSG by the posterior approach is a safe and effective procedure, enabling a tight sleeve formation leading to satisfactory %EWL results. Since long-term results of LSG are unknown, further studies are needed to define the exact place of the LSG as a standalone bariatric procedure.

Cancer stem cells and their potential implications for the treatment of solid tumors.

Grotenhuis BA, Wijnhoven BP, Van Lanschot JJ. J Surg Oncol.2012 Aug 1; 106(2): 209-15. Review. PMID: 22371125.

BACKGROUND AND OBJECTIVES: There is increasing evidence that a variety of human cancers is maintained by a subset of cells, cancer stem cells (CSCs), which sustain tumor growth, underlie its malignant behavior, and possibly initiate distant metastases. The aim of this review is to evaluate the current evidence for the existence of CSCs and the implications on the present management and treatment of solid tumors. METHODS: A retrospective review of the English-language literature (1997-2010) concerning CSCs and their therapeutic implications was performed. RESULTS: CSCs are characterized by two main properties of normal stem cells: Self-renewal and differentiation, which are best assayed by serial transplantation experiments in immunodeficient mice. Cell-surface antigens that mark cell populations enriched for CSCs have been identified in various solid tumors. As such, the very existence of CSCs has vast clinical implications with regard to cancer treatment. The development of tailor-made CSC-targeted therapies (including therapies directed at these CSC-specific surface markers, and reversal of the intrinsic resistance of CSCs to chemo- and radiotherapy) entails great promises. However, normal stem cell toxicity and treatment resistance have been recognized as serious problems. CONCLUSION: The growing evidence indicating that CSCs drive and maintain various types of solid human malignancies has important implications for the treatment of patients. However, over the years the development of CSC-targeted therapies has faced a number of potential hurdles, which must be considered carefully in order to maximize the chance that such therapies will be successful.

Grotenhuis BA, Klem TMAL, Vrijland WW. Eur J. Surg Oncol. 2012 Dec 8. Epub ahead of print. PMID: 23232205.

INTRODUCTION: In the revised 6th edition of the AJCC-TNM staging system for breast cancer, metastasis in ipsilateral supraclavicular lymph node(s) is considered as a locoregional disease and classified as N3c rather than M1 distant disease. The aim of this review was to search the recent literature in order to investigate whether the reported treatment outcome of patients with ipsilateral supraclavicular metastases in breast cancer patients justifies this revision. METHODS: A review of the recent English-language literature (January 2001-June 2012) concerning breast cancer with supraclavicular involvement was performed. RESULTS: A total number of six studies were included in the current review. All reported comparable data with regard to treatment outcome after multimodality treatment, despite considerable


Treatment outcome in breast cancer patients with ipsilateral supraclavicular lymph node metastasis at time of diagnosis: A review of the literature.

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CHIRURGIE

heterogeneity in study populations. Patients with ipsilateral supraclavicular lymph node involvement showed outcomes more similar to locally advanced breast cancer patients rather than patients with distant tumor spread. CONCLUSION: It seems that the 2002 revision of the AJCC-TNM staging system for breast cancer has appropriately reclassified patients with supraclavicular disease to a new category (N3c).

Long-term functional outcome of patients with longitudinal radial deficiency: cross-sectional evaluation of function, activity and participation.

Holtslag I, Wijk IV, Hartog H, Van der Molen AM, Van der Sluis C. Disabil Rehabil 2012 Nov 20. Epub ahead of print. PMID: 23167292.

PURPOSE: To evaluate all functional aspects of patients with longitudinal radial dysplasia and to clarify the relationship between body functions on the one hand and limitations in activity and participation on the other hand. Methods: Thirty-one arms of seventeen adult patients with longitudinal radial dysplasia were analysed. Body function was assessed by measuring grip and pinch strength and active range of motion (ROM) of the hand. Activities were measured using the “Sequential Occupational Dexterity Assessment “, to measure perceived restrictions in participation the “Impact on Participation and Autonomy questionnaire” was used. Relationships between severity of dysplasia, body function, participation and activity were determined. Results: Patients with a severe type scored significantly lower in body function scores than patients with a mild form. Patients with limited active finger joint motion performed worse on activities. We found no significant differences in activity and participation between mild or severe types and found no correlation in participation scores. Conclusion: Although considerable restrictions in joint mobility and strength were revealed, little or no limitations on the activity and participation level were found. Limitations in body functions hardly influenced capacity on activity level and did not influence participation in societal roles.


Treatment of breast cancer cells by IGF1R tyrosine kinase inhibitor combined with conventional systemic drugs.

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Hartog H, Van der Graaf WT, Boezen HM, Wesseling J. Anticancer Res. 2012 Apr; 32(4): 1309-18. PMID: 22493363.

AIM: Insulin-like growth factor-1 receptor (IGF1R) is a tyrosine kinase receptor mediating cell growth and survival of cancer cells. We studied responses to IGF1R tyrosine kinase inhibitor NVP-AEW541 combined with conventional systemic drugs in breast cancer cell lines of different clinical subtype. MATERIALS AND METHODS: Sensitivity to NVP-AEW541, single treatment and combinations with tamoxifen, trastuzumab, doxorubicin or paclitaxel, was tested in MCF7, SKBR3 and T47D cells. Cells were assayed for proliferation, cell death, cell cycle distribution and phosphorylation of proteins downstream of IGF1R. RESULTS: Treatment of NVP-AEW541 resulted in reduced proliferation, G-1 cell cycle arrest and reduced phosphorylation of protein kinase B (AKT) and extracellular-signal-regulated protein kinase (ERK). Sensitivity to IGF1R tyrosine kinase inhibition was low in T47D cells, despite their high IGF1R expression. NVP-AEW541 combined with trastuzumab had synergistic cytotoxic effects in T47D

CHIRURGIE

cells, and additive effects were shown in MCF7 and SKBR3 cells. Also, combination with doxorubicin had antagonistic effects in T47D cells. Doxorubicin caused up-regulation of phosphorylated ERK in T47D cells, which was not inhibited by NVP-AEW541. CONCLUSION: Antagonistic effects should be anticipated when IGF1R inhibitors are combined with conventional systemic drugs in a subset of breast tumors. Development of functional biomarkers predicting tumor response to tailored IGF1R therapy is warranted.

The surgical anatomy of the small saphenous vein and adjacent nerves in relation to endovenous thermal ablatio.

BACKGROUND: Thermal damage to peripheral nerves is a known complication of endovenous thermal ablation (EVA) of the small saphenous vein (SSV). Therefore, the main objective of this anatomic study was to define a safe zone in the lower leg where EVA of the SSV can be performed safely. METHODS: The anatomy of the SSV and adjacent nerves was studied in 20 embalmed human specimens. The absolute distances between the SSV and the sural nerve (SN) (closest/nearest branch) were measured over the complete length of the leg (>120 data points per leg), and the presence of the interlaying deep fascia was mapped. The distance between the SSV and the tibial nerve (TN) and the common peroneal nerve was assessed. A new analysis method, computer-assisted surgical anatomy mapping, was used to visualize the gathered data. RESULTS: The distance between the SSV and the SN was highly variable. In the proximal one-third of the lower leg, the distance between the vein and the nerve was <5 mm in 70% of the legs. In 95%, the deep fascia was present between the SSV and the SN. In the distal two-thirds of the lower leg, the distance between the vein and the nerve was <5 mm in 90% of the legs. The deep fascia was present between both structures in 15%. In 19 legs, the SN partially ran beneath the deep fascia. In the saphenopopliteal region, the average shortest distance between the SSV and the TN was 4.4 mm. In 20%, the distance was <1 mm. The average, shortest distance between the SSV and the common peroneal nerve was 14.2 mm. The distance was <1 mm in one leg. CONCLUSIONS: At the saphenopopliteal region, the TN is at risk during EVA. In the distal two-thirds of the lower leg, the SN is at risk for (thermal) damage due to the small distance to the SSV and the absence of the deep fascia between both structures. The proximal one-third of the lower leg is the optimal region for EVA of the SSV to avoid nerve damage; the fascia between the SSV and the SN is a natural barrier in this region that could preclude (thermal) damage to the nerve.

Bariatric surgery with OR teams that stayed fixed during the day: a mulicenter analyzing the effects on patiënt outcomes, teamwork and safety climate and duration.

Stepaniak PS, Heij C, Buise MP, Mannaerts GHH, Smulders JF, Nienhuis SW. Anesth Analg 2012, Epub 2012 nov 9. PMID: 23144431.

BACKGROUND: Bariatric surgery durations vary considerably because of differences in surgical procedures and patient factors. We studied the effects on patient outcomes, teamwork and safety climate, and procedure durations resulting from working with operating


Kerver AL, Van der Ham AC, Theeuwes HP, Eilers PH, Poublon AR, Kerver AJH, Kleinrensink GJ. J Vasc Surg 56 (1):181-8 2012. PMID: 22503186.

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room (OR) teams that remain fixed for the day instead of OR teams that vary during the day. METHODS: Data were collected in 2 general teaching hospitals, consisting of patientrelated demographic and intraoperative data and of staffrelated survey data on team work and safety climate. The procedure durations of fixed and conventional OR teams were analyzed by comparison of means tests and by regression methods to control for the effects of surgeon, surgical experience, and procedure type. RESULTS: For both hospitals, we obtained the following 4 results for working on bariatric procedures with OR teams that remained fixed for the day. First, patient outcomes did not worsen. Second, teamwork and safety climate (both measured on a 5-point scale) improved significantly, for teamwork + 0.86 (95% confidence interval [CI], 0.54 to 1.18) and for safety climate + 0.75 (95% CI, 0.40 to 1.11). Third, the procedures were performed significantly faster, as both the mean and the SD of procedure durations decreased. After correcting for learning effects, the average reduction of durations was 10.8% (99% CI, 5.0% to 15.3%, or 4 to 13 minutes). This gain was mainly realized for surgical time (12%; 99% CI, 5% to 18%, or 3 to 11 minutes). The effect on peripheral time, defined as procedure time minus surgical time, is not significant (3%; 99% CI, -6% to 12%, or -1 to 3 minutes). Fourth, additional gains were obtained by performing the same type of procedure multiple times within the same day (5% per every next procedure of the same type; 99% CI, 3% to 7%, or 3 to 6 minutes).

Yield of routine molecular analyses in colorectal cancer patiënt ≤ 70 years to detect underlying Lynch syndrome.


Van Lier MG, Leenen CH, Wagner A, Ramsoekh D, Dubbing HJ, Van den Ouweland AM, Westenend PJ, De Graaf EJ, Wolters LM, Vrijland WW, Kuipers EJ, Van Leerdam ME, Steyerberg EW, Dinjens WN; LIMO Study Group. J Pathol. 2012 Apr; 226(5): 764-74. doi: 10.1002/path. 3963. Epub 2012 Jan 17. PMID: 22081473.

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Although early detection of Lynch syndrome (LS) is important, a considerable proportion of patients with LS remains unrecognized. We aimed to study the yield of LS detection by routine molecular analyses in colorectal cancer (CRC) patients until 70 years of age. We prospectively included consecutive CRC patients ≤70 years. Tumour specimens were analysed for microsatellite instability (MSI), immunohistochemical mismatch-repair protein expression and MLH1-promoter methylation. Tumours were classified as either: (a) likely caused by LS; (b) sporadic microsatellite-unstable (MSI-H); or (c) microsatellite-stable (MSS). Predictors of LS were determined by multivariable logistic regression. A total of 1117 CRC patients (57% males, median age 61 years) were included. Fifty patients (4.5%, 95% CI 3.4-5.9) were likely to have LS, and 71 had a sporadic MSI-H tumour (6.4%, 95% CI 5.1-8.0). Thirty-five patients likely to have LS (70%) were aged > 50 years. A molecular profile compatible with LS was detected in 10% (15/144) of patients aged ≤50, in 4% (15/377) of those aged 51-60 and in 3% (20/596) of patients > 61 years. Compared to MSS cases, patients likely to have LS were significantly younger (OR 3.9, 95% CI 1.7-8.7) and more often had right-sided CRCs (OR 14, 95% CI 6.0-34). In conclusion, molecular screening for LS in CRC patients ≤70 years leads to identification of a molecular profile compatible with LS in 4.5% of patients, with most of them not fulfilling the age criterion (≤50 years) routinely used for LS assessment. Routine use of MSI testing may be considered in CRC patients up to the age of 70 years, with a central role for the pathologist in the selection of patients.

CHIRURGIE

Comparison of the 6th and 7th Editions of the UICC-AJCC TNM Classification for Esophageal Cancer.

Talsma K, Van Hagen P, Grotenhuis BA, Steyerberg EW, Tilanus HW, Van Lanschot JJ, Wijnhoven BP. Ann Surg Oncol. 2012 Jul; 19(7): 2142-8. PMID: 22395974.

BACKGROUND: The new 7th edition of the Union for International Cancer Control-American Joint Committee on Cancer (UICC-AJCC) tumor, node, metastasis (TNM) staging system is the ratification of data-driven recommendations from the Worldwide Esophageal Cancer Collaboration database. Generalizability remains questionable for single institutions. The present study serves as a validation of the 7th edition of the TNM system in a prospective cohort of patients with predominantly adenocarcinomas from a single institution.METHODS: Included were patients who underwent transhiatal esophagectomy with curative intent between 1991 and 2008 for invasive carcinoma of the esophagus or gastroesophageal junction. Excluded were patients who had received neoadjuvant chemo(radio)therapy, patients after a noncurative resection and patients who died in the hospital. Tumors were staged according to both the 6th and the 7th editions of the UICC-AJCC staging systems. Survival was calculated by the Kaplan-Meier method, and multivariate analysis was performed with a Cox regression model. The likelihood ratio chi-square test related to the Cox regression model and the Akaike information criterion were used for measuring goodness of fit. RESULTS: A study population of 358 patients was identified. All patients underwent transhiatal esophagectomy for adenocarcinoma. Overall 5-year survival rate was 38%. Univariate analysis revealed that pT stage, pN stage, and pM stage significantly predicted overall survival. Prediction was best for the 7th edition, stratifying for all substages.CONCLUSIONS: The application of the 7th UICC-AJCC staging system results in a better prognostic stratification of overall survival compared to the 6th edition. The fact that the 7th edition performs better predominantly in patients with adenocarcinomas who underwent a transhiatal surgical approach, in addition to findings from earlier research in other cohorts, supports its generalizability for different esophageal cancer practices.

Slieker J, Komen NA, Mannaerts GHH, Karsten TM, Willemsen P, Murawska M, Jeekel J, Lange JF. Arch Surg 2012; 147 (8); 447-52. PMID:22249852. OBJECTIVE: To determine the risk factors for symptomatic anastomotic leakage (AL) after colorectal resection. DESIGN: Review of records of patients who participated in the Analysis of Predictive Parameters for Evident Anastomotic Leakage study. SETTING: Eight health centers. PATIENTS: Two hundred fifty-nine patients who underwent left-sided colorectal anastomoses. INTERVENTION: Corticosteroids taken as long-term medication for underlying disease or perioperatively for the prevention of postoperative pulmonary complications. MAIN OUTCOME MEASURES: Prospective evaluations for risk factors for symptomatic AL. RESULTS: In 23% of patients, a defunctioning stoma was constructed. The incidence of AL was 7.3%. The clinical course of patients with AL showed that in 21% of leaks, the drain indicated leakage; in the remaining patients, computed tomography or laparotomy resulted equally often in the


Long-term and perioperative corticosteroids in anastomotic leakage: a prospective of 259 left-sided colorectal anastomoses.

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CHIRURGIE

detection of AL. In 50% of patients with AL, a Hartmann operation was needed. The incidence of AL was significantly higher in patients with pulmonary comorbidity (22.6% leakage), patients taking corticosteroids as longterm medication (50% leakage), and patients taking corticosteroids perioperatively (19% leakage). Perioperative corticosteroids were prescribed in 8% of patients for the prevention of postoperative pulmonary complications. CONCLUSIONS: We found a significantly increased incidence of AL in patients treated with long-term corticosteroids and perioperative corticosteroids for pulmonary comorbidity. Therefore, we recommend that in this patient category, anastomoses should be protected by a diverting stoma or a Hartmann procedure should be considered to avoid AL.

Overige publicaties Preoperative Assessment of Tumor Location an Station-Specific Lymfh Node Status in Patients with Adenocarcinoma of the Gastroesophageal Junction.

Grotenhuis BA, Wijnhoven BP, Poley JW, Hermans JJ, Biermann K, Spaander MC, Bruno MJ, Tilanus HW, Van Lanschot JJ. World J Surg. 2012 Sep 27. Epub ahead of print.

Onderzoek “Onderarmgips bij distale fracturen van radius en ulna” een multicentrisch gerandomiseerd onderzoek bij kinderen.

Colaris JW, Biter LU, Allema JH, Bloem RM, Van de Ven CP, De Vries MR, Kerver AJH, Reijman M, Verhaar J. Ned Tijdschr Geneesk.2012; 156:A5332.

Voordrachten


Onderarmgips in de behandeling van de fractura antebrachii. Een gerandomiseerde multicenter studie.

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Colaris JW, Allema JH, Biter LU, De Vries MR, Van der Ven CP, Bloem RM, Kerver AJH, Reijman M, Verhaar JAN. Veldhoven: NOV najaarsvergadering, 4-5 oktober 2012.

Rotterdam Advanced Foot Ankle Trauma Course. Improving through Practice.

Schepers T, Den Hartog D, Kleinrensink GJ, Kerver AJH, Reijman M, Verhaar JAN. Rotterdam: SkillsLab, Erasmus MC, 9 maart 2012.

De nieuwe richtlijn behandeling polsfracturen.

Kerver AJH, Klem TMAL. Rotterdam: Regionale Refereeravond Heelkunde, 16 april 2012.

CHIRURGIE

EARP cursus abdomen.

Kerver AJH. Rotterdam: Extra auriculair onderwijs studenten geneeskunde EMC, 1 mei 2012.

Behandeling van wervelfracturen.

Kerver AJH. Rotterdam: Regionale SEH artsen onderwijs, 4 juni 2012.

ATLS.

Kerver AJH. Instructeur. Riel: 26-27 juni 2012.

ATLS.

Kerver AJH. Instructeur. Riel: 10-11 december 2012.

Fysiologie en pathofysiologie van het vaatstelsel. Klem TMAL. Utrecht: Vasculaire specialisatie, 10-09-2012.

ATLS cursus (instructor).

Klem TMAL. Riel: ATLS, 13 en 14 september 2012.

Sleeve gastrectomy is the future technique of choice.

Mannaerts GHH. Arnhem: NVEC annual congress “Looking better”, March 12-13th 2012.

Fast-track sleeve gastrectomy.

Modernisering Medische opleidingen: is de SEH opleiding al modern? De Ridder VA. Egmond aan Zee: NVSHA, 30 mei - 1 juni 2012.

Acetabulumfrakturen Röntgendiagnostik und Klassification. Anterior fractures of the acetabulum. Ilio inguinal Approach and alternatives. Reduction techniques of sacrum fractures. Pelvic trauma, trial and error or science? De Ridder VA. Invited speaker, practical exercises expert en session chairman. Hamburg: AO Pelvic course, 12-15 juni 2012.


Mannaerts GHH. Rotterdam: NVEC-Johnson & Johnson Expert meeting 2012, 29 december 2012.

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CHIRURGIE

Change in epidemiology of trauma in adolescents in Europe. De Ridder VA. Minneapolis: OTA, 2-6 oktober 2012.

Change in epidemiology of trauma in adolescents in Europe. De Ridder VA. Berlijn: DKOU, 22-25 oktober 2012.

Endoveneuze laserbehandeling vergeleken met conventionele chirurgie in de behandeling van insufficiëntie van de vena saphena parva: korte termijn resultaten van een multicenter randomized controlled trial. Roopram AD, Lind MY, Van Brussel JP, De Smet AAEA, Van der Ham AC. Ede: Najaarsvergadering Nederlandse Vereniging voor Vaatchirurgie, 12 oktober 2012.

Endovenous laser ablation versus conventional surgery in the treatment of small saphenous vein incompetence: short term results of a multicenter randomized controlled trial. Roopram AD, Lind MY, Van Brussel JP, De Smet AAEA, Van der Ham AC. Brugge: Zomervergadering Benelux Vereniging voor Flebologie, 1-2 juni.

Endoveneuze laserbehandeling vergeleken met conventionele chirurgie in de behandeling van insufficiëntie van de vena saphena parva: korte termijn resultaten van een multicenter randomized controlled trial. Roopram AD, Lind MY, Van Brussel JP, De Smet AAEA, Van der Ham AC. Rotterdam: Multidisciplinair Flebologisch Overleg, 15 mei 2012.

Endoveneuze laserbehandeling vergeleken met conventionele chirurgie in de behandeling van insufficiëntie van de vena saphena parva: korte termijn resultaten van een multicenter randomized controlled trial.


Roopram AD, Lind MY, Van Brussel JP, De Smet AAEA, Van der Ham AC. Rotterdam: Vascular Rounds Zuidwest Nederland, 19 maart 2012.

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Posters Prevention of iatrogenic radial nerve palsy in the treatment of humeral shaft fractures: an anatomical study with radiological guidance.

Van der Ende B, Theeuwes HP, Potters JW, Kerver AJH, Bessems JH, Kleinrensink GJ. Basel: ECTES 2012, 12-15 mei 2012.

A baclofen-overdosed patiënt with normal renal function; treatment by hemodialysis. Bontemps S, Geerlings CJC, De Feiter PW, De Ridder VA. Rotterdam: Wetenschapsdag SFG, 13 april 2012.

Publication rate en impact. De Ridder VA. Chicago: OTA, March 28th 2012.


DERMATOLOGIE

DERMATOLOGIE

DERMATOLOGIE

Pubmed artikelen Granulomateuze secundaire syfilis, een zeldzame uiting van een polymorf ziektebeeld. Schrader AMR, Racz E, Noordhoek Hegt V, Van der Snoek EM, Van Praag MCG. Ned Tijdschr Geneeskd 2012;156:A5130. PMID: 22894801.

BACKGROUND: Due to a great diversity of clinical presentations secondary syphilis can mimic various skin diseases, which means that the diagnosis of this sexually transmitted condition can be missed. Occurrence of a granulomatous inflammatory reaction in secondary syphilis is rare and may be confused with other granulomatous dermatoses. CASE DESCRIPTION: We present a 37-year-old homosexual male with a granulomatous dermatitis due to secondary syphilis. The differential diagnosis based on clinical and histopathological findings was lengthy and the initial syphilitic serology results were negative, resulting in delayed diagnosis. After revision of the histopathology and repeated serological testing secondary syphilis could be diagnosed. CONCLUSION: Not only the clinical, but also the histopathological presentation of secondary syphilis is variable. To prevent transmission, treatment delay and complications, we recommend repeating syphilitic serology following negative results if there is clinical or histopathological suspicion of this disease, especially in patients displaying high-risk behaviour. Syphilis should be also excluded in granulomatous dermatoses with plasma cells.

Lamotrigine hypersensitivity syndrome and spiking fever.


Bakker CV, Noordhoek Hegt V, Van Praag MCG. Indian J Dermatol. 2012;57:504-505. PMID: 23248384. PMCID: PMC3519273. Free PMC Article.

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We report a case of a 26 year old woman with rash, lymphadenopathy, liver enzyme abnormalities and spiking fever. She was diagnosed with drug-induced hypersensitivity syndrome (DHS) to lamotrigine. Spiking fever in relation to drug-induced hypersensitivity syndrome has not earlier been described in adults. Spiking fever is an important symptom of the wide spectrum of disease presentation. The syndrome is commonly referred to as either Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) or DHS. In accord with previous authors we see both syndromes as two ends of a spectrum, with a wide range of symptoms and presentations. Therefore we plea for unity in nomenclature.

Overige artikelen Granulaire parakeratose.

Racz E, Noordhoek Hegt V, Van Praag MCG. Ned tijdschr Dermatol Venereol 2012; 22: 606-607.

Voordrachten Kinderdermatologie in combinatie met infectieuze ziektebeelden Van Praag MCG, Verhallen JTCM. Rotterdam: Huisartsen parallelsymposium Kindergeneeskunde, 3 april 2012.

Dermatochirurgie in de huisartsenpraktijk.

DERMATOLOGIE

DERMATOLOGIE

Van Praag MCG. Rotterdam: Nascholing dermato-oncologie Sint Franciscus Gasthuis, 13 december 2012.

Niet gepigmenteerde huidmaligniteiten.

Assen YJ. Rotterdam: Nascholing dermato-oncologie Sint Franciscus Gasthuis, 13 december 2012.

Melanoom.

Snels DGCTM. Rotterdam: Nascholing dermato-oncologie Sint Franciscus Gasthuis, 13 december 2012.

Introductie met casuïstieken huidmaligniteiten.

Loots MAM, Herman E. Rotterdam: Nascholing dermato-oncologie Sint Franciscus Gasthuis, 13 december 2012.

Posters SSSS: loslatende huid!

Chan STJ, Van Praag MCG. Rotterdam: Wetenschapsdag 2012, Sint Franciscus Gasthuis, 13 april 2012.

Langerhanscelhistiocytose.


Hajdarbegovic E, Noordhoek Hegt V, van Praag MCG Rotterdam: Wetenschapsdag 2012, Sint Franciscus Gasthuis, 13 april 2012.

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GYNAECOLOGIE

GYNAECOLOGIE

GYNAECOLOGIE

Pubmed artikelen Laparoscopic sacrocolpopexy with bone anchor fixatio: short-term anatomic and functional results. Withagen MI, Vierhout ME, Mannaerts GHH, Van der Weiden RMF. Int Urogynecol J 2012; 23: 481-6. PMID: 22086264.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate short-term anatomic and functional outcomes and safety of laparoscopic sacrocolpopexy with bone anchor fixation.METHODS: A prospective cohort study of women undergoing laparoscopic sacrocolpopexy between 2004 and 2009. Anatomic outcome was assessed using the pelvic organ prolapse quantification score (POP-Q). Functional outcomes were assessed using the Urogenital Distress Inventory, Defecatory Distress Inventory, and the Incontinence Impact Questionnaire preoperatively and at 6 months postoperatively. The Wilcoxon signed rank test was used to test differences between related samples. RESULTS: Forty-nine women underwent laparoscopic sacrocolpopexy. The objective success rate in the apical compartment was 98%, subjective success rate was 79%. One mesh exposure (2%) was found. One conversion was necessary due to injury to the ileum. CONCLUSIONS: Laparoscopic sacrocolpopexy with bone anchor fixation is a safe and efficacious treatment for apical compartment prolapse. It provides excellent apical support and good functional outcome 6 months postoperatively.

Successful myomectomy of a bleeding myoma in a twin pregnancy.

Doerga – Bachasingh SR, Karsdorp VHM, Yo G, Van der Weiden RMF, Van Hooff MHA. JRSM Short Rep 2012;3: 13. PMID: 22393474. Geen abstract. DOI 10.1258 / shorts.2011.011087. PMCID: 3291420. Free article.

Succesfull treatment of pituitary tumour apoplexy with bromocryptine in pregnancy.

Prospective evaluation of molecular screening for Lynch syndrome in patients with endometrial cancer = 70 years.

Leenen CH, Van Lier MG, Van Doorn HC, Van Leerdam ME, Kooi SG, de Waard J, Hoedemaeker RF, Van den Ouweland AM, Hulspas SM, Dubbink HJ, Kuipers EJ, Wagner A, Dinjens WN, Steyerberg EW. Gynecol Oncol. 2012;125:414-20. Epub 2012 Feb 1. PMID: 22306203. DOI: 10.1016/j.ygyno.2012.01.049. Lynch syndrome (LS) is a hereditary syndrome that predisposes to multiple malignancies including endometrial cancer (EC). We aimed to evaluate a diagnostic strategy for LS based on routine analysis of microsatellite instability (MSI) and immunohistochemical (IHC) staining for mismatch repair (MMR) proteins in tumour tissue of all newly diagnosed EC patients =70 years.


Jansen NM, Dreyer K, Van der Weiden RMF. JRSM Short Rep 2012; 3: 43. PMID: 22768377. Geen abstract. DOI 10.1258 / shorts.2012.011144. PMCID: 338661. Free article.

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GYNAECOLOGIE

Consecutive EC patients = 70 years were included prospectively in eight Dutch centres. EC specimens were analysed for MSI, IHC of four MMR proteins, MMR gene methylation status and BRAF-mutations. tumours were classified as; 1) likely to be caused by LS, 2) sporadic MSI-H, or 3) microsatellite stable (MSS). Tumour specimens of 179 patients (median age 61 years, IQR 57-66) were analysed. In our study 92% of included patients were over 50 years of age. Eleven EC patients were found likely to have LS (6%; 95% CI 3-11%), including 1 patient suspected of an MLH1, 2 of an MSH2, 6 of an MSH6 and 2 of a PMS2 gene defect. Germline mutation analyses revealed 7 MMR gene germline mutations. Ten patients likely to have LS (92%) were older than 50 years. In addition, 31 sporadic MSI-H tumours with MLH1 promoter hypermethylation (17%; 95% CI 13-24%) were identified. Molecular screening for LS in patients with EC diagnosed = 70 years, leads to identification of a profile likely to have LS in 6% of cases. New screening guidelines for LS are needed, including recommendations for EC patients older than 50 years of age.

Fluid shift out of the fetal circulation during intrauterine red cell transfusion.


Kamping MA, Pasman SA, Bil-van den Brink CP, Oepkes D, Adama van Scheltema PN, Vandenbussche FP. Ultrasound Obstet Gynecol. 2012 Nov 5. doi: 10.1002/uog.12338. [Epub ahead of print] PMID: 23124821.

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OBJECTIVES: Intrauterine transfusion presents a considerable burden on the fetal circulation by increasing volume and pressure. Already during transfusion, a fluid shift out of the fetal circulation occurs. Aim of the study was to quantify the intraprocedural fluid shift, and the effect of procedural and fetal characteristics on this fluid shift. METHODS: In 95 alloimmunized pregnancies, we calculated fluid shift at first intrauterine transfusions, by determining initial and final blood volumes. We evaluated the association of the fluid shift with speed and volume of transfusion, severity of anemia and presence of hydrops. RESULTS: Of the included fetuses, 11 were mildly hydropic and 4 were severely hydropic. A mean fluid shift of 36% of transfused volume was found. Fluid shift related positively to transfused volume (p<0.00). The percentage fluid shift of transfused volume was inversely related to speed of transfusion (ml/kg/min) (p<0.041) and not related to severity of anemia (p=0.55) or hydrops (p=0.66). At low gestational age, fetuses had been unintentionally burdened with relative high volume and speed of transfusion. CONCLUSION: Around one third of transfused volume is lost from the intravascular compartment already during intrauterine transfusion. A large variation, partly explained by volume and speed of transfusion, was observed. Neither severity of anemia or hydrops played a clear-cut role, thus other factors may explain the variation in fluid shift. The probability that hematocrit will still increase after transfusion, due to a continuing fluid shift, should be considered in transfusion policy. Advice is given on gestational age adjusted speed of transfusion.

Sequential urodynamic assessment before and after laparoscopic sacrocolpopexy. Kummeling MT, Rietbergen JB, Withagen MI, Mannaerts GHH, Van der Weiden RMF. Acta Obstet Gynecol Scand 2012; Nov 16. doi: 1111-aogs. 12045. PMID: 23157606.

GYNAECOLOGIE

OBJECTIVE: Controversial data are available as to whether to perform a simultaneous abdominal or vaginal colposuspension operation in laparoscopic sacrocolpopexy procedures. We wanted to evaluate the effect of a modified laparoscopic operation technique on urodynamic parameters and lower urinary tract symptoms. DESIGN: Prospective single center cohort study. SETTING: Teaching hospital. POPULATION: Forty-nine consecutive patients who underwent a modified laparoscopic sacrocolpopexy/hysteropexy operation using bone anchor fixation and synthetic mesh, performed by the same laparoscopic surgeons. METHODS: Pre- and postoperative multichannel urodynamic evaluation and validated questionnaires. The same urologist, blinded to the results of the questionnaire survey, interpreted all urodynamic evaluations. MAIN OUTCOME MEASURES: The effects of surgery on pelvic anatomy and patient satisfaction, urodynamic observations and diagnoses and symptom scores in validated questionnaires. RESULTS: Forty-two patients consented to pre- and postoperative urodynamic evaluation. Laparoscopic sacrocolpopexy successfully corrected vaginal vault prolapse in all 42 patients with urodynamic evaluation six months after surgery. The bladder volume at first desire to void was significantly increased and the maximal detrusor pressure at voiding phase was significantly decreased. In the questionnaires, irritative and storage voiding symptoms were significantly decreased. CONCLUSIONS: The results of the study demonstrate that there are no adverse urodynamic findings following this modified technique for laparoscopic sacrocolpopexy. The statistically significant urodynamic improvements are in accordance with the scores on the Urogenital Distress Inventory questionnaires. These results do not support a simultaneous routine prophylactic colposuspension procedure.

Overige artikelen Improved performance of maternal-fetal medicine staff after maternal cardiac arrest simulation-based training.


Vencken PM, Van Hooff MHA, Van der Weiden RMF. Am J Obstet Gynecol 2012; 206: e4. (correspondence).

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INTENSIVE CARE

INTENSIVE CARE

INTENSIVE CARE

Pubmed artikel Cardiac arrest in pregnancy: lessons to be learned!


Van Waning VH, Van der Weiden RMF, de Feiter PW, Brouwers AJ. Intensive Care Med. 2012 Apr;38(4):721. doi: 10.1007/s00134-012-2506-3. PMID: 22323080. Geen abstract.

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INTERNE GENEESKUNDE

INTERNE GENEESKUNDE

INTERNE GENEESKUNDE

Pubmed artikelen Treatment of amiodarone-induced thyrotoxicosis type 2: a randomised clinical trial.

Eskes SA, Endert E, Fliers E, Geskus RB, Dullaart RP, Links TP, Wiersinga WM. Journal of Clinical Endocrinology and Metabolism, 2012 feb:97(2):499-506. PMID: 22130792.

Increased IL-17A expression in granulomas and in circulating memory T cells in sarcoidosis.

Paats MS, Ten Berge B, Bergen IM, Van den Blink B, Hoogsteden HC, Lambrecht BN, Hendriks RW, Kleinjan A. Rheumatology (Oxford). 2012 Jan;51(1):37-46. doi: 10.1093/rheumatology/ker316. Epub 2011 Nov. 10. PMID: 22075064.

OBJECTIVE: Sarcoidosis is a systemic inflammatory disorder characterized by granulomas. Although the aetiology is unknown, sarcoidosis is thought to be mediated by Th1 lymphocytes. Recently, IL-17A has been implicated in granuloma formation in various diseases, including tuberculosis. Therefore, we hypothesized that Th17 cells play a role in sarcoidosis, paralleling recent findings in autoimmune diseases such as RA. The aim of our study was to investigate the role of Th17 cells in sarcoidosis. METHODS: T cells were investigated by intracellular flow cytometry and immunohistochemistry, in blood, bronchoalveolar lavages (BALs) and bronchial mucosal biopsies from a cohort of newly diagnosed sarcoidosis patients and healthy controls.


CONTEXT: Amiodarone-induced thyrotoxicosis (AIT) type 2 is self-limiting in nature, but most physicians are reluctant to continue amiodarone. When prednisone fails to restore euthyroidism, possibly due to mixed cases of AIT type 1 and 2, perchlorate (ClO(4)) might be useful because ClO(4) reduces the cytotoxic effect of amiodarone on thyrocytes. OBJECTIVES: Our objectives were to demonstrate the feasibility of continuation of amiodarone in AIT type 2 and to evaluate the usefulness of ClO(4) (given alone or in combination with prednisone) in AIT type 2. DESIGN AND SETTING: A randomized multicenter study was conducted in 10 Dutch hospitals. METHODS: Patients with AIT type 2 were randomized to receive prednisone 30 mg/d (group A, n = 12), sodium perchlorate 500 mg twice daily (group B, n = 14), or prednisone plus perchlorate (group C, n = 10); all patients continued amiodarone and were also treated with methimazole 30 mg/d. Follow-up was 2 yr. MAIN OUTCOME MEASURES: Treatment efficacy (defined as TSH values = 0.4 mU/liter under continuation of amiodarone) and recurrent thyrotoxicosis were evaluated. RESULTS: Initial therapy was efficacious in 100, 71, and 100% of groups A, B, and C, respectively (P = 0.03). The 29% failures in group B became euthyroid after addition of prednisone. Neither the time to reach TSH of 0.4 mU/liter or higher [8 wk (4-20), 14 wk (4-32), and 12 wk (4-28) in groups A, B, and C respectively] nor the time to reach free T(4) of 25 pmol/liter or below [4 wk (4-20), 12 wk (4-20), and 8 wk (4-20) in groups A, B, and C) were significantly different between groups (values as median with range). Recurrent thyrotoxicosis occurred in 8.3%. CONCLUSION: Euthyroidism was reached despite continuation of amiodarone in all patients. Prednisone remains the preferred treatment modality of AIT type 2, because perchlorate given alone or in combination with prednisone had no better outcomes.

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INTERNE GENEESKUNDE

RESULTS: Circulating memory CD4(+) T-cell populations of sarcoidosis patients contained significantly increased proportions of IL-17A(+) cells when compared with healthy controls. Interestingly, proportions of IL-17A/IFN-γ and IL-17A/IL-4 double-producing cells were significantly increased in blood of sarcoidosis patients and were present in substantial numbers in BAL. In granuloma-containing, but not in non-granulomatous sarcoidosis biopsies, we found significantly increased numbers of IL-17A(+) T cells, located in and around granulomas throughout the lamina propria. IL-22(+) T cells were increased in the subepithelial layer. CONCLUSIONS: Enhanced IL-17A expression in granulomas and the presence of IL-17A(+), IL-17A(+)IFN-γ(+) and IL-17A(+)IL-4(+)memory Th cells in the circulation and BAL indicate Th17 cell involvement in granuloma induction or maintenance in sarcoidosis. Therefore, neutralization of IL-17A activity may be a novel strategy to treat sarcoidosis.

Systemic CD4+ and CD8+ T-cell cytokine profiles correlate with GOLD stage in stable COPD.


Paats MS, Bergen IM, Hoogsteden HC, Van der Eerden MM, Hendriks RW. Eur Respir J. 2012 Aug;40(2):330-7. doi: 10.1183/09031936.00079611. Epub 2011 Dec 19. PMID: 22183488.

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Chronic obstructive pulmonary disease (COPD) is associated with pulmonary and systemic inflammation. Both CD4+ and CD8+ T-lymphocytes play a key role in COPD pathogenesis, Witt cytokine profiles in circulating T-lymphocytes have not been well characterised. Here we report the analysis of peripheral blood T-cells from 30 stable COPD patients and 10 healthy never-smokers for interferon (IFN)-γ, interleukin (IL)-4, tumour necrosis factor (TNF)-α and the T-helper 17 cytokines IL-17A, IL-17F and IL-22 by intracellular flow cytometry. We found significantly increased proportions of IFN-γ+ and TNF-α+ CD8+ T-cells in COPD patients, when compared with healthy controls. This was most evident in patients with less severe disease. In contrast, expression profiles in circulating CD4+ T-cells were similar in COPD patients and healthy controls for all cytokines tested, except for IL-17F. COPD patients with more severely reduced diffusing capacity had lower proportions of IL-17A+ CD4+ T-cells. Proportions of IL-22+ cells in the CD4+ memory T-cell population were significantly increased in active smokers, when compared with past smokers. Collectively, this comprehensive cytokine analysis of circulating T-cells in COPD patients revealed a correlation for CD8+ T-cells between Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage and IFN-γ or TNF-α expression, but not for CD4+ T-cells.

Incidence of viral respiratory pathogens causing exacerbations in adult cystic fibrosis patients.

Hoek RA, Paats MS, Pas SD, Bakker M, Hoogsteden HC, Boucher CA, Eerden MM Van der. Scand J Infect Dis. 2013 Jan;45(1):65-9. doi: 10.3109/00365548.2012.708942. Epub 2012 Sep 19. PMID: 22992129. Respiratory infections caused by respiratory viruses are common in paediatric cystic fibrosis (CF) patients and are associated with increased morbidity. There is only little data on the incidence of viral respiratory pathogens causing exacerbations in the adult CF patient population. In this observational pilot study we show, by using molecular as well as conventional techniques for viral isolation, that during 1 y a viral pathogen could be isolated in 8/24 (33%) adult CF patients who presented with a pulmonary exacerbation. This result shows that

INTERNE GENEESKUNDE

there is a considerable incidence of viral pathogens in pulmonary exacerbations in adult CF patients. Newly identified viruses such as pandemic influenza A/H1N1, human metapneumovirus, human bocavirus, and human coronavirus NL63 were not detected in our population, except for 1 human coronavirus NL63.

Novel aspects of nonfasting lipemia in relation to vascular biology.

Castro Cabezas M, Botham KM, Mamo JCL, Proctor SD. Int J Vasc Med 2012; volume 2012: doi: 10.1155/2012/419015. PMID:22548177. No Abstract.

A physician’s guide for the management of hypertriglyceridemia: the etiology of hypertiglyceridemia determines treatment strategy.

Hypertriglyceridemia is a common lipid disorder associated to different, highly prevalent metabolic derangements like diabetes mellitus, the metabolic syndrome and obesity. The choice of treatment depends on the underlying pathogenesis and the consequences for atherosclerosis or pancreatitis. A family history, physical examination and analysis of the lipid profile including measurement of apolipoprotein B or non-HDL-C are necessary to establish the underlying primary or secondary cause. Due to physiological diurnal variations of triglycerides (TG), the time of measurement (fasting or postprandial) should be taken into account when evaluating TG values. Increased awareness arises concerning the impact of postprandial hypertriglyceridemia on the development of atherosclerosis. Hypertriglyceridemia is strongly associated to postprandial hyperlipidemia, remnant accumulation, increased small dense LDL concentrations, low HDL-C, increased oxidative stress, endothelial dysfunction, leukocyte activation and insulin resistance. All these factors are strongly linked to the development of atherosclerosis. Treatment should be aimed at reducing the secretion of triglyceride-rich lipoproteins, increasing intravascular lipolysis and reducing the number of circulating remnants. The main intervention is a change of lifestyle with decreased alcohol consumption, increased physical activity, dietary changes and, if applicable, adaptation of used medication. Fibrates, fish oil and nicotinic acid are the first choice of treatment in sporadic and familial hypertriglyceridemia to reduce the risk of pancreatitis, whereas high dose statins, sometimes in combination with fibrates, nicotinic acid, or fish oil capsules, are indicated for familial combined hyperlipidemia. Statins are necessary to reach low LDL-C concentrations in patients with type 2 diabetes mellitus and statin dosage should be increased when hypertriglyceridemia is present to reach secondary treatment targets for apolipoprotein B or non-HDL-C. Finally, family screening is mandatory to detect familial lipid disorders for early intervention in other family members.

Skin autofluorescence and risk of micro- and macrovascular complications in patients with type 2 diabetes mellitus: a multicenter study. Noordzij MJ, Mulder DJ, Oomen PHN, Brouwer T, Jager J, Castro Cabezas M, Lefrandt JD, Smit AJ. Diabetic Medicine 2012; 29; 1556-1561. PMID: 22937960. Skin autofluorescence is a non-invasive marker of advanced glycation end product accumulation. In a previous study, skin autofluorescence correlated with and predicted


Klop B, Jukema JW, Rabelink TJ, Castro Cabezas M. Panminerva Med 2012; 54: 91-103. PMID: 22525564.

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micro- and macrovascular complications in Type 2 diabetes in a primary care setting. The present cross-sectional study aims to confirm the association between skin autofluorescence and diabetic complications in patients with Type 2 diabetes in a multi-centre secondary care setting. METHODS: We analysed 563 subjects with Type 2 diabetes mellitus from five Dutch hospitals. RESULTS: Median age was 64 years, median duration of diabetes 13 years and median HbA(1c) 58 mmol/mol (7.5%). Sixty-one per cent of patients had microvascular complications (38% nephropathy, 36% retinopathy, 35% neuropathy) and 42% had macrovascular complications. Median UK Prospective Diabetes Study 10-year risk for coronary events was 19%. Median skin autofluorescence was elevated compared with age-matched healthy control subjects: 2.77 (interquartile range 2.39-3.28) vs. 2.46 (2.08-2.84) arbitrary units. Skin autofluorescence was particularly increased in patients with complications: no complications, median 2.56 (2.26-2.90); microvascular complications, 2.79 (2.38-3.29); macrovascular complications, 2.85 (2.41-3.41); both micro- and macrovascular complications, 2.96 (2.56-3.60) arbitrary units, P < 0.001. Logistic regression analysis showed that age, duration of diabetes, renal function, gender, atrial fibrillation and skin autofluorescence were independently associated with macrovascular complications. Multiple regression analysis identified age, smoking, renal function, macrovascular complications and the number of microvascular complications as the determinants of skin autofluorescence. CONCLUSIONS: This study confirms that skin autofluorescence is increased in patients with Type 2 diabetes in a secondary care setting. Skin autofluorescence was associated with macrovascular complications in patients with diabetes and this association was independent of classical risk factors.

Effects of metformin on the regulation of free fatty acids in insulin resistance: a double-blind, placebo controlled study.


Castro Cabezas M, van Wijk JPH, Elte JWF, Klop B. J Nutr Metab 2012; doi: 10.1155/2012/394623. PMID 23094143.

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INTRODUCTION: Impaired free fatty acid (FFA) metabolism is closely linked to insulin resistance. Our aim was to evaluate plasma FFA changes in insulin resistance in a physiological situation after improvement of insulin sensitivity by metformin. Methods. A double-blind, placebo-controlled intervention with metformin was carried out in patients with insulin resistance. Nineteen patients were randomized to receive metformin 850 mg b.i.d. during 6 weeks or placebo. Participants underwent a mental stress test and an oral glucose tolerance test (OGTT) before and after treatment. Results. Fasting plasma glucose, FFA, and HOMA-IR tended to decrease after metformin, suggesting improved insulin sensitivity. FFA concentrations during the mental stress test showed a similar pattern after metformin, albeit lower at all time points, in contrast to the placebo group. The decrease in fasting plasma FFAs was positively associated to the decrease in HbA1c (r = 0.70; P = 0.03) and in fasting glucose (r = 0.74; P = 0.01). The suppression of plasma FFAs during OGTT did not change by metformin or placebo. Conclusion. Metformin in insulin resistance did not lead to improved FFA dynamics despite a trend of improved insulin sensitivity. Metformin most likely decreases plasma FFAs mainly by suppressing fasting FFA concentrations and not by suppression of acute stress-induced lipolysis.

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Randomized trial of short-course high-dose erythropoietin in donation after cardiac death kidney transplant recipients.

Aydin Z, Mallat MJ, Schaapherder AF, van Zonneveld AJ, van Kooten C, Rabelink TJ, de Fijter JW. Am J Transplant 2012;12 (7):1793-800. PMID: 22429395.

Eryhropoiesis-stimulating agents have demonstrated tissue-protective effects in experimental models of ischemia-reperfusion injury. PROTECT was a 12-month, randomized, double-blind, placebo-controlled, single center study with high-dose recombinant human erythropoietin-β (Epoetin) in 92 donation after cardiac death (DCD) kidney transplant recipients. Patients were randomized to receive an intravenous bolus of Epoetin (3.3 × 10(4) international unit (IU); n = 45) or placebo (saline 0.9% solution; n = 47) on 3 consecutive days, starting 3-4 h before the transplantation and 24 h and 48 h after reperfusion. The immunosuppressive regimen included an anti-CD25 antibody, steroids, mycophenolate mofetil and delayed introduction of cyclosporine. Primary end point was a composite of the incidence of primary nonfunction and delayed graft function, either defined by spontaneous functional recovery or need for dialysis in the first week. Secondary objectives included duration of delayed function, renal function and proteinuria up to 1 year and thrombotic adverse events. Results showed no differences in the incidence or duration of delayed graft function and/or primary nonfunction (Epoetin 77.8 vs. placebo 78.7%, p = 1.00). Epoetin treatment significantly increased the risk of thrombotic events at 1 month and 1 year (Epoetin 24.4% vs. placebo 6.4%, p = 0.02).

Pitfalls in urinary complement measurements.

Local activation of the complement system has been associated with ischemia/reperfusion injury following kidney transplantation and tubular injury under proteinuric conditions. The soluble terminal complement complex sC5b-9 is a stable end-product of the complement cascade, and as such a promising urinary biomarker. In the early post-transplant period we found high urinary levels of sC5b-9, significantly correlating with the degree of proteinuria, suggesting activation of filtered complement components at the tubular epithelial surface of the kidney. However, when mimicking proteinuria in vitro by exposing serum (or blood) to urine (both negative for sC5b-9), we found extensive generation of sC5b-9 in urine. This process was inhibited by EDTA, confirming activation of the complement system. In conclusion, although sC5b-9 is an attractive urinary biomarker, one should be aware of the risk of extra-renal complement activation independent of a renal contribution. This may be of special interest when measuring urinary sC5b-9 following kidney transplantation in which procedure-related (microscopic) hematuria and proteinuria are common.


Van der Pol P, de Vries DK, van Gijlswijk DJ, van Anken GE, Schlagwein N, Daha MR, Aydin Z, de Fijter JW, Schaapherder AF, van Kooten C. Transpl Immunol 2012;27(1):55-8. PMID: 22709941.

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Topical psoralenen plus UV-A therapy for Tyrosine kinase inhibitor induced hand foot syndrome. Bos WE, Nijsten TE, de Jonge MJ, Hamberg AP. Arch Dermatol 2012; 148(4):546-547. PMID:22508887. Geen abstract.

Effects of CYP induction by rifampicin on tamoxifen exposure.

Binkhorst L, van Gelder T, Loos WJ, de Jongh FE, Hamberg AP, Ghobadi Moghaddam-Helmantel IM, de Jonge E, Jager A, Seynaeve C, van Schaik RHN, Verweij J, Mathijssen RHJ. Clin Pharmacol Ther 2012; 92(1): 62-62. PMID: 22617226. Tamoxifen undergoes biotransformation into several metabolites, including endoxifen. Differences in metabolism contribute to the interindividual variability in endoxifen concentrations, potentially affecting treatment efficacy. We evaluated the effects of cytochrome P450 (CYP) induction by rifampicin on the exposure levels of tamoxifen and its metabolites and found that coadministration of rifampicin resulted in markedly reduced (up to 86%, P ≤ 0.040) concentrations of tamoxifen and its metabolites. Given the extensive metabolism undergone by tamoxifen, several factors may have contributed to this effect. Similar drug-drug interactions may exist between tamoxifen and other strong CYP inducers.

Phase I and pharmacokinetic study of pazopanib and lapatinib combination therapy in patients with advanced solid tumors.


De Jonge MJA, Hamberg AP, Verweij J, Savage S, Suttle AB, Hodge J, Arumugham T, Pandite LN, Hurwitz HI.

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Investigational New Drugs 2012 Oct 6 [Epub ahead of print]. PMID: 23054212. This phase I, open-label, dose-escalation study assessed the maximum-tolerated dose, safety, pharmacokinetics, and preliminary antitumor activity of pazopanib plus lapatinib combination therapy in patients with solid tumors. Patients were to take pazopanib and lapatinib orally once daily in a fasting condition. During the escalation phase, pazopanib and lapatinib doses were escalated in serial patient cohorts, and a limited blood sampling scheme was applied for pharmacokinetic evaluation. In the expansion phase, potential pharmacokinetic interaction between pazopanib and lapatinib was evaluated more extensively. Seventy-five patients were treated. Multiple dosing levels were studied, combining pazopanib up to 800 mg/day with lapatinib up to 1,500 mg/day. Dose-limiting toxicities observed included grade 3 neutropenia, fatigue, asymptomatic decline in left ventricular ejection fraction, diarrhea, and liver enzyme elevations. The most common drug-related adverse events were diarrhea, nausea, anorexia, fatigue, vomiting, rash, hair depigmentation, and hypertension. The dose recommended for further evaluation was pazopanib 800 mg plus lapatinib 1,500 mg (paz-800/lap-1500). No clinically significant drug-drug interaction was observed at the paz-400/lap-1000 level. However, at paz-800/lap-1500, an increase in both the AUC(0-t) and C(max) of pazopanib was observed. Four partial responses were observed in patients with renal cancer (n=2), giant-cell tumor of the bone (n=1), and thyroid cancer (n=1). Stable disease for ≥18 weeks was seen in 12 patients. Pazopanib and lapatinib can be administered in combination at their respective single-agent doses with an acceptable safety profile. Further evaluation of the combination will be pursued, exploring both paz-800/lap-1500 and paz-400/lap-1000.

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Small bowel angioedema due to acquired C1 inhibitor deficiency: a case report and overview. Oostergo T, Prins G, Schrama YC, Leeuwenburgh I. Eur J Gastroenterol Hepatol. 2012 Dec 18. [Epub ahead of print] PMID: 23255023.

Acquired angioedema is a rare disorder caused by an acquired deficiency of C1 inhibitor. It is characterized by nonpitting, nonpruritic subcutaneous or submucosal edema of the skin, or of the respiratory or gastrointestinal tract. When localized in the gastrointestinal tract, it can cause severe abdominal pain, mimicking an acute surgical abdomen, or chronic recurrent pain of moderate intensity. We report a case of a 48-year-old man presenting with recurrent episodes of hypotension and abdominal pain. Computed tomography of the abdomen showed edema of the small bowel. The first determinations of C1 inhibitor level and activity, measured in a symptom-free period, were normal. Repetition of the laboratory tests in the acute phase, however, showed a low C1 inhibitor level. Further diagnostic work-up indicated an acquired C1 inhibitor deficiency caused by a monoclonal gammopathy. He was treated with tranexamic acid as prophylaxis for his frequent attacks and to date, he has remained symptom free. Acquired C1 inhibitor deficiency is a rare cause of angioedema and is, among others, related to autoantibodies and abnormal B-cell proliferation, for example monoclonal gammopathy. The diagnosis of acquired C1 inhibitor deficiency is made on the basis of the medical history and on the level and activity of plasma C4, C1q, and C1 inhibitor. In case of high suspicion and a normal C1 inhibitor activity, it is recommended to repeat this test during an angioedema attack. Early diagnosis is important for the treatment of severe, potentially life-threatening attacks and to start prophylactic treatment in patients with frequent or severe angioedema attacks.

Local and systemic cytokine profiles in non-severe and severe community-acquired pneumonia.

Local inflammatory responses in community-acquired pneumonia (CAP) remain insufficiently elucidated, especially in patients with non-severe CAP. In this study we determined local and systemic cytokine responses in CAP patients and correlated these with disease severity and other clinical parameters.Levels of interleukin (IL)-6, IL-8, IL-10, IL-1β, tumour necrosis factor (TNF)α, interferon (IFN)γ, IL-22, IL-17A and IL-4 were determined in bronchoalveolar lavage (BAL) fluid and serum of 20 CAP patients upon admission and 10 healthy individuals. Systemic cytokine levels were also measured on days 7 and 30.In BAL fluid of CAP patients, levels of IL-6, IL-8, and IFNγ were significantly increased compared with healthy individuals, but no correlations with disease severity were found. Systemic levels of IL-6, IL-10 and IFNγ were significantly higher in severe CAP patients than in non-severe CAP patients and healthy individuals. Moreover, these cytokines showed a significant correlation with the pneumonia severity index (PSI). In the total group of CAP patients systemic IL-8 and IL-22 levels were also increased compared with healthy individuals.We therefore conclude that IL-6, IL-10 and IFNγ are important cytokines in CAP, although differences in disease severity upon admission are only reflected by systemic levels of these cytokines.


Paats MS, Bergen IM, Hanselaar WE, Groeninx van Zoelen EC, Hoogsteden HC, Hendriks RW, Van der Eerden MM. Eur Respir J. 2012 Dec 20. [Epub ahead of print]. PMID: 23258791.

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Hypertriglyceridemia, Metabolic Syndrome, and Cardiovascular Disease in HIV-infected patients: effects of antiretroviral therapy and adipose tissue distribution. Van Wijk JPH, Castro Cabezas M. Int J Vasc Med 2012; 2012: 201027 Epub. PMID: 21876813.

The use of combination antiretroviral therapy (CART) in HIV-infected patients has resulted in a dramatic decline in AIDS-related mortality. However, mortality due to non-AIDS conditions, particularly cardiovascular disease (CVD) seems to increase in this population. CART has been associated with several metabolic risk factors, including insulin resistance, low HDL-cholesterol, hypertriglyceridemia and postprandial hyperlipidemia. In addition, HIV itself, as well as specific antiretroviral agents, may further increase cardiovascular risk by interfering with endothelial function. As the HIV population is aging, CVD may become an increasingly growing health problem in the future. Therefore, early diagnosis and treatment of cardiovascular risk factors is warranted in this population. This paper reviews the contribution of both, HIV infection and CART, to insulin resistance, postprandial hyperlipidemia and cardiovascular risk in HIV-infected patients. Strategies to reduce cardiovascular risk are also discussed.

Exploring the value of apoB48 as a marker for atherosclerosis in clinical practice.


Alipour A, Valdivielso P, Elte JWF, Janssen JW, Rioja J, van der Meulen N, van Mechelen R, Njo TL, González-Santos P, Rietveld AP, Castro Cabezas M. Eur J Clin Invest. 2012 Jul;42(7):702-8. PMID :22224712.

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BACKGROUND: Postprandial accumulation of atherogenic remnants has been described in patients with type 2 diabetes mellitus (T2DM), familial combined hyperlipidaemia (FCH), familial hypercholesterolaemia (FH) and coronary artery disease (CAD). Scarce data are available on fasting plasma apolipoprotein (apo) B48 levels in relation to these conditions and atherosclerosis. DESIGN: Treated patients with FCH (18), FH (20), T2DM (26), CAD (65), T2DM with CAD (T2DM/ CAD) (28) and 33 healthy controls were included. Intima-media thickness (IMT) measurements were carried out to investigate subclinical atherosclerosis. RESULTS: LDL-C and total apoB were lowest in patients with T2DM/CAD owing to the more frequent use of lipid-lowering medication. Fasting plasma apoB48 was mg/L) and T2DM/CAD 1·50 ± elevated in patients with FCH (11·38 mg/L) compared with the other groups (anova, P 1·14 ± (9·65<0·01). CAD mg/L) had higher apoB48 levels than controls 0·57 ± patients (8·09 0·02). IMT was = mg/L) (P 0·51 ± mg/L) and FH patients (5·40 0·55 ± (5·74 mm) (P 0·03 ± highest in subjects with T2DM/CAD (0·77<0·01). The lowest IMT mm). In 0·03 ± mm) and FCH patients (0·60 0·02 ± was measured in controls (0·56 the total group, the best association for apoB48 was found with fasting 0·72, P = triglyceride (Pearson’s r<0·001). In the subjects not using 0·52; = 74), the best correlation was found with IMT (r = statins (n P<0·20, = 0·001), whereas total apoB was not associated with IMT (r 0·12). = P CONCLUSIONS: ApoB48 concentrations are highest in patients with FCH and in atherosclerotic subjects with T2DM. In patients not using statins, the surrogate atherosclerosis marker IMT correlates best with apoB48, suggesting that fasting apoB48 may help to detect subjects at risk.

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Overige artikelen A male with a painful left knee.

Veltman JD, Grewal S, Aydin Z, Rietveld AP. Accepted for publication 1 dec 2012, Neth J Med.

Boeken Commentaren Medicatiebewaking 2012/2013.

Castro Cabezas M. 27ste jaargang Health Base, Houten; pag 834-839 familiaire hyperlipidemie.

Diagnose en Therapie 2013-2014.

Elte JWF, Castro Cabezas M, Goudswaard AN, Guchelaar HJ, Schaper NC. Bohn, Stafleu & van Loghum Houten 2013; Hoofdstuk 3, pag 123-156.

Handboek Diabetes Mellitus onder redactie van CJ Tack, M Diamant en EJP de Koning. 4e, herziene druk, 2012; De Tijdstroom Utrecht. Hoofdstuk 24, pag 313-326. Castro Cabezas M, Elte JWF.

Voordrachten GLP-1 therapie in de 1e lijn.

Van der Loos ThLJM. Rotterdam: Nascholing voor huisartsen, 26 januari 2012.

Complexe patient casus in diabetes.

Moderne behandeling Diabetes Mellitus.

Van der Loos ThLJM. Rotterdam: Sint Franciscus Gasthuis, POH bijeenkomst, 15 maart 2012.

Elektrolyten stoornissen.

Van der Loos ThLJM. Rotterdam: Sint Franciscus Gasthuis, Bijeenkomst Verpleging, 20 maart 2012.

Basaal Plus.

Van der Loos ThLJM. Rotterdam: Sint Franciscus Gasthuis, Nascholing voor huisartsen, 27 maart 2012.


Van der Loos ThLJM. Nieuwerkerk a/d IJssel: EADV-regiobijscholing, 13 maart 2012.

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Behandeling en Complicaties van Diabetes Mellitus. Van der Loos ThLJM. Vlaardingen: Nascholing voor huisartsen, 10 april 2012.

Basaal Plus.

Van der Loos ThLJM. Ridderkerk: Nascholing voor huisartsen, 12 april 2012.

Nieren en Diabetes Mellitus.

Van der Loos ThLJM. Rotterdam: Sint Franciscus Gasthuis, Nascholing voor huisartsen, 17 april 2012.

Ramadan en Diabetes Mellitus.

Van der Loos ThLJM. Rotterdam: Sint Franciscus Gasthuis, POH bijeenkomst, 15 mei 2012.

Ramadan en Diabetes.

Van der Loos ThLJM. Rotterdam:Symposium AMAN, Diabetes en Hypertensie, 1 september 2012.

GLP-1 therapie in de 1e lijn.

Van der Loos ThLJM. Rotterdam: Nascholing voor huisartsen, 4 september 2012.

Basaal Plus.

Van der Loos ThLJM. Ridderkerk: Nascholing voor huisartsen, 13 september 2012.

Diabetes Complicaties.

Van der Loos ThLJM. Rotterdam: Sint Franciscus Gasthuis, POH bijeenkomst, 20 september 2012.


Gene expression profiles of circulating tumor cells in metastatic breast cancer patients.

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Mostert B, Sieuwerts AM, Kraan J, Bolt-de Vries J, Peeters D, Dirix LY, Seynaeve CM, Jager A, de Jongh FE, Hamberg AP, Stouthard JML, Kehrer DFS, Look MP, Smid M, Jiang Y, Wang Y, Gratama JW, Foekens JA, Martens JWM, Sleijfer S. Proceedings Annual Meeting Am Soc Clin Oncol 2012, June 2012, Chicago (USA), abstract 10504 (oral presentation).

Systemische therapie bij mammacarcinoom. (Neo) adjuvant en gemetastaseerd. Zuetenhorst JM. Rotterdam: Mammaopleiding, 12 april 2012.

Her2Neu blokkade bij mammacarcinoom. Is er nieuws te vertellen? Zuetenhorst JM. Middelburg: IKNL Netwerkdagen, 30 november 2012.

INTERNE GENEESKUNDE

Local and Systemic Cytokine profiles in Patients with CommunityAcquired Pneumonia.

Paats MS. Rotterdam: Symposium “New insights into pulmonary infectious diseases”, 20 september 2012.

Sunitinib associated pseudothrombocytopenia: not always what it seems. Schilders J, Albersen A, Porcelijn L, Zuetenhorst H, Njo T, Hamberg AP. Proceedings Annual Meeting Netherlands Association of Internal Medicine 2012, April 2012 Maastricht (The Netherlands), abstract 52 (oral presentation).

Nefrotisch syndroom: het (eiwit)lek boven.

Van der Zwaan HB, Aydin Z. Rotterdam: Regionale Nierbiopsie Avond, 14 juni 2012.

Exploring interventions in the postprandial situation.

Castro Cabezas M. Sydney: 3rd International Symposium on Chylomicrons in Disease, 23-24, March, 2012.

Vitamin D improves arterial stiffness and decreases leukocyte activation postprandially. Klop B. Sydney, Australia; 3rd International Symposium on Chylomicrons in Disease, 23-24 March 2012.

Lipids, immunity and atherocslerosis.

Castro Cabezas M. Reus, Spain: 25th Congress of the Spanish Atherosclerosis Society, 6-8 June, 2012

Lipid, Immunity and Atherosclerosis: Old concepts and new perspectives. Keynote Lecture.

Thrombotic microangiopathy following administration of docetaxel and zoledronic acid in a patient with castrate refractory prostate cancer. Van Oosten MJM, Schrama YC, Boeve ER, Hamberg AP. Rotterdam: SFG Wetenschapsdag 2012.

Oncologie aan de plas.

Van Zaanen HCT. Rotterdam: Hematologie- nascholing huisartsen, DOK 99, 10 oktober 2012.

Association of skin autofluorescence with cardiovascular disease.

Klop B, van de Geijn GJM, van der Meulen N, Birnie E, van Miltenburg A, Janssen JW, Njo TL, Castro Cabezas M. Oostvoorne: Nederlandse Vereniging voor Diabetes Onderzoek 2012.


Castro Cabezas M. Valencia, Spain: INCLIVA Seminar, 22 November 2012.

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Vitamin D3 improves arterial stiffness and decreases leukocyte activation postprandially: a pilot study. Klop B, van de Geijn GJM, Birnie E, Njo TL, Janssen JW, Elte JWF, Castro Cabezas M. Sydney: International Symposium on Chylomicron Disease 2012.

Vitamin D3 improves arterial stiffness and decreases leukocyte activation postprandially: a pilot study. Klop B, van de Geijn GJM, Birnie E, Njo TL, Janssen JW, Elte JWF, Castro Cabezas M. Rotterdam: SFG Wetenschapsdag 2012.

Vitamin D3 improves arterial stiffness and decreases leukocyte activation postprandially: a pilot study. Klop B, van de Geijn GJM, Birnie E, Njo TL, Janssen JW, Elte JWF, Castro Cabezas M. Los Angeles: AHA Scientific Sessions 2012.

Een praktisch ertapenem doseerregime bij hemodialyse patiënten. Bosma MS, Rietveld AR, de Man P, Touw DJ, Geerlings CJC. Rotterdam: SFG Wetenschapsdag 2012.

Comorbidity and complications in patients undergoing bariatric surgery: the value of ICU admission criteria. Meijer N, de Quelery M, van Velzen, Luitweiler R, Gadiot RPM, van der Voet J, van der Klooster J, de Feiter PW, Mannaerts GHH, Verbrugge SJC. Rotterdam: SFG wetenschapsdag 2012.

Een patiënte met een jonge ziekte.

Altenburg – van der Velden S. Rhoon: 6e hematologie bijeenkomst, 30 oktober 2012.


Abstracts

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Phase I and pharmacokinetic (PK) study of pazopanib (P) in combination with two schedules of ifosfamide (I) in patients (pts) with advanced solid tumors (STs).

Hamberg AP, Boers-Sonderen M, Loos WJ, de Jonge MJA, van der Graaf WT, Eskens FA, Verweij J, van Herpen CM, Sleijfer S. Proceedings Annual Meeting Am Soc Clin Oncol 2012, June 2012, Chicago (USA), abstract 2593.

Induction of tamoxifen metabolism by rifampicin: a worrying drug-drug interaction. Binkhorst L, Loos WJ, de Jongh FE, Hamberg AP, Ghobadi Moghaddam-Helmantel IM, Jager A, Seynaeve C, Verweij J, van Gelder T, Mathijssen RHJ. Meeting of the Dutch Society of Clinical Farmacokinetics and biofarmacia 2012; Utrecht, (The Netherlands).

INTERNE GENEESKUNDE

Evaluation of the economic burden and impact on patients’ quality of life of metastatic castration resistant prostate cancer: implementation of an observational study in 6 European countries.

Dass RN, Hamberg AP, Spencer M, Wheatley Price P. Mirrors of Medicine 2012: Proceedings of the Global congress on prostate cancer 2012 page 12, June 2012, Brussels (Belgium) abstract nr 25.

Quality of life of patients with metastatic castration-resistant prostate cancer: Results from an observational study in 6 European countries.

Dass RN, Hamberg AP, Spencer M, Wheatley Price P. European Society of Medical Oncology, Vienna (Austria), abstract e954.

The evaluation of healthcare resource utilization in patients with metastatic castration resistant prostate cancer: Results of a multinational observational study.

Dass RN, Hamberg AP, Spencer M, Wheatley Price P. ISPOR 15th Annual European Congress, Berlin (Germany), abstract PCN 140.

Mapping FACT-P to EQ-5D in a large cross-sectional study of metastatic castrate-resistant prostate cancer patients.

Diels J, Spencer M, Hamberg AP, Wheatley Price P, Dass RN. ISPOR 15th Annual European Congress, Berlin (Germany), abstract PCN116.

Phase I and pharmacokinetic (PK) study of pazopanib in combination with two schedules of docetaxel (D) in patients (pts) with advanced solid tumors.

Hamberg AP, Mathijssen RH, de Bruijn P, van de Biessen D, Loos WJ, Sleijfer S, Verweij J, de Jonge MJ. 24th EORTC-NCI-AACR Symposium on ‘Molecular Targets and Cancer Therapeutics’, November 2012 Dublin, Ireland; abstract 579.

Oostergo T, Prins G, Schrama YC, Leeuwenburgh I. Rotterdam: Wetenschapsdag SFG, 13 april 2012.

Thrombotic thrombocytpenic purpura, haemolytic uremic syndrome (TTP-HUS) following administration of docetaxel and zoledronic acid in a patient with castrate refractory prostate cancer (CRPC). Van Oosten MJM, Schrama YC , Boevé ER , Hamberg AP. Rotterdam: Wetenschapsdag SFG, 13 april 2012.


Small bowel angioedema due to acquired C1 inhibitor deficiency: a case report and overview.

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INTERNE GENEESKUNDE

Posters Erythrocyte-bound apolipoprotein B may be a protective factor of clinical and subclinical atherosclerosis.

Klop B, van de Geijn GJM, Alcala-Diaz JF, Birnie E, Njo TL, Janssen JW, van Miltenburg AJM, Jukema JW, Rabelink TJ, Elte JWF, Castro Cabezas M. Los Angeles: American Heart Association Scientific Sessions, 3-7 november 2012.

Complement receptor type 1 is involved in the binding of LDL to erythrocytes: an anti-atherogenic mechanism.

Klop B, van der Pol P, van de Geijn GJM, Wang Y, Njo TL, Janssen JW, Birnie E, van Miltenburg AJM, Jukema JW, Rabelink TJ, van Kooten C, Castro Cabezas M. Rotterdam: Wetenschapsdag Sint Franciscus Gasthuis, 13 april 2012.

Low alcohol ingestion is associated with decreased postprandial triglyceridemia compared to high and moderate users in both genders.

Torres do Rego A, Klop B, Birnie E, Elte JWF, Alvarez-Sala Walther LA, Castro Cabezas M. Sydney: XVI International Symposium on Atherosclerosis, 2012.

Apolipoprotein B bound to lymphocytes and neutrophils is increased in rheumatoid arthritis.

Klop B, van Breukelen-van der Stoep DF, van de Geijn GJM, Janssen JW, Njo TL, van Zeben J, Huisman M, Castro Cabezas M. Sydney: XVI International Symposium on Atherosclerosis, 2012.

Effect van bariatrische chirurgie op astma: 3 maanden follow-up. Van Huisstede A, Castro Cabezas M, Zengerink H, Luitweiler RL, Taube C. Hiemstra PS, Braunstahl GJ. Rotterdam: Wetenschapsdag Sint Franciscus Gasthuis, 13 april 2012.

Case report: Hemolytic anemia caused by a kinked hemodialysis line.


Burger M, Rietveld AP, Schrama Y. Rotterdam: Wetenschapsdag Sint Franciscus Gasthuis, 13 april 2012.

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A rare case of hepatitis C negative mixed type (type 2) cryoglobulinemia.

Schilders JEM, Brouwers AJBW, van Zaanen HCT. Rotterdam: Wetenschapsdag Sint Franciscus Gasthuis, 13 april 2012.

Diagnose in beeld: Een anefrische vrouw met “urine”-incontinentie. Prins G, Schrama YC. Rotterdam: Wetenschapsdag Sint Franciscus Gasthuis, 13 april 2012.

Haemodynamic instability following bariatric surgery: an unusual complication?

Zighenhorn M, van de Poll S, Wiebolt J, Elte JWF, Rietveld AP, Mannaerts GHH, Castro Cabezas M. Rotterdam: Wetenschapsdag Sint Franciscus Gasthuis, 13 april 2012. Cursief: werkzaam in het Sint Franciscus Gasthuis

KINDERGENEESKUNDE

KINDERGENEESKUNDE

KINDERGENEESKUNDE

Overige publicaties Aplasia cutis congenita en foetus papyraceus.

Mooij MG, Van Heel WJM, Eggink-Meester BJ, Oranje AP. Tijdschrift voor kindergeneeskunde, 2012; 80: (3): 81-82.

Boekbespreking “Incontinentie bij kinderen”.


Verhallen JTCM. Tijdschrift voor Kindergeneeskunde, 2012; 80: 106.

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KLINISCHE CHEMIE

KLINISCHE CHEMIE KCHL


Pubmed artikelen Sunitinib-associated pseudothrombocytopenia induced by IgM antibody. Albersen A, Porcelijn L, Schilders J, Zuetenhorst H, Njo TL, Hamberg P. Platelets. 2012 Oct 15. PMID: 23066976.

BACKGROUND: Thrombocytopenia is a well-documented adverse reaction of sunitinib. Thrombocytopenia was observed in a patient with metastatic renal clear-cell carcinoma undergoing sunitinib treatment. Platelet count in an ethylenediaminetetraacetic acid (EDTA) sample was 19 × 10(9)/l. To exclude pseudothrombocytopenia (PTCP), a platelet count in citrate-anticoagulated blood was performed, showing a platelet count of 6 × 10(9)/l. Due to the apparent thrombocytopenia, the patient received platelet concentrates. Subsequent analyses revealed PTCP whereby platelet clumping was most abundant in citrate - followed by EDTA- and heparin-anticoagulated blood samples. This effect was partially reversed after placing blood samples at 37°C. The IgM antiplatelet autoantibodies responsible for in vitro agglutination are temperature and multianticoagulant dependent and did not react to amikacin pre-supplementation. Remarkably, the antibody revealed specificity to platelet antigens other than GPIIb/IIIa, GPIb/IX, GPIa/IIa, GPIV, and GPV. After 16 days of discontinuing sunitinib, no PTCP and no platelet reactive antibodies could be detected. We report a case of PTCP with clear time-relation with sunitinib, strongly suggesting the mechanism to be sunitinib dependent. Since this finding has not been described before, non-recognition of PTCP during sunitinib treatment might lead to dose reduction or unwarranted therapy.

Voordrachten Sunitinib Associated Thrombocytopenia: Not always what it seems. Albersen A, Porcelijn L, Schilders J, Zuetenhorst H, Njo TL, Hamberg P. Rotterdam: Wetenschapsdag Sint Franciscus Gasthuis, 13 april 2012. Tweede prijs beste voordracht.


Celtellingen als 24 uurs service: Flowcytometrie from bench to bedside?

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Van de Geijn GJM. Rotterdam: Sint Franciscus Gasthuis, Wetenschappelijk Café, 1 Februari 2012.

Differentiatie tussen bacteriële en niet-bacteriële infecties bij COPD patiënten met exacerbatie op de SEH. Van de Geijn GJM, Denker S, Koeleman JGM, Birnie E, Braunstahl GJ, Njo TL. Amersfoort: Wetenschapsdag Ned. Vereniging Klinische Chemie, 19 April 2012.

Leukocyten telling in bloed mbv flowcytometrie.

Van de Geijn GJM. Rotterdam: Refereeravond Klinische Chemie, Sint Franciscus Gasthuis en IJsselland Ziekenhuis, 25 Juni 2012.


Hematoflow: what and how to report.

Njo TL. Parijs: Scientific Advisory board Beckman Coulter: Hematoflow™ and Cytodiff™, 10-11 oktober 2012.

Discrimination between bacterial and non-bacterial infections in patients with chronic obstructive pulmonary disease (COPD).

Van de Geijn GJM, Denker S, Van Waning VH, Koeleman JGM, Birnie E, Braunstahl GJ, Njo TL. Parijs: Scientific Advisory board Beckman Coulter: Hematoflow™ and Cytodiff™, 10-11 oktober 2012.

Leuko-diff, integratie met flowcytometrie.

Njo TL. Zwolle: Ned. Vereniging Cytometrie, 22 November 2012.

Groot bloedverlies, acuut en massaal.

Beunis MH, van Zaanen HCT, van Oossanen J. Rotterdam: Sint Franciscus Gasthuis, Wetenschappelijk café, 24 oktober 2012.

Interferentie van (diverse) antilichamen in FT4-assays.

Revet I. Rotterdam: Wetenschappelijke OOR-avond Klinische Chemie Regio Zuidwest, 29 maart 2012.

Posters Interfering antibodies in thyroid immunoassays is platform dependent. Albersen A, Revet I, Boesten LSM, Janssen JW. Rotterdam: Wetenschapsdag Sint Franciscus Gasthuis, 13 april 2012.

Interfering antibodies in thyroid immunoassays is platform dependent.

Sunitinib Associated Thrombocytopenia: Not always what it seems. Albersen A, Porcelijn L, Schilders J, Zuetenhorst H, Njo TL, Hamberg P. Rotterdam: Wetenschapsdag Sint Franciscus Gasthuis, 13 april 2012.

Sunitinib Associated Thrombocytopenia: Not always what it seems. Albersen A, Porcelijn L, Schilders J, Zuetenhorst H, Njo TL, Hamberg P. Amersfoort: NVKC wetenschapsdag, 19 april 2012.

Sunitinib Associated Thrombocytopenia: Not always what it seems.

Albersen A, Porcelijn L, Schilders J, Zuetenhorst H, Njo TL, Hamberg P. Frankrijk (Nice): International Symposium on Technological Innovations in Laboratory Hematology (ISLH), 22 mei 2012.


Albersen A, Revet I, Boesten LSM, Janssen JW. Amersfoort: NVKC wetenschapsdag, 19 april 2012.

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New laboratory tests to discriminate bacterial from non-bacterial infections in COPD patients presenting with exacerbations in the emergency room.

Van de Geijn GJM, Denker S, Koeleman JGM, Birnie E, Van Waning VH, Braunstahl GJ , Njo TL. Nice: International Society of Laboratory Medicine, 21-23 Mei 2012.

Resultaten TRIX in 2011.

Folman CC, Vossen R, Van den Bos A, Van der Wijst J, Smeenk R, Wiersum-Osselton JC, Beunis MH. Ede: Ned. Ver Bloedtransfusie, TRIP Symposium, 23-24 Mei 2012, Posterprijs.

Leukocyte differentiation by flow cytometry: comparison of two flow cytometric protocols, Leukoflow and CytodiffTM, with microscopy and hematology analyzer.

Van de Geijn GJM, Van Dijk M, Meijer R, Blaauw Y, Bakker R, Janssen JW, Beunis MH, Njo TL. Rotterdam: Wetenschapsdag Sint Franciscus Gasthuis, 13 April 2012.


Van de Geijn GJM, Van Dijk M, Meijer R, Blaauw Y, Bakker R, Janssen JW, Beunis MH, Njo TL. Amersfoort: Wetenschapsdag Ned. Vereniging Klinische Chemie, 19 April 2012.


Van de Geijn GJM, Van Dijk M, Meijer R, Blaauw Y, Bakker R, Janssen JW, Beunis MH, Njo TL. Nice: International Society of Laboratory Medicine, 21-23 Mei 2012.

Antibody interference in thyroid immunoassays is platform dependent. Albersen A, Revet I, Van Toor H, De Rijke YB, Boesten LSM, Janssen JW. Rotterdam: Wetenschapsdag Sint Franciscus Gasthuis, 13 April 2012.


Antibody interference in thyroid immunoassays is platform dependent.

Albersen A, Revet I, Van Toor H, De Rijke YB, Boesten LSM, Janssen JW. Amersfoort: Wetenschapsdag Ned. Vereniging Klinische Chemie, 19 April 2012.

Antibody interference in thyroid immunoassays is platform dependent. Albersen A, Revet I, Van Toor H, De Rijke YB, Boesten LSM, Janssen JW. Nice: International Society of Laboratory Medicine, 21-23 Mei 2012.

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Pubmed artikelen Antineutrophil cytoplasmic autoantibodies: how are they detected and what is their use for diagnosis, classification, and follow-up ?

Cohen Tervaert JW, Damoiseaux JG. Clin Rev Allergy Immunol 2012; 43:211-219 PMID: 22153879

Exposure to silica dust has been examined as a possible risk factor for autoimmune diseases, including scleroderma, rheumatoid arthritis and systemic lupus erythematosus. Since CTLA-4 [CD152] and PD-1 [CD279] are important for the maintenance of peripheral tolerance by regulating T cell responsiveness, we evaluated the expression of these molecules on the surface of CD4 and CD8 T cells, as well as single nucleotide polymorphisms (SNP) in CTLA-4 and PDCD1 genes, of 70 silica-exposed workers and 30 non-exposed, age-, ethnically- and sex-matched controls. Expression of CTLA-4 was significantly (P<0.05) reduced in CD4 T cells of exposed individuals [median=0.1% and interquartile range, IQR 0.0-0.1% (exposed), median=0.20%, IQR 0.0-0.4% (control)]. Also the expression of PD-1 was significantly (P<0.0001) reduced in both CD4 [median=0.9%, IQR 0.4-2.3% (exposed), median=5.7%, IQR 1.4-13.3% (control)] and CD8 T cells [median=0.9%, IQR 0.3-1.9% (exposed), median=5.0%, IQR 3.4-8.9% (control)]. The study of polymorphisms demonstrated a lower frequency of the A allele in the analysis of the PD1.3 SNP in the exposed group, which might be associated with the lower expression of PD-1 on the surface of CD4 T cells. Our findings provide evidence for the association of silica exposure and the maintenance of self-tolerance, i.e., the susceptibility to autoimmune disorders.

Overige artikelen Genetic polymorphisms and surface expression of CTLA-4 and PD-1 on T-cells of silica-exposed workers.


Rocha MC, Santos LM, Bagatin E, Cohen Tervaert JW, Damoiseaux JG, Lido AV, Longhini AL, Torello CO, Queiroz ML. Int J Hyg Environ Health 2012; 215: 562-569.

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Pubmed artikelen Concerns About Exercise Are Related to Walk Test Results in Pulmonary Rehabilitation for Patients with COPD. Fischer MJ, Scharloo M, Abbink J, van ‘t Hul A, van Ranst D, Rudolphus A, Weinman J, Rabe KF, Kaptein AA. Int J Behav Med. 2012, 19:39–47. PMID: 21080250.


BACKGROUND: Although international guidelines on pulmonary rehabilitation acknowledge that psychological factors contribute to exercise intolerance in patients with chronic obstructive pulmonary disease (COPD), the few empirical studies investigating this association have found inconsistent results. PURPOSE: The purpose of this study is to investigate whether negative affect and beliefs about exercise of patients with COPD would be related to baseline 6-min walk (6-MW) test results in a pulmonary rehabilitation setting, after correction for physical variables (sex, age, height, weight, and lung function). A second aim was to examine whether patients’ beliefs are associated with treatment outcomes, as measured by an improvement in 6-MW distance. METHOD: A 12-week pulmonary rehabilitation program was completed by 166 patients. Beliefs (perceived necessity and concerns) about exercise and negative affect were assessed by a questionnaire. Clinical data were obtained from medical records. RESULTS: Baseline 6-MW distance was positively related to younger age, male gender, better pulmonary function, and having fewer concerns about exercise. After rehabilitation, patients had increased their walk distance by 12% (32 m), on average. Baseline physiological and psychological variables were unrelated to patients’ response to treatment (increase in walk distance). However, subgroup analysis showed that for patients with mild to moderate airflow obstruction, concerns about exercise were negatively related to response to treatment. CONCLUSION: We conclude that patients’ beliefs about the negative consequences of exercise are associated with baseline 6-MW test performance and response to treatment for patients with mild to moderate COPD. We recommend that patients’ concerns about exercise are discussed and, if necessary, corrected during the intake phase.

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Morbidly obese human subjects have increased peripheral blood CD4+ T cells with skewing toward a Treg- and Th2-dominated phenotype. van der Weerd K, Dik WA, Schrijver B, Schweitzer DH, Langerak AW, Drexhage HA, Kiewiet RM, van Aken MO, van Huisstede A, van Dongen JJ, van der Lelij AJ, Staal FJ, van Hagen PM. Diabetes. 2012 Feb;61(2):401-8. Epub 2012 Jan 6. PMID: 22228716. PMCID: PMC3266399.Free PMC Article. Obesity is associated with local T-cell abnormalities in adipose tissue. Systemic obesityrelated abnormalities in the peripheral blood T-cell compartment are not well defined. In this study, we investigated the peripheral blood T-cell compartment of morbidly obese and lean subjects. We determined all major T-cell subpopulations via six-color flow cytometry, including CD8+ and CD4+ T cells, CD4+ T-helper (Th) subpopulations, and natural CD4+CD25+FoxP3+ T-regulatory (Treg) cells. Moreover, molecular analyses to assess thymic output, T-cell proliferation (T-cell receptor excision circle analysis), and T-cell receptor-β (TCRB) repertoire (GeneScan analysis) were performed. In addition, we determined plasma levels of proinflammatory cytokines and cytokines associated with

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Th subpopulations and T-cell proliferation. Morbidly obese subjects had a selective increase in peripheral blood CD4+ naive, memory, natural CD4+CD25+FoxP3+ Treg, and Th2 T cells, whereas CD8+ T cells were normal. CD4+ and CD8+ T-cell proliferation was increased, whereas the TCRB repertoire was not significantly altered. Plasma levels of cytokines CCL5 and IL-7 were elevated. CD4+ T-cell numbers correlated positively with fasting insulin levels. The peripheral blood T-cell compartment of morbidly obese subjects is characterized by increased homeostatic T-cell proliferation to which cytokines IL-7 and CCL5, among others, might contribute. This is associated with increased CD4+ T cells, with skewing toward a Treg- and Th2-dominated.

ABSTRACT BACKGROUND: Omalizumab, licensed for patients with uncontrolled persistent allergic (IgE mediated) asthma, was found to be cost-effective based upon its clinical trial data. Observational studies have been undertaken to determine the real life outcomes of using omalizumab in the community. Objective: To determine the cost-effectiveness of omalizumab based upon observational data from the Netherlands and compare to its cost-effectiveness using clinical trial data. Methods: An observational study (eXpeRience) recruited allergic asthma patients eligible for Omalizumab therapy and followed them while on treatment. At 1 year, data from the Dutch patients enrolled in eXpeRience were examined to estimate the number of exacerbations and resource use while on omalizumab therapy compared to the year prior to omalizumab use. Observational data were used in a Markov model to calculate the lifetime cost-effectiveness ratios. Results: In the 1 year prior to omalizumab therapy the per-person rate of exacerbations was 3.39 compared to 1.07 in the year taking omalizumab. The discounted incremental lifetime additional costs for omalizumab were €55,865 for 1.46 additional quality-adjusted life years (QALY), resulting in €38,371/QALY. Using the INNOVATE clinical trial outcomes and current resource use, the prior ratio was €34,911/QALY, similar to the observational ratio. As in all observational studies, the main limitation is obtaining complete and accurate data. Patients with missing exacerbation or response data were excluded from this analysis. Conclusion: Non-clinical trial experience with omalizumab supported the finding of fewer exacerbations in the allergic asthma population while treated with omalizumab, and therapy was found to continue to have an attractive cost-effectiveness ratio.


Cost-effectiveness of omalizumab for uncontrolled allergic asthma in the Netherlands. van Nooten F, Stern S, Braunstahl GJ, Thompson C, Groot M, Brown RE. J Med Econ. 2012 Dec 18. Epub ahead of print. PMID: 23216016.

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Overige artikelen Astma en rhinitis op de werkvloer. Braunstahl GJ, in ‘t Veen JC, Bruinvels DJ, van der Zee J. Ned Tijdschr v Allergie Astma 2012;12:122-127. Online selfmanagement in patients with COPD or asthma: with or without the healthcare provider? In ’t Veen JCCM, Mennema T, van Noort E. Eur Respir J, 2012: P1284 Impaired survival of regulatory T cells in pulmonary sarcoidosis patients. Broos CE, van Nimwegen M, Kleinjan A, ten Berge B, Muskens F, In ‘t Veen JCCM, Hoogsteden HC, Hendriks RW, Lambrecht BN, Kool M, van den Blink B. Pneumologie 2012; 66 - P4_001 DOI: 10.1055/s-0032-1329827 De medicamenteuze behandeling van COPD In ’t Veen JCCM, van Schayck CP. Farmacotherapie Online 2012 Astma en rhinitis op de werkvloer. Braunstahl GJ, In ‘t Veen JCCM, Bruinvels DJ, van der Zee J. Ned Tijdschr Allergie & Astma, 2012;12:122-127 Rapport van een verkenning over een mogelijke Zorgmodule Arbeid. In ’t Veen JCCM, Limburg M, de Grauw WJC, Franx GC, Blaauwbroek H, Niemer S, Sol-de Rijk B, Benedictus J, Zwart K, Hulshof CTJ, van Dijk L, Struijs JN, van Genabeek J, van der Klink JJL, Boersma C, Kliphuis L, Rutte E, van Vuuren CV.


http://www.zorgstandaarden.nl/fileadmin/ www.zorgstandaardindepraktijk.nl/Verkenning_Zorgmodule_Arbeid.pdf

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Voordrachten Effect of bariatric surgery on asthma: 3 months follow-up. Huisstede A van, Castro Cabezas M, Zengerink H, Taube C, Hiemstra P, Braunstahl GJ. Wenen, Oostenrijk: ERS Congres, 1-5 augustus 2012. Pro- contra obesitas veroorzaakt astma. van Huisstede A, Braunstahl GJ. Davos, Zwitserland: Symposium Ernstig Astma, 18-21 maart 2012.

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Omalizumab in real-world practice: 2-year data from the eXpeRience registry. Braunstahl GJ. Wenen, Oostenrijk: ERS Congres, 1-5 augustus 2012. Reductions in exacerbations with omalizumab in a real-world setting. Braunstahl GJ. Wenen, Oostenrijk: ERS Congres, 1-5 augustus 2012. Effect of bariatric surgery on asthma: 3 months follow-up. Van Huisstede A, Castro Cabezas M, Zengerink H, Taube C, Hiemstra P, Braunstahl GJ. Wenen, Oostenrijk: ERS Congres, 1-5 augustus 2012. Workshop Longrevalidatie. Fransens F, Rudolphus A. Arnhem: Papendal, Longartsenweek 2-5 april 2012. Integrale zorg COPD en de zorgstandaard. In ’t Veen JCCM. Zwolle: Nascholing Regionaal, februari 2012. Rol tweede lijn bij COPD. In ’t Veen JCCM. Den Haag: Nascholing Regionaal, februari 2012. Integrale zorg voor beleidsmakers in de zorg: COPD High Volume, High Risk. In ’t Veen JCCM. Zeist: Landelijke nascholing, maart 2012.

Spirometrie op maat, de vervolgcursus. In ’t Veen JCCM. Bleiswijk: Regionale nascholing, september 2012. E-Health: the Rotterdam experience. In ‘t Veen JCCM. Rotterdam: Webcast International, september 2012. Bijwerkingen van TKi in de oncologie. In ’t Veen JCCM. Rotterdam: Minisymposium Regionaal, oktober 2012.


Kleine deeltjes, wie, hoe, wat, waar? In ’t Veen JCCM. Schiedam: Regionale nascholing, mei 2012.

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Behandeling van longkanker voor radiotherapeuten: de plaats van chemotherapie. In ’t Veen JCCM. Rotterdam: Nascholing Regionaal, oktober 2012. Zorgstandaard en ziektelastmeter. In ’t Veen JCCM. Rotterdam: De Machinist, Symposium Preventie tot Palliatie (P2P), 9 oktober 2012. Integrale zorg, COPD en de apotheker. In ’t Veen JCCM. Rotterdam: Nascholing Regionaal, oktober 2012. Paraneoplastische syndromen bij longcarcinoom. In ’t Veen JCCM. Ede: De Reehorst, Oncologiedagen, 26-28 oktober 2012. Longfunctie voor huisartsen. In ’t Veen JCCM. Rotterdam, Landelijk symposium, oktober 2012. Integrale zorgstandaard COPD 2012. In ’t Veen JCCM. Arnhem: nascholing longartsen, regionaal, 6 november 2012.

Posters


Effect of bariatric surgery on asthma: 3 months follow-up. van Huisstede A, Castro Cabezas M, Zengerink H, Taube C, Hiemstra P, Braunstahl GJ. Amsterdam: NRS Young Investigators Day, 9 november 2012.

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Longfunctie is gerelateerd aan complicaties van bariatrische chirurgie. van Huisstede A van, Biter LU, Birnie E, Mannaerts GHH, Luitwieler RL, Hiemstra P, Braunstahl GJ. Rotterdam: Sint Franciscus Gasthuis, Wetenschapsdag, 13 april 2012, Beste poster 1e prijs Effect of bariatric surgery on asthma: 3 months follow-up. Van Huisstede A, Castro Cabezas M, Zengerink H, Taube C, Hiemstra P, Braunstahl GJ. Amsterdam: NRS Young Investigators Day, 9 november 2012. Effect van bariatrische chirurgie op astma: 3 maanden follow-up. Huisstede A van, Castro Cabezas M, Zengerink H, Luitwieler RL, Taube C, Hiemstra P, Braunstahl GJ. Rotterdam: Sint Franciscus Gasthuis, Wetenschapsdag, 13 april 2012.

LONGZIEKTEN

Improvements in asthma control and quality of life with omalizumab in allergic (IgE-mediated) asthma patients. Braunstahl GJ, Deenstra M, Canvin J, Georgiou P, Peachey G, Chen CW. Wenen, Oostenrijk: ERS Congres, 1-5 augustus 2012.


Local and systemic T helper 17 responses in patients with community-acquired pneumonia. Paats MS, Bergen IM, Hanselaar WE, Groeninx van Zoelen EC, Verbrugh HA, van den Blink B, Hoogsteden HC, Hendriks RW, Van der Eerden MM. San Francisco, USA: American Thoracic Society International Conference, 21 mei 2012.

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Pubmed artikelen Autoimmune hepatitis following treatment with infliximab for inflammatory bowel disease.

Casteren-Messidoro C, Prins G, van Tilburg AJP, Zelinkova Z, Schouten J, de Man RA. J Crohns Colitis 2012;6:630-1. PMID: 22398075. Geen abstract.Comment on: Autoimmune hepatitis during infliximab therapy for Crohn’s disease: a case report. [J Crohns Colitis. 2011].

The global rating scale in clinical practice.

BACKGROUND: The Global Rating Scale is an endoscopy quality assurance programme, successfully implemented in England. It remains uncertain whether it is applicable in another health care setting. AIM: To assess the applicability of the Global Rating Scale as benchmark tool in an international context. METHODS: Eleven Dutch endoscopy departments were included for a Global Rating Scale-census, performed as a cross-sectional evaluation, July 2010. Two Global Rating Scale-dimensions - ‘clinical quality’ and ‘patient experience’ - were assessed across six items using a range of levels: from level-D (basic) to level-A (excellent). Construct validity was assessed by comparing department-specific colonoscopy audit data to GRS-levels. RESULTS: For ‘clinical quality’, variable scores were achieved in items ‘safety’ (9%=B, 27%=C, 64%=D) and ‘communication’ (46%=A, 18%=C, 36%=D). All departments achieved a basic score in ‘quality’ (100%=D). For ‘patient experience’, variable scores were achieved in ‘timeliness’ (18%=A, 9%=B, 73%=D) and ‘booking-choice’ (36%=B, 46%=C, 18%=D). All departments achieved basic scores in ‘equality’ (100%=D). Departments obtaining level-C or above in ‘information’, ‘comfort’, ‘communication’, ‘timeliness’ and ‘aftercare’, achieved significantly better audit outcomes compared to those obtaining level-D (p<0.05). CONCLUSION: The Global Rating Scale is appropriate to use outside England. There was significant variance across departments in dimensions. Most Global Rating Scale-levels were in line with departments’ audit outcomes, indicating construct validity.

The incidence of 30-day adverse events after colonoscopy among outpatiens in the Netherlands.

de Jonge V, Sint Nicolaas J, van Baalen O, Brouwer JT, Stolk MF, Tang TJ, van Tilburg AJP, van Leerdam ME, Kuipers EJ; SCoPE consortium. Am J Gastroenterol. 2012 Jun;107(6):878-84. PMID: 22391645.

OBJECTIVES: Colonoscopy is the gold standard for visualization of the colon. It is generally accepted as a safe procedure and major adverse events occur at a low rate. However, few data are available on structured assessment of (minor) post-procedural adverse events.


Sint Nicolaas J, de Jonge V, de Man RA, ter Borg F, Cahen DL, Moolenaar W, Stolk MF, van Tilburg AJP, Valori RM, van Leerdam ME, Kuipers EJ; SCoPE consortium. Dig Liver Dis. 2012 Nov;44(11):919-24. PMID: 22840567.

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METHODS: Consecutive outpatients undergoing colonoscopy were asked for permission to be called 30 days after their procedure. A standard telephone interview was developed to assess the occurrence of (i) major adverse events (hospital visit required), (ii) minor adverse events, and (iii) days missed from work. Adverse events were further categorized in definite-, possible-, and unrelated adverse events. Patients were contacted between January 2010 and September 2010. RESULTS: Out of a total of 1,528 patients who underwent colonoscopy and gave permission for a telephone call, 1,144 patients were contacted (response: 75%), 49% were male, the mean age was 59 years (s.d.: 14). Thirty-four patients (3%) reported major adverse events. These were definite-related in nine (1%) patients, possible-related in 6 (1%), and unrelated in 19 patients (2%). Minor adverse events were reported by 466 patients (41%). These were definite-related in 336 patients (29%), possible-related in 36 (3%), and unrelated in the remaining 94 patients (8%). Female gender (odds ratio (OR): 1.5), age <50 years (OR: 1.5), colonoscopy for colorectal cancer screening/surveillance (OR: 1.6), and fellow-endoscopy (OR: 1.7) were risk factors for the occurrence of any definite-related adverse event. Patients who reported definite-related adverse events were significantly less often willing to return for colonoscopy (81 vs. 88%, P<0.01) and were less often positive about the entire colonoscopy experience (84 vs. 89%, P=0.04). CONCLUSIONS: Structured assessment of post-colonoscopy adverse events shows that these are more common than generally reported. Close to one-third of patients report definite-related adverse events, which are major in close to 1 in 100 patients. The occurrence of adverse events does have an impact on the willingness to return for colonoscopy.

Awareness of surveillance recommendations among patients with colorectal adenomas.


Sint Nicolaas J, de Jonge V, Cahen DL, Ouwendijk RJ, Tang TJ, van Tilburg AJP, van Leerdam ME, Kuipers EJ; SCoPE Consortium. Clin Gastroenterol Hepatol. 2012 Apr;10(4):405-11. PMID: 22155559.

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BACKGROUND AIMS: The efficacy of colorectal cancer screening programs depends on the rate of attendance at surveillance colonoscopy examinations. Increasing patients’ awareness about the importance of surveillance might improve attendance, but it is not clear how much they know about their follow-up recommendations. We assessed the awareness of patients with adenomas about their surveillance recommendations. METHODS: Ten endoscopy departments provided access to their colonoscopy database for quality assurance; 2 datasets were obtained. We analyzed data from 4000 colonoscopies (400 per department) performed on patients with adenomas. All the patients were mailed a survey to determine how much information they had about their colonoscopy results and their follow-up recommendations. Data from 549 patients were included in the analysis. We also assessed surveillance attendance among 500 patients (50 per department) who had adenomas removed. RESULTS: Of the patients analyzed, 85% recalled retrieval of polyps during their colonoscopy, and 85% recalled whether they needed surveillance or not. The indication for surveillance was recalled by 69% of patients (range between departments, 55%-83%; P < .01). Factors that were associated with awareness of recommendations were younger age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.06-1.09), treatment by a

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gastroenterologist (OR, 5.53; 95% CI, 3.28-9.32), and presence of 3 or more adenomas (OR, 2.97; 95% CI, 1.29-6.85). Attendance among patients with adenomas varied among departments, from 60% to 89% (P < .01), and was not associated with awareness of patients about their recommendations per department (P = .59). CONCLUSIONS: Not enough patients (only 85%) who receive colonoscopies are aware of their results or surveillance recommendations. Although awareness of findings and recommendations did not correlate with follow-up attendance, patients should be better informed about findings and their need for surveillance.

Quality evaluation of colonoscopy reporting and colonoscopy perfomance in daily clinical practice.

BACKGROUND: Comprehensive monitoring of colonoscopy quality requires complete and accurate colonoscopy reporting. OBJECTIVE: This study aimed to assess the compliance with colonoscopy reporting and to assess the quality of colonoscopy performance. DESIGN: Consecutive colonoscopy reports were reviewed by hand. Four hundred reports were included from each department. SETTING: Daily clinical practice in 12 Dutch endoscopy departments. PATIENTS: Consecutive patients undergoing scheduled colonoscopy procedures. MAIN OUTCOME MEASUREMENTS: Quality of reporting was assessed by using the American Society for Gastrointestinal Endoscopy criteria for colonoscopy reporting. Quality of colonoscopy performance was evaluated by using the cecal intubation rate and adenoma detection rate (ADR). RESULTS: A total of 4800 colonoscopies were performed by 116 endoscopists: 70% by gastroenterologists, 16% by gastroenterology fellows, 10% by internists, 3% by nurseendoscopists, and 1% by surgeons. The mean age of the patients was 59 years (standard deviation 16), and 47% were male. Reports contained information on indication, sedation practice, and extent of the procedure in more than 90%. Only 62% of the reports mentioned the quality of bowel preparation (range between departments 7%-100%); photographic documentation of the cecal landmarks was present in 71% (range 22%-97%). The adjusted cecal intubation rate was 92% (range 84%-97%). The ADR was 24% (range 13%-32%). LIMITATIONS: Dependent on reports, no intervention in endoscopic practice. No analysis for performance per endoscopist. CONCLUSION: Colonoscopy reporting varied significantly in clinical practice. Colonoscopy performance met the suggested standards; however, considerable variability between endoscopy departments was found. The results of this study underline the importance of the implementation of quality indicators and guidelines. Moreover, by continuous monitoring of quality parameters, the quality of both colonoscopy reporting and colonoscopy performance can easily be improved. COMMENT IN: Quality benchmarking for colonoscopy: how do we pick products from the shelf? [Gastrointest Endosc. 2012].


de Jonge V, Sint Nicolaas J, Cahen DL, Moolenaar W, Ouwendijk RJ, Tang TJ, van Tilburg AJP, Kuipers EJ, van Leerdam ME; SCoPE Consortium. Gastrointest Endosc. 2012 Jan;75(1):98-106. PMID: 21907986.

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Small bowel angioedema due to acquired C1 inhibitor deficiency: a case report and overview. Oostergo T, Prins G, Schrama YC, Leeuwenburgh I. Eur J Gastroenterol Hepatol, 2012 Dec 18: Epub. PMID: 23255023.

Acquired angioedema is a rare disorder caused by an acquired deficiency of C1 inhibitor. It is characterized by nonpitting, nonpruritic subcutaneous or submucosal edema of the skin, or of the respiratory or gastrointestinal tract. When localized in the gastrointestinal tract, it can cause severe abdominal pain, mimicking an acute surgical abdomen, or chronic recurrent pain of moderate intensity. We report a case of a 48-year-old man presenting with recurrent episodes of hypotension and abdominal pain. Computed tomography of the abdomen showed edema of the small bowel. The first determinations of C1 inhibitor level and activity, measured in a symptom-free period, were normal. Repetition of the laboratory tests in the acute phase, however, showed a low C1 inhibitor level. Further diagnostic work-up indicated an acquired C1 inhibitor deficiency caused by a monoclonal gammopathy. He was treated with tranexamic acid as prophylaxis for his frequent attacks and to date, he has remained symptom free. Acquired C1 inhibitor deficiency is a rare cause of angioedema and is, among others, related to autoantibodies and abnormal B-cell proliferation, for example monoclonal gammopathy. The diagnosis of acquired C1 inhibitor deficiency is made on the basis of the medical history and on the level and activity of plasma C4, C1q, and C1 inhibitor. In case of high suspicion and a normal C1 inhibitor activity, it is recommended to repeat this test during an angioedema attack. Early diagnosis is important for the treatment of severe, potentially life-threatening attacks and to start prophylactic treatment in patients with frequent or severe angioedema attacks.

Barrett’s esophagus and esophageal adenocarcinoma are common after treatment for achalasia.


Leeuwenburgh I, Scholten P, Calje TJ, Vaessen RJ, Tilanus HW, Hansen BE, Kuipers EJ. Dig Dis Sci: 2012 nov 22, Epub. DOI 10.1007/s10620-012-2157-9. PMID: 23179142

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Achalasia is characterized by esophageal aperistalsis and impaired relaxation of the lower esophageal sphincter (LES). This contrasts with an insufficient LES, predisposing to gastro-esophageal reflux and Barrett’s esophagus. The co-incidence of achalasia and BE is rare. Pneumatic dilatation (PD) may lead to gastro-esophageal reflux, Barrett’s esophagus development, and esophageal adenocarcinoma. AIMS: To determine the incidence of Barrett’s esophagus and esophageal adenocarcinoma in achalasia patients treated with PD. METHODS: We performed a single-center cohort follow-up study of 331 achalasia patients treated with PD. Mean follow-up was 8.9 years, consisting of regular esophageal manometry, timed barium esophagram, and endoscopy. RESULTS: Twenty-eight (8.4 %) patients were diagnosed with Barrett’s esophagus, one at baseline endoscopy. This corresponds with an annual incidence of Barrett’s esophagus of 1.00 % (95 % CI 0.62-1.37). Hiatal herniation was present in 74 patients and 21 developed Barrett’s esophagus compared to seven of 257 patients without a hiatal hernia. Statistical analysis revealed a hazard ratio of 8.04 to develop Barrett’s esophagus if a hiatal hernia was present. Post-treatment LES pressures were lower in patients with Barrett’s esophagus than in those without (13.9 vs. 17.4 mmHg; p = 0.03). Two (0.6 %) patients developed

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esophageal adenocarcinoma during follow-up. CONCLUSIONS: Barrett’s esophagus is incidentally diagnosed in untreated achalasia patients despite high LES pressures, but is more common after successful treatment, especially in the presence of hiatal herniation. Patients treated for achalasia should be considered for GERD treatment and surveillance of development of Barrett’s esophagus, in particular, when they have low LES pressures and a hiatal herniation.

Voordrachten Oncologie aan de plas: coloncarcinoom.

Leeuwenburgh I. Rotterdam: nascholing voor huisartsen, 10 okt 2012.

Posters Phenotype of inflammatory bowel disease at diagnosis in the Netherlands: a population-based inception cohort study (the DELTA cohort).

Nuij V, Zelinkova Z, Rijk M, Beukers R, Ouwendijk R, Quispel R, van Tilburg AJP, Tang T, Smalbraak H, Bruin K, Lindenburg F, Peyrin-Biroulet L, van der Woude CJ. Barcelona: 7e ECCO congres, 16-18 februari 2012.

Microscopic severity is related to earlier surgery in newly diagnosed CD patients: results from the DELTA cohort. Nuij V, Looman C, Rijk M, Beukers R, Ouwendijk R, Quispel R, van Tilburg AJP, Tang T, Smalbraak H, Bruin K, Lindenburg F, Peyrin-Biroulet L, van der Woude CJ. Barcelona: 7e ECCO congres, 16-18 februari 2012.

van Putten PG, Massl R, Steyerberg EW, van Tilburg AJP, Lai J, de Ridder RJ, Brouwer JT, Verburg R, Alderliesten J, Schoon EJ, van Leerdam M, Kuipers EJ. San Diego: Digestive Disease Week, 19-22 mei 2012.

Quality assessment of colonoscopies performed by nurse and physician endoscopists reveals high safety and good quality in nurse endoscopists. Massl R, van Putten PG, Steyerberg EW, van Tilburg AJP, Lai J, de Ridder RJ, Brouwer JT, Verburg R, Alderliesten J, Schoon EJ, Kuipers EJ, van Leerdam M. San Diego: Digestive Disease Week, 19-22 mei 2012.

P53 Immunohistochemistry Differentiates Between Low-Grade Dysplasia and Regenerative Changes in Barrett’s Esophagus.

Kastelein F, Spaander M, Biermann K, Steyerberg EW, Kalisvaart M, Walter L, Stoop H, Beukers R, Geldof H, ter Borg P, ter Borg F, Felt-Bersma RJ, van Tilburg AJP, Tan G, den Hartog G, Peters FT, Engels LG, Kolkman JJ, Kuipers EJ, Bruno MJ. San Diego: Digestive Disease Week, 19-22 mei 2012. Cursief: werkzaam in het Sint Franciscus Gasthuis


Colonoscopy performed by nurse endoscopists is associated with high patient satisfaction.

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NEUROLOGIE

NEUROLOGIE

Pubmed artikelen Beriberi after bariatric surgery.

Goselink RJ, Harlaar JJ, Vermeij FH, Biter UL, Mannaerts GHH, den Heijer T Ned Tijdschr Geneeskd. 2012; 155(23):A4500. Pubmed; 22727224. Bariatric surgery is in general the only effective treatment for morbid obesity. Bariatric surgery is frequently associated with vitamin and mineral deficiencies which may lead to neurological and other symptoms. We describe a case of severe vitamin B1 (thiamine) deficiency. CASE DESCRIPTION: A 49-year-old man visited the emergency department with acute confusion, muscle weakness in arms and legs and visual impairment after a period of dysphagia and recurrent vomiting. Four months earlier, he had had bariatric gastric sleeve surgery for morbid obesity. Laboratory tests demonstrated that he had vitamin B1 deficiency, in view of which the diagnosis of beriberi and Wernicke encephalopathy was made. Despite normalisation of the vitamin B1 concentration following intravenous supplementation, the muscle strength hardly recovered and the patient developed Korsakov syndrome. CONCLUSION: For this deficiency there is no other treatment than vitamin B1 supplementation. Timely recognition of vitamin deficiencies and pro-active supplementation are essential in order to prevent serious complications following bariatric surgery.

Common variants at 12q14 and 12q24 are associated with hippocampal volume.

Aging is associated with reductions in hippocampal volume that are accelerated by Alzheimer’s disease and vascular risk factors. Our genome-wide association study (GWAS) of dementia-free persons (n = 9,232) identified 46 SNPs at four loci with P values of <4.0 × 10(-7). In two additional samples (n = 2,318), associations were replicated at 12q14 within MSRB3-WIF1 (discovery and replication; rs17178006; P = 5.3 × 10(-11)) and at 12q24 near HRK-FBXW8 (rs7294919; P = 2.9 × 10(-11)). Remaining associations included one SNP at 2q24 within DPP4 (rs6741949; P = 2.9 × 10(-7)) and nine SNPs at 9p33 within ASTN2 (rs7852872; P = 1.0 × 10(-7)); along with the chromosome 12 associations, these loci were also associated with hippocampal volume (P < 0.05) in a third younger, more heterogeneous sample (n = 7,794). The SNP in ASTN2 also showed suggestive association with decline in cognition in a largely independent sample (n = 1,563). These associations implicate genes related to apoptosis (HRK), development (WIF1), oxidative stress (MSR3B), ubiquitination (FBXW8) and neuronal migration (ASTN2), as well as enzymes targeted by new diabetes medications (DPP4), indicating new genetic influences on hippocampal size and possibly the risk of cognitive decline and dementia.


Bis JC, DeCarli C, Smith AV, den Heijer T (et al)CHARGE Consortium. Nat Genet 2012; 44:545-552. PMID: 22504421. Free PMC Article.

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The thyroid hormone receptor alpha locus and white matter lesions: a role for the clock gene REV-ERBα.

Medici M, Ikram MA, van der Lijn F, den Heijer T, Vernooij MW, Hofman A, Niessen WJ, Visser TJ, Breteler MMB, Peeters RP. Thyroid 2012;22(11):1181-1186. PMID: 23083441. Thyroid disorders are associated with an increased risk of cognitive impairment and Alzheimer’s disease. Both small vessel disease and neurodegeneration have a role in the pathogenesis of cognitive impairment and Alzheimer’s disease. Thyroid hormone receptor alpha (TRα) is the predominant TR in brain. The circadian clock gene REV-ERBα overlaps with the TRα gene and interferes with TRα expression. Limited data are available on the role of the TRα/REV-ERBα locus in small vessel disease and neurodegeneration. We therefore studied genetic variation in the TRα/REV-ERBα locus in relation to brain imaging data, as early markers for small vessel disease and neurodegeneration. Fifteen polymorphisms, covering the TRα/REV-ERBα locus, were studied in relation to white matter lesion (WML), total brain, and hippocampal volumes in the Rotterdam Study I (RS-I, n=454). Associations that remained significant after multiple testing correction were subsequently studied in an independent population for replication (RS-II, n=607). No associations with total brain or hippocampal volumes were detected. A haplotype block in REV-ERBα was associated with WML volumes in RS-I. Absence of this haplotype was associated with larger WML volumes in women (0.38%±0.18% [β±SE], p=0.007), but not in men (0.04%±0.11%, p=0.24), which was replicated in RS-II (women: 0.15%±0.05%, p=0.04; men: 0.05%±0.07%, p=0.80). Meta-analysis of the two populations showed that women lacking this haplotype have a 1.9 times larger WML volume (p=0.001). Our results suggest a role for REV-ERBα in the pathogenesis of WMLs.

Antibiotic therapy for preventing infections in patients with acute stroke.


Westendorp WF, Vermeij JD, Vermeij F, Den Hertog HM, Dippel DW, van de Beek D, Nederkoorn PJ. Cochrane Database Syst Rev. 2012 Jan 18;1:CD008530. doi: 10.1002/14651858.CD008530. pub2. Review. PMID: 22258987.

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BACKGROUND: Stroke is the main cause of disability in high income countries and ranks second as a cause of death worldwide. Infections occur frequently after stroke and may adversely affect outcome. Preventive antibiotic therapy in the acute phase of stroke may reduce infections and improve outcome. OBJECTIVES: 1. To assess whether preventive antibiotic therapy in patients with acute stroke reduces the risk of dependency and death at follow-up. 2. To assess whether preventive antibiotic therapy in patients with acute stroke reduces infection rate. SEARCH METHODS: We searched the Cochrane Stroke Group’s Trials Register (October 2010); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3); MEDLINE (1950 to October 2010) and EMBASE (1980 to October 2010). In an effort to identify further published, unpublished and ongoing trials we searched trials and research registers, scanned reference lists and contacted authors, colleagues and researchers in the field.

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SELECTION CRITERIA: Randomised controlled trials (RCTs) of preventive antibiotic therapy versus control (placebo or open control) in patients with acute ischaemic or haemorrhagic stroke. DATA COLLECTION AND ANALYSIS: Two authors independently selected articles and performed data extraction; we discussed and resolved discrepancies in a consensus meeting with a third observer. We contacted the study authors to obtain missing data when required. An independent observer assessed methodological quality. We calculated relative risks (RRs) for dichotomous outcomes, assessed heterogeneity amongst included studies and performed subgroup analyses on study quality. MAIN RESULTS: We included five studies involving 506 patients. Study population, study design, type of antibiotic and definition of infection differed considerably. The number of patients who died in the preventive antibiotic group was non-significantly reduced (33/248 (13%) versus 38/258 (15%), RR 0.85, 95% confidence interval (CI) 0.47 to 1.51); the number of dependent patients in the preventive antibiotic therapy group was also nonsignificantly reduced (97/208 (47%) versus 127/208 (61%), RR 0.67, 95% CI 0.32 to 1.43). Preventive antibiotic therapy did reduce the incidence of infections in patients with acute stroke from 36% to 22% (36/166 (22%) versus 61/169 (36%), RR 0.58, 95% CI 0.43 to 0.79). No major side-effects of preventive antibiotic therapy were reported. AUTHORS’ CONCLUSIONS: In this meta-analysis, preventive antibiotic therapy seemed to reduce the risk of infection, but did not reduce the number of dependent or deceased patients. However, the included studies were small and heterogeneous. Large randomised trials are urgently needed.

Overige artikelen Structural and diffusion MRI measures of the hippocampus and memory performance.

den Heijer T, van der Lijn F, Vernooij MW, de Groot M, Koudstaal PJ, van der Lugt A, Krestin GP, Hofman A, Niessen WJ, Breteler MMB. NeuroImage 2012;63:1782-1789.

Westendorp WF, Vermeij JD, Vermeij FH, Hertog HM den, Dippel DWJ, Van de Beek D, Nederkoorn PJ. Stroke; a journal of cerebral circulation. 11/2012; 43(11):e113-4.

Voordrachten Praktische Neurologie voor de huisarts: “(sub)acute hoofdpijnen”, “bewegingsstoornissen in de neurologie” en “zwakte en/of pijn aan de extremiteiten”. Bakker SLM. Paramaribo: Nascholing huisartsen Suriname, 10-18 november 2012.


Preventive antibiotics in acute stroke: summary of a cochrane systematic review and meta-analysis.

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Beriberi na bariatrische chirurgie.

Goselink RJ, Harlaar JJ, Biter UL, Vermeij FH, den Heijer T. Rotterdam: Sint Franciscus Gasthuis, Wetenschapsdag, 13 april 2012.

Case report: a spinal epidural abscess.

Hanewinckel R, den Heijer T. Rotterdam: Sint Franciscus Gasthuis, Wetenschapsdag, 13 april 2012.

Slaap; hoe was ‘t ook al weer?


Vermeij FH. Rotterdam: Regionale neurologen bijeenkomst, Lantaren Venster, 18 september 2012.

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OOGHEELKUNDE

OOGHEELKUNDE

OOGHEELKUNDE

Pubmed artikel Incidental finding of alpha-methylacyl-CoA racemase deficiency in a patient with oculocutaneous albinism type 4.

Verhagen JM, Huijmans JG, Williams M, Van Ruyven RL, Bergen AA, Wouters CH, Brooks AS. Am J Med Genet A. 2012 Nov;158A(11):2931-4. PMID: 22987308.


Genome-wide studies may lead to the discovery of genetic variants of potential clinical importance beyond the aims of the study. We performed single nucleotide polymorphism array analysis in a boy with oculocutaneous albinism to identify copy-neutral regions of homozygosity harboring genes involved in melanin biosynthesis. An unanticipated homozygous deletion of chromosome 5p13.3 was discovered, encompassing not only the OCA gene SLC45A2, but also four additional genes. This led to an unexpected presymptomatic diagnosis of alpha-methylacyl-CoA racemase deficiency in the same patient.

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ORTHOPEDIE

ORTHOPEDIE

ORTHOPEDIE

Pubmed artikel In end stage osteoarthritis, cartilage tissue pentosidine levels are inversely related to parameters of cartilage damage. Vos PA, Mastbergen SC, de Boer TN, Huisman AM, de Groot J, Polak AA, Lafeber FP. Osteoarthritis Cartilage 2012 Mar;20(3):233-240. PMID: 22227209.


Age is the most prominent predisposition for development of osteoarthritis (OA). Age-related changes of articular cartilage are likely to play a role. Advanced glycation endproducts (AGEs) accumulate in cartilage matrix with increasing age and adversely affect the biomechanical properties of the cartilage matrix and influence chondrocyte activity. In clinical studies AGEing of cartilage and its relation to actual cartilage damage can only be measured by surrogate markers (e.g., serum, skin or urine AGE levels and imaging or biochemical markers of cartilage damage). In this study actual cartilage AGE levels were directly related to actual cartilage damage by use of cartilage obtained at joint replacement surgery. METHODS: Cartilage and urine samples were obtained from 69 patients undergoing total knee replacement. Samples were analyzed for pentosidine as marker of AGE. Cartilage damage was evaluated macroscopically, histologically, and biochemically. RESULTS: Cartilage and urine pentosidine both increased with increasing age. The higher the macroscopic, histological, and biochemical cartilage damage the lower the cartilage pentosidine levels were. In multiple regression analysis age is not found to be a confounder. CONCLUSION: There is an inverse relation between cartilage AGEs and actual cartilage damage in end-stage OA. This is likely due to ongoing (ineffective) increased turnover of cartilage matrix proteins even in end stage disease.

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PATHOLOGIE/ PATHAN

PATHOLOGIE/PATHAN

PATHOLOGIE/PATHAN

Overige artikelen Geen BCC toch Mohs. Bijzondere indicaties voor Mohs micrografische chirurgie.

Dikrama PK, Munte K, Koljenovic S, Noordhoek Hegt V, Neumann M, de Haas ERM. Ned. Tijdschr. Dermatopathologie en Venereologie 2012; 22 (1): 98-102.

Dermatopathologie, kennistest.

Dikrama P, Middelburg T, Noordhoek Hegt V. Ned. Tijdschr. Dermatopathologie en Venereologie 2012; 22; (4): 256-7; 277

Dermatopathologie, kennisquiz.

Dikrama P, Middelburg T, Noordhoek Hegt V. Ned. Tijdschr. Dermatopathologie en Venereologie 2012; 22 (5): 312; 324-5.

Dermatopathologie, kennisquiz.


Dikrama P, Middelburg T, Noordhoek Hegt V. Ned. Tijdschr. Dermatopathologie en Venereologie 2012; 22; (10): 616-7; 628-9.

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PSYCHIATRIE

PSYCHIATRIE

PSYCHIATRIE

Overige artikelen Zwangerschap niet altijd een roze wolk.

Kats S. Magazine voor Vrouwelijke Artsen met Power (VAMP) van de Vereniging van Nederlandse Vrouwelijke Artsen ; 2012: 40: 16-17.

Voordrachten Zwangerschap en Psychofarmaca.

Kats S, Schoof P. Rotterdam: Regionale nascholingsbijeenkomst huisartsen over Zwangerschap en Psychiatrie, 6 maart 2012.

Psychiatrische beelden postpartum.

de Boer B. Rotterdam: Regionale nascholingsbijeenkomst huisartsen over Zwangerschap en Psychiatrie, 6 maart 2012.

Seksuele stoornissen postpartum.

Spelbrink M. Rotterdam: Regionale nascholingsbijeenkomst huisartsen over Zwangerschap en Psychiatrie, 6 maart 2012.

Zwangerschap niet altijd een roze wolk.

Kats S, van Lith K. Rotterdam: Sint Franciscus Gasthuis, Lunchreferaat afdeling Gynaecologie en Verloskunde, 24 april 2012.

Cognitieve gedragstherapie bij nomina. WETENSCHAPPELIJK JAARVERSLAG 2012

Vlaminck J. Rotterdam: Rotterdamse Regionale Neurologen Bijeenkomst, 18 september 2012.

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Kats S, Lith K. Schiedam: Vlietlandziekenhuis, lunchreferaat afdeling Psychiatrie, Gynaecologie en Kindergeneeskunde, 16 oktober 2012.


Kats S, van Lith K. Rotterdam: Kringsymposium Verloskundigen Rijnmond, 22 november 2012.


Kats S, van Lith K. Ede: Symposium :”Als de roze wolk wordt overschaduwd”, 14 december 2012. Cursief: werkzaam in het Sint Franciscus Gasthuis

REUMATOLOGIE

REUMATOLOGIE

REUMATOLOGIE

Pubmed artikelen Induction therapy with a combination of DMARDs is better than methotrexate monotherapy: first results of the TREACH trial. de Jong PH, Hazes JMW, Barendregt PJ, Huisman AM, van Zeben D, (et al). Ann Rheum Dis 2012; Epub 2012 june 7. PMID: 22679301.

OBJECTIVE: To determine the most effective induction disease-modifying antirheumatic drug (DMARD) strategy in early rheumatoid arthritis (RA), second to compare one single dose of intramuscular glucocorticoids (GCs) with daily oral GCs during the induction phase. METHODS: The 3-month data of a single-blinded clinical trial in patients with recent-onset arthritis (tREACH) were used. Patients were included who had a high probability (>70%) of progressing to persistent arthritis, based on the prediction model of Visser. Patients were randomised into three induction therapy strategies: (A) combination therapy (methotrexate (MTX) + sulfasalazine + hydroxychloroquine) with GCs intramuscularly; (B) combination therapy with an oral GC tapering scheme and (C) MTX with oral GCs similar to B. A total of 281 patients were randomly assigned to strategy (A) (n=91), (B) (n=93) or (C) (n=97). RESULTS: The Disease Activity Score (DAS) after 3 months was lower in patients receiving initial combination therapy than in those receiving MTX monotherapy (0.39 (0.67 to 0.11, 95% CI)). DAS did not differ between the different GC bridging treatments. After 3 months 50% fewer biological agents were prescribed in the combination therapy groups. Although the proportion of patients with medication adjustments differed significantly between the treatment arms, no differences were seen in these adjustments due to adverse events after stratification for drug. CONCLUSION: Triple DMARD induction therapy is better than MTX monotherapy in early RA. Furthermore, no differences were seen in medication adjustments due to adverse events after stratification for drug. Intramuscular and oral GCs are equally effective as bridging treatments and both can be used.

Demographic clinical and antibody characteristics of patients with digital ulcers in systemic sclerosis: data from the DUO registry.


Collaborators: Denton CP, Krieg T, Guillevin, van Zeben D, (et al). Ann Rheum Dis 2012; 71: 718-721. PMID: 22247218.

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OBJECTIVES: The Digital Ulcers Outcome (DUO) Registry was designed to describe the clinical and antibody characteristics, disease course and outcomes of patients with digital ulcers associated with systemic sclerosis (SSc). METHODS: The DUO Registry is a European, prospective, multicentre, observational, registry of SSc patients with ongoing digital ulcer disease, irrespective of treatment regimen. Data collected included demographics, SSc duration, SSc subset, internal organ manifestations, autoantibodies, previous and ongoing interventions and complications related to digital ulcers. RESULTS: Up to 19 November 2010 a total of 2439 patients had enrolled into the registry. Most were classified as either limited cutaneous SSc (lcSSc; 52.2%) or diffuse cutaneous SSc (dcSSc; 36.9%). Digital ulcers developed earlier in patients with dcSSc compared with lcSSc. Almost all patients (95.7%) tested positive for antinuclear antibodies, 45.2% for anti-scleroderma-70 and 43.6% for anticentromere antibodies (ACA). The first digital ulcer

REUMATOLOGIE

in the anti-scleroderma-70-positive patient cohort occurred approximately 5 years earlier than the ACA-positive patient group. CONCLUSIONS: This study provides data from a large cohort of SSc patients with a history of digital ulcers. The early occurrence and high frequency of digital ulcer complications are especially seen in patients with dcSSc and/or anti-scleroderma-70 antibodies.

Treatment decisions and related costs differ significantly depending on the choice of a disease activity index, in rheumatoid arthritis according to 1987 and 2010 classification criteria.

OBJECTIVE: To evaluate the therapeutic and economic consequences of various disease activity indices (DAIs) in RA according to 1987 and 2010 criteria. METHODS: Data on disease activity states from all sustained visits were assessed from all patients who participate in the treatment in the Rotterdam Early Arthritis Cohort (tREACH) study, a stratified randomized trial to evaluate different treatment strategies in patients with a symptom duration of <1 year. Frequencies of treatment adaptations, based upon exclusive thresholds of various DAIs, were visualized in reclassification tables. The Stuart-Maxwell test was applied to analyse any significant differences between treatment decisions according to the different DAIs. Simulated annual median medication costs were estimated using the tREACH medication protocol with standard national costs. RESULTS: DAIs perform similar in RA according to 1987 and 2010 criteria. A total of 1104 DASs per DAI were available from 296 patients. DAIs differ significantly, compared with DASs, in classifying a patient’s disease state. Consequently, treatment intensifications occur more frequently with SDAI, CDAI and DAS-28 usage, compared with DAS. Tapering treatment occurs less frequently with SDAI and CDAI and more frequently with DAS-28 usage. Simulated annual median medication costs are significantly higher if DAS-28, SDAI and CDAI are used compared with DAS usage. CONCLUSION: Usage of various DAIs in a single patient leads to inconsistent disease state categorizations. Consequently, these inconsistencies significantly influence therapeutic decisions and accompanying costs. As DAI usage is imperative to uphold current European League Against Rheumatology (EULAR) treatment recommendations, physicians should consider these therapeutic and economic consequences before choosing a particular DAI.

In vitro glucocorticoïd sensitivity is associated with clinical glucocorticoïd therapy outcome in rheumatoid arthritis. Quax R, Koper JW, de Jong P, van Heerebeek R, Weel A, van Zeben D, Huisman AM, (et al). Arthritis Res Ther 24 augustus 2012; 14(4):R195. PMID: 22920577.

INTRODUCTION: Genetic and disease-related factors give rise to a wide spectrum of glucocorticoid (GC) sensitivity in rheumatoid arthritis (RA). In clinical practice, GC treatment is not adapted to these differences in GC sensitivity. In vitro assessment of GC sensitivity before the start of therapy could allow more individualized GC therapy. The aim of the study was to investigate the association between in vitro and in vivo GC sensitivity in RA.


de Jong PH, Hazes JMW, van Zeben D, van derLubbe PA, de Jager MH, de Sonnaville PBJ de, Luime J, Weel A. Rheumatology (Oxford) 2012;51(7:1269-77) PMID: 22378716.

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METHODS: Thirty-eight early and 37 established RA patients were prospectively studied. In vitro GC sensitivity was assessed with dexamethasone-induced effects on interleukin-2 (IL-2) and glucocorticoid-induced leucine zipper (GILZ) messenger RNA expression in peripheral blood mononuclear cells (PBMCs). A whole-cell dexamethasone-binding assay was used to measure number and affinity (1/KD) of glucocorticoid receptors (GRs).In vivo GC sensitivity was determined by measuring the disease activity score (DAS) and health assessment questionnaire disability index (HAQ-DI) score before and after 2 weeks of standardized GC treatment. RESULTS: GR number was positively correlated with improvement in DAS. IL-2-EC50 and GILZ-EC50 values both had weak near-significant correlations with clinical improvement in DAS in intramuscularly treated patients only. HAQ responders had lower GILZ-EC50 values and higher GR number and KD. CONCLUSIONS: Baseline cellular in vitro glucocorticoid sensitivity is modestly associated with in vivo improvement in DAS and HAQ-DI score after GC bridging therapy in RA. Further studies are needed to evaluate whether in vitro GC sensitivity may support the development of tailor-made GC therapy in RA.

Brief Report: to squeeze or not to squeeze, that is the question! Optimizing the disease activity score in 28 joints by adding the squeeze test of metatarsophalangeal joints in early rheumatoid arthritis.


de Jong PH, Weel AE, de Man YA, Huisman AM, Gerards AH, van Krugten MV, Luime JJ, Hazes JM. Arthritis Reum. 2012 Oct;64(10):3095-101. PMID:22673898.

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OBJECTIVE: To optimize use of the Disease Activity Score in 28 joints (DAS28) in early rheumatoid arthritis (RA) by adding the “squeeze test” of forefeet.METHODS: The squeeze test is used to examine bilateral compression pain (BCP) across the metatarsophalangeal (MTP) joints. For this study, data for patients participating in the Treatment in the Rotterdam Early Arthritis Cohort study, an ongoing clinical trial that evaluates different induction therapies in patients with early RA, were randomly divided into 2 subsets. In subset 1 (149 patients and 819 disease activity assessments), the mathematical function of the DAS28-squeeze was constructed using a linear regression model with the DAS as the dependent variable and the DAS28 and squeeze test as the independent variables. A DAS28-BCP disease state was also constructed, in which DAS28 disease state categorizations were upgraded one state if the result of the squeeze test was positive. In subset 2 (153 patients and 754 assessments), concordance in disease states between the DAS28, DAS28-squeeze, and DAS28-BCP disease states was compared, using both the DAS and Boolean-defined remission criteria as reference.RESULTS: Agreement between the DAS and the DAS28-squeeze (82%) was significantly higher than agreement between the DAS and the DAS28 (76%). When we assessed the group of patients who had arthritis of the forefeet only (22 patients and 46 assessments), overall agreement between the DAS and the DAS28 was 40%, while agreement between the DAS and the DAS28-squeeze was 59% and that between the DAS and the DAS28-BCP disease state was 65%. Furthermore, the specificities of the DAS28-squeeze and the DAS28-BCP (80% and 81%, respectively) were higher than that of the DAS28 (76%), while the sensitivities of the DAS28, DAS28-squeeze, and DAS28-BCP to identify true remission according to the Boolean criteria were 88%, 87%, and 81%, respectively.CONCLUSION: Adding the squeeze test of forefeet to the DAS28 has value for dependably classifying the disease state in patients with early RA.

REUMATOLOGIE

Serum adipokines in osteoarthritis; comparison with controls and relationship with local parameters of synovial inflammation and cartilage damage.

Huisman AM, de Boer TN, van Spil WE, Polak AA, Bijlsma JW, Lafeber FP, Mastbergen SC. Osteoarthritis Cartilage 2012 Aug;20(8):846-53. PMID:22595228.

OBJECTIVE: Adipose tissue is an endocrine tissue releasing adipokines suggested to be involved in the pathogenesis of osteoarthritis (OA). Nevertheless, their relative contribution and exact mechanisms are still ambiguous. The aim of this study is to compare serum adipokine levels between end-stage knee OA patients and controls and to relate these serum levels to local parameters of cartilage damage and synovial inflammation. METHODS: Serum was collected from 172 severe knee OA patients, shortly before total knee replacement (TKR) surgery and from 132 controls without radiographic knee OA [Kellgren & Lawrence (K&L) = 0]. Serum adiponectin, leptin, and resistin levels were measured by enzyme-linked immunosorbent assay (ELISA). Cartilage and synovial tissue were collected at TKR surgery and assessed for cartilage degeneration and synovial inflammation by histochemistry and biochemical analyses. RESULTS: The adipokine levels were all distinctly higher in OA patients as compared to controls. Especially adiponectin and leptin were associated with female gender (stand beta = 0.239 and 0.467, respectively, P < 0.001) and body mass index (BMI) (stand beta = -0.189 and 0.396, respectively, P < 0.001). No associations between serum levels of adipokines and cartilage damage (histochemistry, proteoglycan content) were found whereas weak but positive associations with synovial inflammation were found [adiponectin and interleukin-1β (IL-1β), stand beta = 0.172, P = 0.02; resistin and histology, stand beta = 0.183, P = 0.034, adjusted for demographics]. CONCLUSION: This study suggests an important involvement of adipokines in OA patients considering their high serum levels compared to controls. Associations of systemic adipokines with local synovial tissue inflammation were found, although not represented by similar relations with cartilage damage, suggesting that adipokines are of relevance in the inflammatory component of OA.

Hoofdpijn op het reumatologisch spreekuur.

van de Geijn FE, Schrauwen SL, Huisman AM, van der Loos TLJM. Ned. Tijdschrift voor Reumatologie, juni 2012(2); 49-52.

SLE, zo komt de ziekte aan het licht?

Huisman AM, Hamer MA, Bonte-Mineur F, Schrama YC. Ned. Tijdschrift voor Reumatologie 2012: 39-43.


Overige artikelen

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REUMATOLOGIE

Voordrachten Bacteriële artritis update en pro-contra debat over orthopedisch spoelen versus naald aspiratie en intra-articulair. Van Casteren-Messidoro C. Rotterdam: Regionale refereeravond Reumatologie, oktober 2012.

Methotrexaat en pneumonitis.

Huisman AM. Rotterdam: Complicatiebespreking Interne Specialismen SFG, 7 maart 2012.

Reumatoïde artritis en anti-CCP.

Huisman AM. Rotterdam: Medische Microbiologie en Infectieziekten SFG, Mei 2012.

All about Methotrexaat.

Huisman AM. Rotterdam: Maatschap Interne Specialismen SFG, 27 juni 2012.

Polyartritis: reumatoïde artritis en kristalartritis.

Huisman AM. Capelle aan den IJssel: Geaccrediteerde nascholing huisartsen regio Rotterdam (georganiseerd door maatschap Interne Geneeskunde, IJsselland Ziekenhuis), 26 september 2012.

Klinische demonstratie ANCA-geassocieerde vasculitis.

van Zeben D. Rotterdam: Klinische demonstratie, Sint Franciscus Gasthuis, 15 februari 2012.

Pro-Contra Debat ‘puncteren of chirurgisch draineren bij bacteriële artritis’; een update van de literatuur.


van Zeben D. Rotterdam: Regionale refereeravond Stizoro Maasstad Ziekenhuis, 17 oktober 2012.

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Bacteriële artritis.

van Zeben D. Rotterdam: Klinische demonstratie SFG, 24 oktober 2012

Vasculitis voor 3e en 4e jaars AIOS.

van Zeben D. Rotterdam: RIOGR vasculitis, EMC 19 december 2012.

REUMATOLOGIE

Abstracts Early glucocorticosteroid response predicts the effect of DMARDS after 3 months of therapy.

Huisman AM, de Jong PHP, Quax R, Gerards A, Feelders R, de Sonnaville P, Luime J, Weel A, Hazes J. EULAR 2012 abstract.

Radiographic joint damage as a predictor of short-term clinical outcome of totale knee replacement surgery.

Huisman AM, de Boer TN, Welsing PM, Polak AA, Noord-van der Laan WH, Mastbergen SC, Labeber FP. EULAR 2012 abstract.

Poster Comparison between complement component 3 (C3) and apolipoprotein B as markers for the metabolic syndrome in subjects using statins. Van Breukelen-van der Stoep DF, Klop B, Elte JWF, Njo TL, Janssen H, Birnie E, Castro Cabezas M. Sydney: International Society Atherosclerosis, 27 maart 2012.

Franciscus Rheumatoid Arthritis and Cardiovascular Intervention Study – opzet en rationale.


Van Breukelen-van der Stoep DF, Casteren-Messidoro C, Huisman AM, van Zeben D, Klop B, Verwer N, Van de Geijn GJM, Njo TL, Janssen JW, Birnie E, Bakker R, Castro Cabezas M. Rotterdam: Wetenschapsdag Sint Franciscus Gasthuis, 13 april 2012.

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Spoedeisende Hulp ( SEH )

Spoedeisende Hulp ( SEH )

SPOEDEISENDE HULP ( SEH )

Voordrachten A Dissolved Vertebra.

Van den Hengel LC, Bayliss A, van der Velden JJIM, Varin DSE. Egmond aan Zee: Sixth Dutch North Sea Emergency Medicine Conference, 31 mei- 1 juni 2012.

Ultrasound in the ED, the FAST was only the beginning…

Boeije T; Azizi N; Bijvoet M, van Overbeeke P, Rietveld V, Rosendaal A. Egmond aan Zee: Sixth Dutch North Sea Emergency Medicine Conference, 30 mei 2012. (Pre-conference workshop gedurende de gehele dag op 30 mei 2012.)

The FASTer you begin, the better!

Boeije T, Azizi N, Bijvoet M, van Overbeeke P, Rietveld V, Rosendaal A. Egmond aan Zee: Sixth Dutch North Sea Emergency Medicine Conference, 31 mei-1 juni 2012. (Drie workshops op donderdag 31 mei 2012 en vrijdag 1 juni 2012.)

Is discharge of minimally injured, trauma patients after primary and secondary survey, justified? Brown AV, Grimminck B, De Ridder V. Egmond aan zee: NVSHA 6th Dutch North Sea Emergency Medicine Conference, 31 mei 2012

Is discharge of minimally injured, trauma patients after primary and secondary survey, justified? Brown AV, Grimminck B, De Ridder V. Rotterdam: Sint Franciscus Gasthuis, Wetenschapsdag, 12 april 2012.

Dood door broodje Döner? Een harttamponade door harttumor.

Posters Posterior reversible encephalopathy syndrome secondary to a post-streptococcal glomerulonephritis in an otherwise healthy child. Grimminck B, Brown AV. Egmond aan Zee: NVSHA 6th Dutch North Sea Emergency Medicine Conference, 31 mei 2012

Poppers intoxication on an emergency ward: With methemoglobinemia as a result.

Brown AV, Grimminck B. Egmond aan Zee: NVSHA 6th Dutch North Sea Emergency Medicine Conference, 31 mei 2012.


Sukul P, De Ridder VA. Egmond aan Zee: NVSHA, 30 mei – 1 juni 2012.

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SPOEDEISENDE HULP ( SEH )

Patent foramen ovale.

Bontemps S, Veerhoek R, Bakker S. Dublin: ICEM, 27-30 juni 2012.

Case-report: a baclofen-overdosed patient with normal renal function; treatment by hemodialysis.


Bontemps S, Geerlings CJC, De Feiter P. Dublin: 14th International Conference on Emergency Medicine (ICEM), 27 – 30 juni 2012.

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UROLOGIE

UROLOGIE

UROLOGIE

Pubmed artikelen Extravasation of intravesical chemotherapy for non-muscle-invasive bladder cancer.

Mertens LS, Meinhardt W, Rier WB, Nooter RI, Horenblas S. Urol Int. 2012; 89:332-6. PMID: 22965138.

PURPOSE: To report our experience with symptomatic extravasation of intravesical chemotherapy administered within 24 h after transurethral resection (TUR) over the past 10 years. METHODS: We identified all consecutive patients who presented with symptomatic extravasation of intravesical chemotherapy following TUR between 2001 and 2011. We assessed the severity of the postoperative complications using the modified Clavien system. RESULTS: We identified 9 patients (mean age 59, range 40-76 years) with symptomatic extravasation. One patient had grade II, 2 had grade IIIa, and 5 patients had grade IIIb complications according to the Clavien system. Surgery was needed in 6 of 9 patients. One required ICU management (Clavien IV). No patients died in the postoperative course. CONCLUSION: Extravasation can cause severe complications and diagnosis is often protracted. Considering the growing practice of immediate intravesical instillations, the number of patients with symptomatic extravasation is expected to rise. An increased awareness of this possible complication is warranted.

Active Surveillance for Low-Risk Prostate Cancer Worldwide: The PRIAS Study.


Bul M, Zhu X, Valdagni R, Pickles T, Kakehi Y, Rannikko A, Bjartell A, van der Schoot DK, Cornel EB, Conti GN, Boevé ER, Staerman F, Vis-Maters JJ, Vergunst H, Jaspars JJ, Strölin P, van Muilekom E, Schröder FH, Bangma CH, Roobol MJ. Eur Urol. 2012 Nov 12. doi:pii: S0302-2838(12)01336-X. 10.1016/j.eururo.2012.11.005. [Epub ahead of print] PMID: 23159452.

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BACKGROUND: Overdiagnosis and subsequent overtreatment are important side effects of screening for, and early detection of, prostate cancer (PCa). Active surveillance (AS) is of growing interest as an alternative to radical treatment of low-risk PCa.OBJECTIVE: To update our experience in the largest worldwide prospective AS cohort.DESIGN, SETTING, AND PARTICIPANTS: Eligible patients had clinical stage T1/T2 PCa, prostate-specific antigen (PSA) ≤10 ng/ml, PSA density <0.2 ng/ml per milliliter, one or two positive biopsy cores, and Gleason score ≤6. PSA was measured every 3-6 mo, and volume-based repeat biopsies were scheduled after 1, 4, and 7 yr. Reclassification was defined as more than two positive cores or Gleason >6 at repeat biopsy. Recommendation for treatment was triggered in case of PSA doubling time <3 yr or reclassification. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariate regression analysis was used to evaluate predictors for reclassification at repeat biopsy. Active therapy-free survival (ATFS) was assessed with a Kaplan-Meier analysis, and Cox regression was used to evaluate the association of clinical characteristics with active therapy over time.RESULTS AND LIMITATIONS: In total, 2494 patients were included and followed for a median of 1.6 yr. One or more repeat biopsies were performed in 1480 men, of whom 415 men (28%) showed reclassification. Compliance with the first repeat biopsy was estimated to be 81%. During follow-up, 527 patients (21.1%) underwent active therapy. ATFS at 2 yr was 77.3%. The strongest predictors for reclassification and

UROLOGIE

switching to deferred treatment were the number of positive cores (two cores compared with one core) and PSA density. The disease-specific survival rate was 100%. Follow-up was too short to draw definitive conclusions about the safety of AS. CONCLUSIONS: Our short-term data support AS as a feasible strategy to reduce overtreatment. Clinical characteristics and PSA kinetics during follow-up can be used for risk stratification. Strict monitoring is even more essential in men with high-risk features to enable timely recognition of potentially aggressive disease and offer curative intervention. Limitations of using surrogate end points and markers in AS should be recognized. TRIAL REGISTRATION: The current program is registered at the Dutch Trial Register with ID NTR1718.

Voordrachten Organisatie prostaatkankercentra.

Rietbergen JBW. Rotterdam: Sint Franciscus Gasthuis, Nascholing voor huisartsen, januari 2012.

Organisatie prostaatkankercentra.

Rietbergen JBW. Rotterdam: Sint Franciscus Gasthuis, Wetenschappelijk Café, 1 februari 2012.

Laparoscopische partiële nefrectomie, stand van zaken.

Rietbergen JBW. Arnhem: Nederlandse Vereniging voor Endoscopische Chirurgie, 12 maart 2012.

Training in Urology; wat gaat er gebeuren in 2012.

Rietbergen JBW, Schout B. Den Bosch: Regionale refereeravond urologen, 15 mei 2012.

Anatomie in de laparoscopie.

Opereren op een proefdier.

Rietbergen JBW. Elancourt: Cursus laparoscopie AIOS, 19 juni 2012.

Transrectale echogeleide prostaatbiopten.

Rietbergen JBW. Eindhoven: Echocursus voor AIOS,22 en 23 november 2012.

Acute urologie.

Rietbergen JBW. Eindhoven: Upfront cursus urologie voor AIOS, 21 december 2012.


Rietbergen JBW. Elancourt: Cursus laparoscopie AIOS, 18 juni 2012.

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Slow wave conduction disturbances proximal and distal to ileal end-toend anastomosis following ileocystoplasty.

Hammad FT, Lammers WJ, Rietbergen JBW, Stephen B, Lubbad L. Bologna: Neurogastroenterology and Motility Meeting, 6-8 september 2012.

De waarde van de MRI bij het prostaatcarcinoom.

Halilovic M. Rotterdam: Regionale refereeravond Urologie, 3 december 2012.

Secundaire maligniteiten gerelateerd aan de bestraling van een prostaatcarcinoom. Roemeling S. Rotterdam: Regionale refereeravond Urologie, 3 december 2012.

Een patiënt met een forse bloeding bij een Millin prostatectomie. Christiaansen C. Rotterdam: Regionale refereeravond Urologie, 3 december 2012.

Het dilemma van de proximale uretersteen.

Boevé ER. Rotterdam: Regionale refereeravond Urologie, 3 december 2012.

Prostaatkankerscreening: Uitleg vanuit een patiënten perspectief de Vries SH. Schiedam: Vlietland Ziekenhuis, 1 oktober 2012.

Prostaatkanker, wat dan?

de Vries SH. Rotterdam: Huisartsen nascholing, 9 oktober 2012.

Prostaatcarcinoom.


de Vries SH, Hamberg P. Rotterdam: Huisartsen nascholing Oncologie aan de Bergse plas, 10 oktober 2012.

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Urolithiasis: endo-urologische behandeling. Boevé ER. Lunteren: Masterclass Urologie, 8-juni-2012.

VERPLEEGKUNDE

VERPLEEGKUNDE

VERPLEEGKUNDE

Overige Publicaties Mannen met kanker en hun uiterlijke verzorging. van der Poel AE. Oncologica, 2012; 29: 30-31.

Voordracht Suicide (laatste inzichten).

Immerzeel J. Rotterdam: Sint Franciscus Gasthuis, Lunchreferaat poli Psychiatrie en Medische Psychologie, 27 november 2012.

Posters Urology oncology nurses take on the challenge.

Bani L, Wildeman S. Rotterdam: Verpleegkundige Wetenschapsdag Sint Franciscus Gasthuis, 19 juni 2012.

Urologisch oncologieverpleegkundigen nemen de uitdaging aan. Bani L, Wildeman S. Ede: Oncologiedagen V&VN, 28 november 2012.

Nieuwe aanpak van voorlichting over nierdonatie bij leven.

Schonau LE, Pennewaard HM, Nette RW, van Kooij AC, van den Dorpel MMA, Smak Gregoor PJH, Zuidema WC, Zietse R, Busschbach JJ, Weimar W, Massey EK. Rotterdam, Wetenschapsdag Sint Franciscus Gasthuis, 13 april 2012



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Schonau LE, Pennewaard HM, Nette RW, van Kooij AC, van den Dorpel MMA, Smak Gregoor PJH, Zuidema WC, Zietse R, Busschbach JJ, Weimar W, Massey EK. Rotterdam: Verpleegkundige Wetenschapsdag Sint Franciscus Gasthuis, 19 juni 2012.

Voetmassage als niet farmacologische pijnbestrijding bij de volwassen patiënt met longcarcinoom. van Broekhoven S. Rotterdam: Sint Franciscus Gasthuis, Verpleegkundige wetenschapsdag, 19 juni 2012.

Alopecia bij Pemetrexed mono of in combinatie met Cisplatin of Carboplatin bij bewezen nonsmall cell lung cancer (NSCLC) IIIB/IV en Mesothelioom (MPM) III/IV.

van Wijk–van Buuren JJE Rotterdam: Sint Franciscus Gasthuis, Verpleegkundige wetenschapsdag, 19 juni 2012.

VERPLEEGKUNDE

Mannen met kanker hebben behoefte aan informatie over uiterlijke verzorging.

van der Poel AE. Rotterdam: Sint Franciscus Gasthuis, Verpleegkundige wetenschapsdag, 19 juni 2012.

Mannen met kanker hebben behoefte aan informatie over uiterlijke erzorging. van der Poel AE. Ede: Oncologiedagen voor verpleegkundigen, 27 en 28 november 2012.

Paraneoplastisch syndroom bij een patiënte met een coecumcarcinoom. van der Spek AM, Vrijland WW, de Jong GJ. Arnhem: Symposium V&VN-VS, 11 en 12 oktober 2012.

Wetenschappelijkonderzoek onder de aandacht. Boshuizen JJ. Rotterdam: Namens VAR, 27 juli 2012.

Samen voor kwaliteit; VAR-out. The best practice.


Boshuizen JJ. Rotterdam: Namens de VAR 11 juni 2012.

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PROMOTIES

PROMOTIES

PROMOTIES

Achalasia, studies on long term outcome. Leeuwenburgh I. Erasmus Universiteit Rotterdam. Rotterdam: 18 april 2012.

Falls in Parkinson’s disease and Huntington’s disease. van Grimbergen YAM. Universiteit Leiden. Leiden: 23 oktober 2012.

Leukocytes and Complement in Atherosclerosis.

Alipour A. Universiteit Leiden. Leiden: 9 februari 2012. ISBN: 978-94-6169-141-5.

Tissue structure damage in late-stage knee osteoarthritis: medication, markers, and disease modification before replacement surgery.


de Boer TN. Huisman AM, co-promotor. Universiteit Utrecht Utrecht: 26 januari 2012.

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ABSTRACTS VOORDRACHTEN WETENSCHAPSDAG SFG 2012



Een praktisch ertapenem doseerregime bij hemodialyse patiënten.

INLEIDING: Infecties zijn de tweede doodsoorzaak bij dialysepatiënten en veroorzaken een kwart van alle sterfgevallen in deze groep. Het behandelen van deze infecties wordt gecompliceerd door een toenemende prevalentie van resistente gram-negatieve bacteriën, waardoor het gebruik van reserve antibiotica als carbapenems zal gaan toenemen. Ertapenem, is een carbapenem antibioticum dat toegediend wordt in een dosering van 1 maal daags 1000 mg intraveneus. Bij een creatinineklaring < 30 ml/min en bij hemodialyse wordt een dosisreductie van 50% geadviseerd. Onze hypothese is dat ertapenem bij dialysepatiënten toegepast kan worden, gebruikmakend van een intervalverlenging in plaats van een dosisreductie, waardoor een toediening drie maal per week na afloop van de dialysesessie mogelijk is. Vraagstelling: Het doel van dit onderzoek is om de farmacokinetiek van Ertapenem te beschrijven wanneer dit driemaal per week wordt toegediend na afloop van een hemodialysesessie. METHODEN: Het onderzoek is uitgevoerd bij 10 infectieuze hemodialysepatiënten in het Sint Franciscus Gasthuis. De minimale inhibitoire concentratie (MIC) werd voor alle aanwezige bacteriën bepaald. 1 Gram ertapenem werd toegediend na afloop van een dialysesessie. Bloedmonsters werden afgenomen 45 minuten na inlopen van het infuus, voorafgaand aan en na afloop van twee aaneensluitende dialysesessies. Ertapenem concentraties werden bepaald met een gevalideerde LC-MSMS bepaling en de farmacokinetische analyse werd uitgevoerd met MWPharm. RESULTATEN: Bij acht van de 10 patiënten is na de behandeling een klinische verbetering opgetreden. Bij één patiënt was het effect niet te beoordelen i.v.m. een co-infectie met Stenotrophomonas maltophilia ontstaan tijdens de ertapenem behandeling. Bij één patiënt is geen klinische verbetering opgetreden. Er was sprake van een volledige occlusie van de supragenuale femoropopliteale bypass rechts, waardoor mogelijk de doorbloeding ter plekke van de wondinfectie onvoldoende was. De farmacokinetische parameters in onze populatie waren verschillend t.o.v. de gerapporteerde waarden bij niet-infectieuze dialysepatiënten. Het verdelingsvolume is hoger (0,16 l/kg vs 0,11 l/kg) en de halfwaardetijd is verlengd (19,9 uur vs 14,1 uur). De ertapenem dalspiegel op 68 uur was 3,7 mg/l (range 0,5 - 9,6 mg/l) en bleef daarmee boven de individuele MIC (range 0,006 – 0,250 mg/l) gedurende het gehele doseerinterval. CONCLUSIE: Dialysepatiënten worden veelvuldig geconfronteerd met infecties waarvoor een behandeling met antibiotica noodzakelijk is. Veel van deze antibiotica moeten meermaal daags intraveneus worden toegepast, waardoor een ziekenhuisopname of het inzetten van de thuiszorg noodzakelijk is. Ertapenem geeft, in het voorgestelde doseerregime, een concentratie boven MIC gedurende het gehele doseerinterval. Met dit onderzoek tonen wij aan dat ertapenem toegepast kan worden in een praktisch driemaal wekelijks doseerregime na afloop van een hemodialysesessie, waardoor de behandeling aansluit rondom de al bestaande logistiek en verzorging van de patiënt.


M.S. Bosma, ziekenhuisapotheker i.o., dr. A.P. Rietveld, internist-nefroloog, dr. P. de Man, arts-microbioloog, dr. D.J. Touw, ziekenhuisapotheker (Apotheek Haagse Ziekenhuizen) dr. C.J.C. Geerlings, ziekenhuisapotheker.

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Is discharge of minimally injured trauma patients after primary and secondary survey justified?


Vanessa Brown, MD LMM, Emergency Medicine, St. Franciscus Gasthuis, Rotterdam Bart Grimminck, MD, Ruwaard van Putten Ziekenhuis, Spijkenisse, Victor de Ridder, MD PhD MBA St. Franciscus Gasthuis, Rotterdam.

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INTRODUCTION: Dramatically increasing health care costs are pushing hospitals and insurance companies to emphasize outpatient management and to decrease length of hospitalization. We hypothesize that the minimally injured trauma patients, instead of admission or a period of observation, can be discharged after primary and secondary surveys at the emergency department. Tertiary survey can take place the next day at the emergency room or at the surgical outpatient clinic, done by either a physician or a trained nurse practitioner. METHODS: The institutional review board approved this study as a retrospective data collection study; as such informed consent was not required. The registry was queried for trauma patients undergoing 24-hour observation from January 2010 till December 2010 at the Sint Franciscus Hospital in Rotterdam, a level II trauma-hospital. For this purpose patients with a diagnose code (DBC code 294) were gathered and multi-trauma patients were excluded. Hospital admittance was defined as all trauma patients observed secondary to: mechanism of injury, lowered state of consciousness, need for further radiographic evaluation or social reasons. The admission records of all patients were reviewed in order to register missed injuries, which is defined as injury found during tertiary survey or during re-examination of radiographic interpretations. RESULTS: A total of 175 trauma patients were reviewed (table 1). Of these 116 were admitted to the hospital after primary and secondary survey (table 2). The most common reasons to admit a patient was for 24-hour observation, pain management and social reasons. The majority of patients, 99 of 116, were discharged after an observational period of 24 hours. Pain management and social reasons for elderly patients were the main reasons for prolonged hospitalization. Two patients were admitted to the intensive care for observational reasons. No missed injuries were found during tertiary survey in any of the patients. DISCUSSION: Our data suggest that in-hospital observation to detect missed injuries, after thorough primary and secondary survey at the emergency department, does not significantly alter detection of clinically relevant missed injuries. We suggest that minimally injured trauma patients should be discharged after primary and secondary surveys and that tertiary survey can take place the following day as an outpatient. This should only be done if radiologic examinations can be re-interpreted by a radiologist and a traumatologist/ traumasurgeon, as misdiagnosis of radiologic examination is till the biggest cause for missing injury in trauma patients. Outpatients could then still be treated adequately.

Vitamine D deficiëntie is vaak geassocieerd met astma in morbide obese patiënten. Clara Shapiro-Koss1, Astrid van Huisstede2, Gert-Jan Brauhnstahl2 1 afdeling interne geneeskunde, Sint Franciscus Gasthuis 2 Afdeling longgeneeskunde, Sint Franciscus Gasthuis

ACHTERGROND: Resultaten van recente publicaties wijzen op een verband tussen vitamine D deficiëntie en astma bij kinderen, waarbij een lage vitamine D spiegel een risicofactor is voor


het ontwikkelen van astma en bijkomend het aantal exacerbaties zou verhogen. Tevens is bekend dat vitamine D deficiëntie vaak voorkomt bij obesitas. Daarnaast zijn overgewicht en astma geassocieerd, waarbij tot nu toe de pathofysiologie van deze relatie nog onbekend is. Vitamine D deficiëntie zou mogelijk ook een rol kunnen spelen bij de associatie tussen obesitas en astma. DOEL: Wat is de associatie tussen een laag serum vitamine D spiegel en astma in morbide obese patiënten. METHODE: Middels een cross-sectionele studieopzet werd in een cohort van 760 patiënten met morbide obesitas (BMI>40 kg/m2 of BMI>35 kg/m2 met comorbiditeit, leeftijd 18-60 jaar) onderzocht of er een associatie bestaat tussen een vitamine D deficiëntie (25(OH)D concentratie serum<50 nmol/L) en astma, als door een longarts gediagnosticeerd middels anamnese en longfunctiewaarden; o.a. FEV1, FVC, Tiffeneau<70% en Delta FEV1 > 12%. RESULTATEN: Drieëntwintig procent (n=173) van het cohort had een door een longarts gediagnosticeerd astma. Er waren geen significante verschillen in de baseline karakteristieken van de groepen patiënten met en zonder astma, met name ras, BMI, buikomtrek of gewicht. Er was een trend dat patiënten met astma meer vet (in kg) hadden (70.23 ± 18.4) dan de groep zonder astma (66.44 ±16.62 , p=0.056). Vitamine D deficiëntie kwam significant vaker voor in de groep van de patiënten met astma (85%) dan in de groep zonder astma (72,4%) (p<0.001). Ook de spiegel van vitamine D (nmol/L) was significant lager in de groep met astma (35.9 ±19.6), dan in de groep zonder astma (39.5 ± 20.8, p=0.044). CONCLUSIE: In een cohort van mensen met morbide obesitas, hadden patiënten met astma vaker een vitamine D deficiëntie dan patiënten zonder astma, waarbij er geen verschil was tussen de groepen in mate van obesitas.

Vitamin D3 improves arterial stiffness and decreases leukocyte activation postprandially: a pilot study.

INTRODUCTION: The postprandial phase is considered pro-atherogenic in part due to generalized inflammation by triglyceride-rich lipoproteins. Vitamin D modulates the immune system and its levels correlate with arterial stiffness and cardiovascular disease, but the exact mechanisms remains unknown. We investigated if supplementation of vitamin D3 affects arterial stiffness and leukocyte activation postprandially. Methods: Healthy volunteers underwent two oral fat loading tests (OFLT) and served as their own control. At 0, 2, 4, 6 and 8 hours the augmentation index (AIx), reflecting vascular elasticity, was measured by pulse wave analysis together with flow cytometric quantification of leukocyte activation markers CD11b, CD66b, CD35 and CD36. After completion of the first OFLT a dose of 100.000 IE of vitamin D3 was administered and a second OFLT was carried out seven days later. RESULTS: A total of 12 volunteers were included. 25-Hydroxyvitamin D3 levels rose from 63.0±28.8 mmol/l to 98.5±26.8 mmol/l after vitamin D3 supplementation (P<0.001). The postprandial triglyceride response remained unaltered. The AIx showed a horizontal postprandial pattern, but after vitamin D3 supplementation a postprandial decrease in AIx was found, reflecting increased arterial elasticity. Vitamin D3 significantly reduced the AIx at T=6 (12.7±15.4% vs 6.9±13.8%, P=0.03) and also the total area under the postprandial AIx


Boudewijn Klop1, Gert-Jan M. van de Geijn2, Erwin Birnie3, Tjin Njo2, Hans Janssen2, Jan Willem Elte1, Manuel Castro Cabezas1 Dpts. of Internal Medicine1, Clinical Chemistry and Haematology2 and Statistics and Education3, Sint Franciscus Gasthuis, Rotterdam, the Netherlands

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curve (93.1±114.1 au vs 68.6±121.4 au, P=0.04). After vitamin D3, a trend was observed at the postprandial triglyceride peak (T=4) with reduced expressions of CD11b and CD35 on neutrophils (24.01±5.3 au vs 21.1±7.1, P=0.06 and 3.0±1.0 vs 2.7±1.0 au, P=0.08, respectively) and CD11b on monocytes (16.5±2.2 au vs 14.9±2.6 au, P=0.09). CONCLUSION: Vitamin D3 increases postprandial arterial elasticity in healthy volunteers, potentially by reducing the expression of endothelial adhesion markers on monocytes and granulocytes.

Comorbidity and complications in patients undergoing bariatric surgery: the value of ICU admission criteria.


Nicole Meijer2, Marcel de Quelerij1, Chris van Velzen1, Ronald Luitwieler1, Ralph P.M. Gadiot3, Jan van der Voet3, Johan van der Klooster4, Peter W. de Feiter5, Guido Mannaerts6, Serge J.C. Verbrugge7 Anesthesiologist1, Resident Anesthesiology2, Resident of Surgery3, Intensivist4, Surgeon-Intensivist5, Surgeon6, Anesthesiologist-Intensivist7

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INTRODUCTION: In 2006 the bariatric surgical program in our hospital was expanded. We defined preselection criteria for routine postoperative Intensive Care admission of selected bariatric patients from risk factors for postoperative complications described in literature. We retrospectively analysed the data of 546 patients undergoing bariatric surgery to 1) analyse the value of these preselection criteria, 2) to register the problems encountered in bariatric patients postoperatively and 3) to identify predisposing factors for postoperative complications. METHODS: Basic characteristics, comorbidities and postoperative complications (dehydration, haematoma-bleeding, infectious complications, pulmonary embolism, anastomotic leakage, gastro-oesophageal reflux/obstruction, respiratory complications, cardiac complications, other) were evaluated for all patients. In patients admitted to the ICU, the reason for ICU admittance was recorded: 1) on the basis of preselection criteria, 2) due to perioperative complications or 3) after re-intervention in a later stage. Furthermore, in each of these ICU categories, the course on the ICU was identified: no, minor or major actions. Eventually this resulted in only 6 categories filled with patients. These groups of intensive care patients were statistically compared to all other patients for basic characteristics and comorbidities (normal distribution was tested using the Kolmogorov and Smirnov test. A t-test was used for normally distributed data; a Mann-Whitney test was used for data not normally distributed. Frequency distributed data were analysed using a contingency table with a Fisher’s exact test. Statistical significance was accepted at p < 0.05). RESULTS: No major actions were needed in patients admitted to our ICU directly postoperative (patients admitted on the basis of preselection criteria or due to perioperative factors). In these patients pulmonary problems were the most significant problems encountered. However, no specific actions were needed on the ICU that could not have been performed on the wards. Bodyweight was significantly higher in patients suffering postoperatively from an infection, pulmonary embolism or respiratory complications. In patients with a known bleeding diathesis there were significantly more postoperative bleedings and pulmonary embolisms. The bleeding diathesis was also significantly increased in the group of ICU patients admitted to the ICU on the basis of reintervention in a later stage with major actions on the ICU. CONCLUSIONS: Preselected criteria formed on the basis of literature are no good predictors


for the need of admittance on the ICU postoperative after bariatric surgery. Bariatric surgery is not a criterion to be admitted to an ICU poster operatively. Provided there is attention for pulmonary problems on the wards, it is safe for these patients to bypass the ICU, as major complications do not happen directly postoperatively. Basic pulmonary support on the wards could be done by providing supplemental oxygen, regular control of breathing frequency and pulse oximetry as suggested by other authors. Patients with a haemorrhagic diathesis were more frequently admitted to the ICU on the basis of reintervention in a later stage with major actions on the ICU.

Sunitinib Associated Thrombocytopenia: Not always what it seems.

INTRODUCTION: Sunitinib is an oral treatment for metastatic renal cell carcinoma (RCC) which is known to cause thrombocytopenia as an adverse affect. Thrombocytopenia may lead to dose reduction or therapy termination. Pseudothrombocytopenia (PTCP) is an in vitro anticoagulant-induced agglutination of platelets by antiplatelet autoantibodies resulting in a falsely low reported platelet count. This occurs commonly, but not exclusively, in EDTA-anticoagulated blood. The target antigen is the platelet membrane glycoprotein (GP) IIb/IIIa complex. Antiplatelet autoantibodies react with hidden antigens on platelet GPIIb/IIIa which are exposed due to the Ca2+ chelating effect of EDTA. Furthermore, pre-supplementation of vacutainers with aminoglycosides (amikacin) can prevent EDTA-dependent PTCP. CASE REPORT: A 63 year old male patient with metastatic clear-cell RCC, undergoing sunitinib treatment, was admitted at the emergency department with nausea and fatigue. No bleeding symptoms were observed. Platelet counts in EDTA- and citrate-anticoagulated blood samples were 19x10e9/l and 8x10e9/l, respectively. Due to the apparent severe thrombocytopenia the patient was transfused with three units of platelets. One hour post-transfusion platelet counts were 43x109/l and 21x109/l in EDTA and citrate, respectively. A heparin blood sample revealed a platelet count of 88x109/l confirming PTCP. RESULTS: Laboratory investigation revealed that vitro platelet clumping was most abundant in citrate- (11x10e9/l) followed by EDTA- (15x10e9/l) and heparin (114x10e9/l) anticoagulated blood samples. This effect was partially reversible after placing blood samples at 37 °C. No clumping was observed in blood smears obtained directly from capillary blood samples, substantiating an in vitro phenomenon. Pre-supplementation with amikacin in citrate-, EDTA- and heparin vacutainers did not reduce in vitro platelet agglutination. Blood collection at 37 °C diminished, but did not eliminate, in vitro agglutination in all three anticoagulants. The indirect platelet immunofluorescence test (iPIFT) revealed strong platelet reactive IgM antibodies (IgG negative) whereas the monoclonal antibody specific immobilisation of platelet antigens (MAIPA, IgM and IgG conjugate) was negative for the GPIIb/IIIa, -Ib/IX and -V. An iPIFT with Glanzmann (GPIIb/IIIa negative) donor platelets also showed positive IgM antibody reactions, confirming the negative GPIIb/IIIa MAIPA. Sixteen days after discontinuing sunitinib, no PTCP and no platelet reactive antibodies could be detected.


Arjan Albersen1, Joyce Schilders2, Leendert Porcelijn3, Hanneke Zuetenhorst2, Tjin Njo1, Paul Hamberg2 1 Department of clinical chemistry and hematology, Sint Franciscus Gasthuis, Rotterdam 2 The Netherlands department of internal medicine, Sint Franciscus Gasthuis, Rotterdam, the Netherlands 3 Sanquin diagnostic services, amsterdam, the Netherlands.

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CONCLUSION: To our knowledge this is the first report of PTCP induced by sunitinib. Platelet counts showed falsely low levels in EDTA-, citrate- and heparin-anticoagulated blood samples with a clear time-relation with sunitinib treatment, strongly suggesting the mechanism to be sunitinib-dependent. The IgM antiplatelet autoantibodies responsible for in vitro agglutination are multianticoagulant- and temperature-dependent but amikacin independent. Remarkably, the IgM antibodies demonstrated specificity to platelet antigens other than GPIIb/IIIa, -Ib/IX and -V. Furthermore, if thrombocytopenia is encountered during sunitinib treatment, PTCP in EDTA- and in citrate-anticoagulated blood samples should be excluded before sunitinib dosing is reduced or interrupted.

Je krijgt meer dan je denkt! Vijflingzwangerschap na plaatsing van 2 embryo’s bij IVF.


Henke Vergers-Spooren en Marcel van Hooff, Gynaecologie en Verloskunde.

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CASUS BESCHRIJVING: Een 29-jarige vrouw en haar 35-jarige echtgenoot bezochten ons spreekuur vanwege primaire subfertiliteit. Behoudens een milde ovulatiestoornis op basis van het polycysteus ovarium syndroom (PCOS) waren er geen afwijkingen en werd de subfertiliteit als ‘onbegrepen’ geclassificeerd. Na zes intra-uteriene inseminaties was patiënte niet zwanger en werd overgegaan tot IVF. Ovariële hyperstimulatie vond plaats met recombinant FSH. Bij de follikelaspiratie werden uit ongeveer 12 follikels van > 15 mm slechts vijf oöcyten verkregen. Hiervan werden er twee bevrucht. Beide embryo’s werden na drie dagen in de uterus geplaatst. Negentien dagen na de embryotransfer had patiënte een positieve zwangerschapstest. Bij een gecorrigeerde amenorroeduur van 8 weken werd bij transvaginale echoscopie een vijfling graviditeit vastgesteld (één monoamniotische, monochoriale tweeling en drie multiamniotische, multichoriale meerlingen). Bij een zwangerschapsduur van 10 weken is de zwangerschap middels selectieve embryoreductie gereduceerd tot een diamniotische, dichoriale tweeling zwangerschap. De zwangerschap verliep tot een amenorroeduur van 35 weken ongecompliceerd. Bij 35 weken ontstond er pre-eclampsie en werd patiënte opgenomen. Bij 36 weken braken de vliezen en is besloten tot een sectio caesarea. Er werd een gezonde zoon van 2792 gram en een gezonde dochter van 2572 gram geboren. VRAAGSTELLING: Wat is de kans op spontane conceptie tijdens een IVF behandeling? Is de kans op een meerlingzwangerschap voldoende reden om coïtus tijdens een IVF behandeling te ontraden? METHODE: Systematisch literatuuronderzoek. RESULTATEN: - Vergelijkbare case-reports: In pubmed vonden we 4 reports vergelijkbaar met de door ons beschreven casus. Verondersteld wordt dat de “extra” zwangerschappen ontstaan door spontane conceptie naast de door IVF ontstane zwangerschappen. Theoretisch kunnen de “extra” zwangerschappen ook ontstaan door splitsing van de geplaatste embryo’s. Indien het een monochoriale zwangerschap betreft kan dit middels echoscopie worden herkend. - Meerlingzwangerschappen na terugplaatsing van één embryo: In een systematic review (McLernon et al. BMJ, 2011) worden drie meerling-zwangerschappen beschreven na 181 plaatsingen van 1 embryo bij IVF (1.7%). Eén van deze zwangerschappen betreft een monoamniotische, monochoriale meerling en is vrijwel zeker van het geplaatste embryo afkomstig. Van de andere twee zwangerschappen is de chorioniciteit niet beschreven. - Tijdens IVF behandelingen verhoogt coïtus tijdens de dagen rondom de embryoplaatsing de kans op zwangerschap.


- Kans op spontane zwangerschap na staken IVF: De kans op een spontane zwangerschap na het staken van IVF behandelingen is ongeveer 15%. CONCLUSIE: Sporadisch is aangetoond dat, naast zwangerschappen ontstaan door IVF, in dezelfde cyclus “spontane” concepties optreden. Ook is aangetoond dat na het staken van IVF behandelingen 15% van de paren alsnog zwanger wordt. Deze bevindingen maken het waarschijnlijk dat een onbekend (beperkt) deel van de zwangerschappen toegeschreven aan IVF spontane concepties betreft. In tegenstelling tot eerdere auteurs van case reports is het sporadisch optreden van high–order meerlingen ons inziens geen reden tot het ontraden van coïtus tijdens de IVF behandeling. Een uitzondering betreft paren waarvoor embryo reductie een niet bespreekbare optie is.

Reducing anastomotic leakage in rectal cancer surgery by laparoscopic or trans-anal supportive suturing. A pilot study.

Ralph P.M. Gadiot, M.D. 1, Konstantinos A. Vakalopoulos 2, Johan F. Lange, M.D., Ph.D.2, Guido H.H. Mannaerts M.D., Ph.D.1 1 Dept. of Surgery, Sint Franciscus Gasthuis. Rotterdam, The Netherlands 2 Dept. of Surgery, Erasmus University Medical Center. Rotterdam, The Netherlands.


AIM: The occurrence of anastomotic leakage remains a major concern in rectal surgery. It is associated with high morbidity, often requires reoperation(s) and represents the most important cause of treatment induced mortality. It was hypothesized that the use of anti-traction sutures to support the circular stapled anastomosis may reduce anastomotic leakage. METHOD: In a prospective cohort of patients the technique of supportive suturing was investigated. In 71 patients low anterior resection for rectal cancer was performed. After excluding patients receiving diverting stoma or inadequate suturing 39 patients received either laparoscopic or transanal supportive suturing. RESULTS: Diverting stoma was performed in 17 out of 71 patients (24%). After exclusion of diverting stoma and partial suturing, 2 of the remaining 49 patients (4%) were diagnosed with anastomotic leakage. Presacral abscess was found in 2 patients (4%). CONCLUSION: In this study a low occurrence rate (4%) of anastomotic leakage was noticed when our technique was used in laparoscopic low anterior resections without diverting stoma. Considering these promising findings it is important to further investigate the effect of these methods in a prospective randomized study.

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ABSTRACTS POSSTERS WETENSCHAPSDAG SFG 2012

ABSTRACTS POSTERS WETENSCHAPSDAG SFG 2012


Langerhanscelhistiocytose.

E. Hajdarbegovic1, V. Noordhoek van Hegt2, M.C.G. van Praag1. Afdeling dermatologie1 en klinische pathologie PATHAN2. Abstract Een 57-jarige man werd naar onze polikliniek verwezen in verband met jeukende, niet genezende wondjes van de hoofdhuid die sinds enkele maanden bestonden. Zijn algemene voorgeschiedenis vermeldt een transient ischaemic attack waarvoor patiënt aspirine gebruikt. Zijn dermatologische voorgeschiedenis is blanco. Bij dermatologisch onderzoek zien we op het behaarde hoofd, verspreid in het gelaat en naast de oren een tiental papels met centrale hemorrhagische korst en ulceratie. Differentiaaldiagnostisch werd gedacht aan lymfomatoide papulosis, pityriasis lichenoides et varioliformis acuta, prurigo nodularis en vasculitis. Bij histopathologisch onderzoek kon de diagnose “langerhanscelhistiocytose” worden gesteld wegens de aanwezigheid van CD1a en S100 positieve cellen in een zeer dicht dermaal gelegen infiltraat Aanvullend onderzoek middels bloedonderzoek, bronchoalveolaire lavage en CT-thorax liet geen aanwijzingen zien voor extracutane localisaties. Concluderend was er sprake van cutane langerhanscelhistiocytose waarvoor topicale therapie met corticosteroiden werd ingesteld. In onze poster presenteren we deze casus, betreffende een gedissemineerde cutane langerhanscelhistiocytose. Hierin wordt dieper ingegaan op de herkomst, morfologie en fysiologie van de langerhanscel. Na de kennismaking met deze cel worden de verschillende facetten van de langerhanscelhistiocytose behandeld: epidemiologie, etiologie, pathogenese, symptomatologie, classificatiesystemen en behandeling.

Small bowel angioedema due to acquired C1 inhibitor deficiency.

Abstract Abdominal angioedema may present acutely with severe abdominal pain, or as a chronic recurrent abdominal pain of moderate intensity. Abdominal involvement in angioedema can be very challenging to diagnose. Angioedema is most frequently a consequence of allergic etiologies. Non-allergic causes of angioedema are rarer and examples of this are medicationinduced angioedema and angioedema caused by C1 inhibitor deficiency. Here, we report a case of small bowel angioedema secondary to acquired C1 inhibitor deficiency due to monoclonal gammopathy. Acquired C1 inhibitor deficiency is a rare cause of angioedema and is, amongst others, related to abnormal B-cell proliferation, i.e. monoclonal gammopathy, and autoantibodies. Plasma C3, C4, C1q and C1 inhibitor levels and activity are used for diagnosis. C1 inhibitor activity can be normal in a symptom free period and thus can be misleading and delay diagnosis of angioedema. In case of high suspicion and a normal C1 inhibitor activity, it is recommended to repeat the test. When frequent or severe attacks occur prophylactic treatment with antifibrinolytic agents or androgens is necessary.


Tanja Oostergo1, Gerrie Prins1, Yvonne Schrama1, Ivonne Leeuwenburgh2. Department of Internal Medicine1 and Gastro-enterology and Hepatology2.

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SSSS: Loslatende huid! S.T.J Chan, M.C.G van Praag Afdeling dermatologie

Een 5 jarige jongen werd naar ons doorverwezen in verband met sinds vijf dagen bestaande rode huiduitslag over het gehele lichaam. Het zou aan de handen en de voeten zijn begonnen, waarna het zich verder heeft uitgebreid naar de oksels, romp en gelaat. Er is sprake van een rode jeukende, maar bij aanraking een pijnlijke huiduitslag. Desloratidine, Hydrocortison zalf FNA en Vaseline Lanette crème zouden geen effect hebben gehad. Er zou eenmalig sprake zijn geweest van koorts (38,7), maar geen algehele malaise. Wel was hij af en toe wat hangerig. De algemene voorgeschiedenis is blanco. DERMATOLOGISCH ONDERZOEK: In het gelaat, op de romp en extremiteiten diffuus erythemateuze maculae en bullae. Perioraal tekenen van secundaire impetiginisatie. Geen afwijkingen op de wangslijmvliezen. Met name in de hals loslating van de huid. Overig lichamelijk onderzoek Matig zieke indruk. Hart: S1, S2, geen souffles. Longen: vesiculair ademgeruis, geen bijgeluiden. Ademhalingsfrequentie: 12 per minuut. Temp. 36,8 ºC. AANVULLEND ONDERZOEK: Klinische Chemie (kchl): CRP 19 mg/l, Hemoglobine 8.1 mmol/l, Leucocyten 12.8 10^9/l. Bacteriële kweek van de mondhoek laat zeer veel Staphylococcus aureus zien. DIAGNOSE: Op basis van het klinisch beeld en de positieve bacteriële kweek werd de diagnose staphylococcal scalded skin syndrome gesteld (SSSS) Staphylococcal scalded skin syndrome (SSSS) is een syndroom dat ontstaat als bacteriën van de stafylococcen aureus stam toxinen produceren die blaarvorming van de huid veroorzaken en blaarvorming plaatsvindt op huid zonder tekenen van infectie. De exfoliatieve toxines A en B, die daarbij vrijkomen, breken desmogleine 1 af in de desmosomen van de epidermis waardoor deze loslaat.

Case Report: An Inappropriate AED-shock?


C. Pieters (AIOS cardiologie); R. van Mechelen (cardioloog)

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BACKGROUND: The use of automated external defibrillators (AED) improves the survival of adults who suffer from cardiopulmonary arrest. The device can be operated in a simple way by nonprofessional rescuers and public AED access is currently standard in many countries, in order to reduce time to defibrillation. Automated external defibrillators detect ventricular fibrillation (VF) with almost perfect sensitivity and specificity; it will only deliver a shock when VF is present. We present a case in which an inappropriate shock was delivered in a conscious patient. CASE: A 62-year old man was working outside when he experienced sudden chest pain. Feeling unwell, he layed himself down on the ground. A co-worker applied the AED-patches, worried about a “heart attack”. At this time the patient was shivering, but conscious and alert. The AED administered a shock. Readings from the device showed a regular rhythm (120bpm) followed by progressive interference, mimicking VF, which provoked a shock. CONCLUSION: Although the shock was technically “appropriate”, it was administered to a patient with intact circulation, who did not suffer from cardiac arrest. Because the device-response cannot be altered in cases like this, it is important to instruct the operator only to apply the AED in an unresponsive patient whom is not breathing normally.


Thrombotic microangiopathy following administration of docetaxel and zolendronic acid in a patient with castrate refractory prostate cancer (CRPC).

BACKGROUND: Thrombotic microangiopathy (TMA) is a rare but severe condition, characterised by microangiopathic haemolytic anemia and thrombocytopenia with or without renal and neurologic abnormalities. CASE REPORT: In a 66-year old patient with CRPC treatment with docetaxel and zoledronic acid was initiated. Prior to treatment there was mild anemia and no signs of hemolysis. Two days after administration of docetaxel and zoledronic acid, he was admitted because of severe fatigue, and a slightly altered mental state. Blood count showed normocytic anemia (hemoglobin, 5.7 mmol/l), thrombocytopenia (platelets, 10x10^9/l) and red cell fragmentation (schistocytes) whilst leukocyte-count was normal. Further evaluation showed a Coombs-negative hemolysis with haptoglobin 0.06 gr/l and renal failure (serum creatinine 471 umol/l). TMA triggered by docetaxel or zoledronic acid was considered. Dialysis and plasma infusion was initiated. No plasma exchange was done based on the assumption that TMA was triggered by treatment and literature is inconclusive with respect to plasma exchange for drug-induced TMA. After a few days, the patient refused further treatment and died ten days after admission. DISCUSSION: TMA is a rare complication in patients with advanced cancer as well chemotherapy-related. Previously a relation with Mitomycin C, Cisplatin and Gemcitabine has been described. A few cases have been reported on docetaxel (n=2) and zoledronic acid (n=3) with a suggestive relation to the occurrence of TMA. In case of multiple triggers, no discriminatory tests are available, although the close timerelation with the administration of docetaxel and zoledronic acid, makes disseminated cancer a less likely cause. Level of ADAMTS 13 activity became available after the patient passed away but was normal (72%). In drug related TMA, less pronounced reductions or normal levels have been noted what makes it not a good diagnostic tool although low levels can be informative. Testing of ADAMTS 13 should not be used to confirm the diagnosis. This is one of the first cases reporting the occurrence of TMA after administration of docetaxel and zoledronic acid. Oncologist and nephrologists should be aware of this untoward side effect.

Reductie van colorectale naadlekkages door steunhechtingen. Een experimenteel model. R.P.M. Gadiot1, K. Vakalopoulos2, G.H.H. Mannaerts1, J.F. Lange2 1 Afdeling Heelkunde, Sint Franciscus Gasthuis, Rotterdam 2 Afdeling experimentele Chirurgie, Erasmus Medisch Centrum, Rotterdam.

INLEIDING: Naadlekkage is een gevreesde complicatie na colorectale chirurgie. Als er dehiscentie van de anastomose optreedt zal er vocht en faecaal materiaal in de peritoneale ruimte kunnen komen wat kan leiden tot sepsis. De exacte pathofysiologie is onbekend. Een mogelijke oorzaak zou de verhoging van intraluminale druk door passerend faecaal


Manon J.M. van Oosten1, Yvonne C. Schrama1, Egbert R. Boevé2, Paul Hamberg1. 1 Department of Internal Medicine, Sint Franciscus Gasthuis, 2 Department of Urology Sint Franciscus Gasthuis.

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materiaal in combinatie met peristaltiek kunnen zijn. Om deze drukken op te vangen zouden er steunhechtingen rondom de naad geplaatst kunnen worden. Naar aanleiding van goede resultaten uit de kliniek is in een experimenteel model de effecten van de steunhechtingen uitgezocht. VRAAGSTELLING: Zorgen de steunhechtingen voor een verhoogde “lekdruk” (anastomotic burst pressure, ABP)? Methoden: Uit 25 Yorkshire varkens werd binnen 30 minuten na farmacologische anesthesie het rectosigmoid verwijderd. Bij 12 varkens werd een circulair gestapelde end-to-end anastomose gecreeerd (SG). Onder water werd middels een probe en een continu flow systeem lucht ingeblazen. De maximale druk bij het ontstaan van luchtbellen ter plaatse van de anastomose werd als ABP genoteerd. Hierna werden bij hetzelfde specimen steunhechtingen geplaatst en hetzelfde protocol werd herhaald. Ter controle is bij 10 specimen een handgelegde enkelrijige anastomose gemaakt (HG). Deze werden volgens hetzelfde protocol getest en ook overhecht. RESULTATEN: Na overhechten nam in beide groepen de ABP significant toe (p<0.001 in beide groepen). CONCLUSIE: Het plaatsen van steunhechtingen rondom de anastomose zorgt voor een significante toename in ABP en zou dus kunnen bijdragen aan een reductie van de naadlekkage incidentie. Een in vivo experiment zou meer inzicht kunnen bieden in de biomechanische en biologische effecten van de hechtingen op de anastomose.

Een zeldzaam paraneoplastisch syndroom. Myelopathie bij coloncarcinoom met anti-amphiphysine antistoffen.


D.E. de Waard, L.S. van Velzen, G.J. de Jong, Y.A.M. Grimbergen Neurologie, Sint Franciscus Gasthuis

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INTRODUCTIE: Paraneoplastische neurologische syndromen hebben een gevarieerde presentatie en worden geassocieerd met verschillende goed beschreven ziektebeelden en daarbij beschreven antistoffen. CASUS: Wij presenteren een casus van een 70-jarige vrouw met een subacute paraparese van de benen. Deze werd veroorzaakt door een myelopathie secundair aan een coloncarcinoom met in het serum aanwezige anti-amphiphysine antistoffen. Patiënte verbeterde significant na het verwijderen van de tumor en toediening van corticosteroïden. BESCHOUWING: Bekende paraneoplastische syndromen geassocieerd met anti-amphiphysine antistoffen zijn stiff-person syndroom, encephalomyelitis en sensore neuropathie. Anti-amphiphysine antistoffen worden vaak aangetoond in relatie tot niet kleincellig longcarcinoom en mammacarcinoom. CONCLUSIE: Anti amphiphysine antistoffen zijn eerder in de literatuur niet in relatie gebracht met coloncarcinoom.

Case-report: A baclofen-overdosed patient with normal renal function; treatment by hemodialysis. S.L.M. Bontemps (SEH-geneeskunde), M. Burger (interne geneeskunde), C. Geerlings (apotheker), P. de Feiter (intensive care)

INTRODUCTION: Baclofen is a β-(ρ-chlorophenyl) derivative of the neurotransmitter γ-aminobutyric acid [1]. Our patient used baclofen in order to cope with her craving for alcohol. Specifically, baclofen has shown to reduce alcohol withdrawal symptoms, as well as

to reduce alcohol craving and intake, and to promote alcohol abstinence [2]. Because baclofen is eliminated predominantly by the kidney, baclofen-related encephalopathy is usually found in patients with end-stage renal diseases or acute renal failure [3,4]. Therefore, hemodialysis has been suggested for those patients to alleviate symptoms and shorten recovery time. Recently, a case was reported to reveal that hemodialysis is beneficial to the baclofen-overdosed patient with normal renal function [5]. Here we present a case of baclofen intoxication with normal renal function with much higher serum concentrations of baclofen. CASE: A 42 year old woman with a history of nicotineabuse, multiple suicide attempts and alcoholabuse, presented at the emergency room after ingesting 120 tablets (25 mg) of baclofen together with 10 cans of beer (500 ml). She did not receive gastric lavage and activated charcoal administration. The patient was intubated because of deep coma (Glasgow Coma Scale score: 3) and respiratory depression. Her blood pressure was 119/57 mm Hg; heart rate: 62 beats per minute and body temperature: 35.8°C. Neurologic examination at admission revealed no localizing signs. Whitin an hour we observed myoclonus and seizures. The EKG was normal at first; later she developed a bradycardia. The laboratory data showed normal liver function. The lactate levels were within normal limits. The alchol-promillage was 65 mmol/l. The patient received emergent hemodialysis. After one session of hemodialysis, the serum baclofen concentration was still high and a second session was needed. Some side effects as hypotension, bradycardias and convulsions were present in our patient. Her consciousness returned after the completion of the second hemodialysis treatment. Blood samples for serum baclofen measurement were collected immediately after arrival and at 5 (end of first hemodialysis), 6 (end of second hemodialysis), 12 and 36 hours. The therapeutic range of baclofen is 80-400 ng/ml in normal subjects [6]. Serum baclofen concentration at arrival was 13.3 mg/L (13.300 ng/ml). The serum concentration of baclofen was decreased by 19.5% after the first hemodialyse and 70.7% after the second. Symptoms like convulsions, myoclonus and bradycardias were gone after the dialysis sessions. The patient was extubated not until day 4 and was discharged soon after. CONCLUSION: In conclusion: patients with baclofen overdose could show a prolonged elimination time even with normal renal function. Thus: hemodialysis would be beneficial to those patients with normal renal function.

Franciscus Rheumatoid Arthritis aNd Cardiovascular Intervention Study – opzet en rationale.

D.F. van Breukelen-van der Stoep1, C. van Casteren-Messidoro1, B. Klop2, N. Verwer, A.M. Huisman1, G.J.M van de Geijn3, T.L Njo3, J.W.Janssen3, E. Birnie4, R.Bakker3, M. Castro Cabezas2, D. Van Zeben1 1 Afdeling reumatologie 2 Afdeling interne geneeskunde 3 Afdeling Klinische Chemie 4 Leerhuis van het Sint Franciscus Gasthuis Rotterdam.

INLEIDING: Het is bekend dat het ontstaan van atherosclerose een inflammatoir proces is. Op basis hiervan wordt verondersteld dat chronisch inflammatoire ziektes zoals reumatoïde



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artritis (RA) hun weerslag hebben op het cardiovasculaire risico. Recente studies laten niet alleen zien dat RA een verhoogd cardiovasculair risico met zich meebrengt maar ook dat dit gelijk is aan het verhoogde risico bij diabetes mellitus. Recent onderzoek is vooral gericht op het in kaart brengen van het cardiovasculair risico en de invloed van de verschillende DMARDS (disease modifying anti-rheumatic drugs) hierop. De aandacht verschuift inmiddels ook naar de rol van klassieke cardiovasculaire risicofactoren zoals hypertensie, diabetes mellitus (DM) en dyslipidemie bij RA patiënten De nieuwe richtlijn cardiovasculair management meldt ook dat patiënten met RA, net als patiënten met DM, gezien moeten worden als een hoogrisico groep. Ook de laatste richtlijn van de EULAR (European League Against Rheumatism) wijst op een hoog risico en de noodzaak om als reumatoloog een actieve houding aan te nemen t.o.v. cardiovasculaire risicofactoren. De FRANCIS studie is de eerste interventiestudie die naar behandeling van deze klassieke cardiovasculaire risicofactoren bij een RA-patientengroep gaat kijken. De studie is een nauw samenwerkingsverband tussen de afdelingen reumatologie, interne geneeskunde en klinische chemie van het Sint Franciscus Gasthuis. VRAAGSTELLING: Is een strikt interventieprogramma (tight control) voor cardiovasculaire risicofactoren effectief in het verminderen van intima media dikte (subklinische atherosclerose) t.o.v. het huidige standaard beleid (usual care) bij patiënten met reumatoïde artritis? METHODE: Een gerandomiseerde open label klinische trial met parallel daaraan een prospectief cohort. Patiënten met RA van 70 jaar of jonger en zonder cardiovasculair event en/of diabetes mellitus in de voorgeschiedenis die tussen 1 januari 2011 en 27 januari 2012 de polikliniek reumatologie bezochten werden geincludeerd (inclusie loopt nog). Geincludeerde patiënten met een cardiovasculair risico volgens de score tabel >10% ontvangen tight control en worden prospectief gevolgd. Geincludeerde patiënten met een cardiovasculair risico volgens de score tabel <10% worden 1:1 gerandomiseerd voor tight control of usual care. Tight control is een geprotocolleerde behandeling ,met strikte streefwaarden voor bloeddruk, cholesterol, glucose en een actieve houding t.o.v. overgewicht en roken, op het diabetes en vasculaire centrum. Usual care betekent terugverwijzing naar de huisarts voor behandeling, waarbij patiënten wel 2 keer per jaar gecontroleerd worden in het diabetes en vasculair centrum. Van alle patiënten worden klinische en biometrische gegevens, laboratoriumwaarden, RA ziekteactiviteitsscores en intima media diktes gecontroleerd gedurende 5 jaar. In totaal zullen 316 patiënten gerandomiseerd worden. RESULTATEN: Momenteel zijn 242 patiënten gerandomiseerd en 7 patiënten geïncludeerd in het hoog risico cohort. In april zullen de eerste resultaten gepresenteerd worden. CONCLUSIE: Patiënten met RA hebben een hoger cardiovasculair risico dan patiënten zonder RA. De FRANCIS studie is de eerste interventiestudie die kijkt naar verschil in progressie van subklinische atherosclerose bij verschillende behandelstrategieën.

Antibody interference in thyroid immunoassays is platform dependent.

A. Albersen1,2,*, I. Revet1,2,*, H. Van Toor3, Y.B. De Rijke3, L.S.M Boesten2, J.W. Janssen1 1 Department of Clinical Chemistry and Hematology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands. 2 Department of Clinical Chemistry and Hematology, IJsselland ziekenhuis, Capelle aan de IJssel, The Netherlands. 3 Department of Clinical Chemistry, Erasmus MC, Rotterdam, The Netherlands. * These authors contributed equally to this study.


INTRODUCTION: In most patients euthyroidism, thyrotoxicosis or hypothyroidism is confirmed with the combination of free T4 (FT4) and thyroxin stimulating hormone (TSH) measurements. Discrepancies between thyroid function tests and the patient’s clinical status should question immunoassay validity. Merely relying on the thyroid function tests may lead to inappropriate treatment. In this study we evaluate several interfering antibodies on four different thyroid hormone immunoassays and the gold standard equilibrium dialysis in order to investigate possible methods to overcome these. MATERIAL AND METHODS: We performed FT4 measurements on four different analyzers (Cobas Modular; Roche, Immulite 2500; Siemens, DXi; Beckman Coulter, Vitros Eci; Ortho Clinical Diagnostics) and compared these to the gold standard equilibrium dialysis. Two patients with aberrant free T4 (FT4) results, two patients with human anti-mouse antibodies (HAMA) and rheumatoid factor (RF), respectively and two external quality samples were included in this study. All samples were measured before and after treatment with heterophilic blocking tubes (Scantibodies Laboratory) or protein A/G agarose beads (Thermo Scientific). RESULTS: Surprisingly the HAMA (2464 ng/ml) and RF (440 IU/ml) positive samples showed no interference on four different FT4 immunoassays and the dialysis method. Aberrant FT4 patient results were only encountered in the Immulite immunoassay whereby the results were falsely elevated. This interference was eliminated after treatment with protein A/G agarose beads but not after heterophilic blocking tube treatment. Furthermore, no thyroid hormone auto-antibodies (THAA) were detected using gel electrophoresis. Remarkably both samples were positive for anti-thyreoglobuline (anti-TG). Heterophilic blocking tube and protein A/G treatment had no significant effect on FT4 results in the external quality samples. CONCLUSION: Anti-TG is a possible cause of interference in the Immulite immunoassay giving falsely elevated results. Treatment with protein A/G, but not heterophilic blocking tube treatment, removed the antibody interference. HAMA, RF and anti-TG exhibit no interference on the Modular, DXi, Vitros analysers or the dialysis method. Furthermore, treatment with protein A/G or heterophilic blocking tube gave reproducible FT4 results.

Gert-Jan van de Geijn, Maarten van Dijk, Rita Meijer, Yolanda Blaauw, Rene Bakker, Hans Janssen, Marlène Beunis, Tjin Njo Department of Clinical Chemistry (KCHL), Sint Franciscus Gasthuis, Rotterdam.

INTRODUCTION: Leukocyte differential counting is a frequently performed diagnostic test. When the automated leukocyte differential generated by a hematology analyser does not meet specific criteria, a microscopic differential is performed. Disadvantages of microscopy are the limited number of counted cells and significant statistical and inter-observer variation. Several laboratories published flow cytometric protocols to perform single-tube leukocyte differentials. Advantages over microscopy are the increased number of counted cells (several ten-thousands) and objective immunological definitions of an increased number of leukocyte populations. Comparison of different flow cytometric protocols on a single data set has not been reported yet. GOAL: The aim of this study was to compare 2 different flow cytometric leukocyte differentiations: Leukoflow (developed by us) and CytodiffTM (Beckman Coulter) with the results from the hematology analyzer and microscopy.


Leukocyte differentiation by flow cytometry: comparison of two protocols, Leukoflow and CytodiffTM, with microscopy and hematology analyzer.

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METHOD: For 217 EDTA blood samples we compared leukocyte differentiation by a hematology analyzer (LH750; Beckman Coulter) and flow cytometry using both Leukoflow (10 antibodies) and Cytodiff™ (6 antibodies) protocols on a 5-color flow cytometer (FC500, Beckman Coulter). For 110 samples a 2x200 cell microscopic count was performed by 2 technicians. RESULTS: When comparing the results from both flow cytometric protocols with the hematology analyser and microscopy we see good correlations between the four techniques for the neutrophils (0.85-0.98), lymphocytes (0.90-0.98) and eosinophils (0.96-0.99). For monocytes the correlations are slightly lower (0.81-0.98). The correlations for basophils range from very poor (r=0.11, hematology analyser versus Leukoflow) to good (r=0.90, microscopy versus CytodiffTM). For immature granulocytes (counted by microscopy), the correlation with CytodiffTM and Leukoflow is 0.66 and 0.73 respectively. Microscopical blast counts correlate well with CytodiffTM and Leukoflow results (r=0.99 and 0.86 respectively). Plasma cell counts by microscopy correlated well with Leukoflow results (r=0.98). The automated gating software provided with the CytodiffTM protocol gave correct gating results for ~75% of the samples. CONCLUSION: Leukocyte differentiation by flow cytometry can be an alternative to screen samples flagged for microscopical review. In the Leukoflow protocol all non-classified cells are counted as basophils, resulting in poor correlations for the Leukoflow basophils counts. In routine practice this can be circumvented by comparing the basophil count by Leukoflow with that of the hematology analyzer. Discrepancies should be investigated because aberrant cell populations are present. This was corroborated by several abnormal samples in our dataset. Advantages of Leukoflow are its ability to identify plasma cells and to obtain a CD34-based blast count. For use in a routine diagnostic setting, automatic gating software, as provided with CytodiffTM, is an advantage, however an additional system to flag aberrant results is required.

Differentiatie tussen bacteriële en niet-bacteriële infecties bij COPD patiënten met exacerbatie op de SEH.


S. Denker1, G.J.M. van de Geijn2, J.G.M. Koeleman3, E. Birnie4, V.H. van Waning1, G.J. Braunstahl1 en T.L. Njo2 Longziekten1, Klinisch Chemisch Hematologisch Laboratorium2, Medische Microbiologie en Infectieziekten3, Leerhuis4, Sint Franciscus Gasthuis, Rotterdam

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INLEIDING: Bij chronisch obstructieve longziekten (COPD) komen frequent benauwdheidsaanvallen (exacerbaties) voor, waarvan ongeveer 30% met een bacteriële oorzaak. De overige 70% wordt veroorzaakt door een virale infectie of andere oorzaak. Voor het correct starten met antibiotica is het belangrijk bacteriële en niet-bacteriële exacerbaties goed te onderscheiden. Hiervoor worden het sputum-aspect, absolute leukocytengetal, CRP en thoraxfoto’s gebruikt. Ongeveer 60% van de exacerbaties krijgt antibiotica. Er is dus sprake van overbehandeling, met als risico resistentieontwikkeling. VRAAGSTELLING: Wij testen of bacteriële en niet-bacteriële COPD exacerbaties beter onderscheiden kunnen worden met extra diagnostische bloedtesten, deels gebaseerd op flow cytometrie. Hierdoor zou het onnodig gebruik van antibiotica voorkomen kunnen worden. METHODEN: Bij COPD patiënten die zich op de SEH presenteerden met een exacerbatie COPD (patiëntengroep) en COPD patiënten die ter controle op de longpoli kwamen (controlegroep), werden naast de gebruikelijke diagnostiek ook extra laboratorium


bepalingen gedaan: automatische leukocyten differentiatie (hematologie analyzer), immunologische flow cytometrische leukocyten differentiatie (Leukoflow en CytodiffTM), flow cytometrische Leuko64 sepsis detectie kit (IQP/Trillium Diagnostics) en procalcitonine (Thermo Fisher/Brahms). Inclusie criteria: COPD GOLD klasse 1-4, geen recent antibiotica of prednison gebruik, geen systemische ziekte of maligniteit. Op basis van klinisch beloop en de uitkomst van de sputumkweek is de patiëntengroep retrospectief ingedeeld in bacteriële en niet-bacteriële exacerbaties. Met ROC-curves is gekeken welke test deze groepen het beste kan onderscheiden op basis van de “area under the curve” (AUC). RESULTATEN: De inclusie van patiënten loopt nog. Tot nu toe zijn patiënten met bacteriële (n=7), en met niet-bacteriële COPD exacerbaties (n=10) en COPD patiënten zonder exacerbatie (n=18) geïncludeerd. Tussentijdse analyse wijst uit dat de parameters die de bacteriële exacerbaties het beste kunnen onderscheiden zijn: 1) eosinofiele granulocyten (hematologie analyzer en flow cytometrie), AUC: 0.792, sensitiviteit 83%, specificiteit 75%. 2) CD4-positieve T-cellen (flow cytometrie: Leukoflow), AUC: 0.778, sensitiviteit 86%, specificiteit 57%. Het onderscheidend vermogen van deze parameters is vergelijkbaar met CRP (AUC 0.778, sensitiviteit 71%, specificiteit 78%) en groter dan het absolute leukocyten getal (AUC 0.543, sensitiviteit 86%, specificiteit 30%), procalcitonine (AUC 0.543, sensitiviteit 57%, specificiteit 50%), en de Leuko64 sepsis detectie kit (AUC 0.733, sensitiviteit 83%, specificiteit 40%). CONCLUSIE: Voor het onderscheiden van bacteriële versus niet-bacteriële exacerbaties COPD is de absolute leukocyten concentratie slecht bruikbaar. Veelbelovend zijn de CD4-positieve T-cellen, bepaald met Leukoflow. Het absolute aantal eosinofielen lijkt een goed onderscheidende parameter, die eenvoudig bepaald kan worden met bestaande technieken (hematologie analyzer).

L.E. Schönau1, H.M. Pennewaard1, R.W.Nette2, A.C.van Kooij3, M.M.A. van den Dorpel3, P.J.H.Smak Gregoor4, W.C.Zuidema5, R.Zietse5, J.J. Busschbach6. W.Weimar5, E.K.Massey5 1 Medisch Maatschappelijk Werk, Sint Franciscus Gasthuis Rotterdam 2 Afdeling Interne geneeskunde, Sint Franciscus Gasthuis Rotterdam 3 Afdeling Interne geneeskunde, Maasstadziekenhuis Rotterdam 4 Afdeling Interne geneeskunde Albert Schweitzerziekenhuis, Dordrecht 5 Afdeling Interne Geneeskunde, Niertransplantatie, Erasmus MC, Rotterdam 6 Afdeling Medische Psychologie en Psychotherapie, Eramus MC, Rotterdam. INLEIDING: Een nierdonatie bij leven, welke plaatsvindt voordat dialyse noodzakelijk is, geeft voor de patiënt een betere levensprognose. Op dit moment vindt de helft van levende nierdonaties pas plaats, wanneer gestart is met dialyse. In samenwerking met het Erasmus MC, Albert Schweitzer Ziekenhuis en het Maasstadziekenhuis is er ook in het Sint Franciscus Gasthuis een voorlichtingproject ontwikkeld waarin in de thuissituatie vroegtijdige voorlichting word gegeven door de medisch maatschappelijk werker over vormen van niervervangende therapie en levende donatie. Het project wordt door de Nierstichting gefinancierd. VRAAGSTELLING: Wij willen de kennis toetsen rondom nierfunctievervangendetherapie en levende nierdonatie in het bijzonder bij de patiënt in de pre-dialyse fase en zijn sociale netwerk. Verder willen we het voorlichtingsproject, zoals dat ontwikkeld is, evalueren. METHODE: Na het bezoek bij de nefroloog, worden patiënten met een MDRD van ≤ 25 ml/



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min, waarbij te verwachten is dat een nierfunctievervangende therapie binnen 1 á 2 jaar noodzakelijk is, uitgenodigd om deel te nemen aan het voorlichtingsproject. Patiënten en hun sociale netwerk worden door de medisch maatschappelijk werker voorgelicht over vormen van nierfunctievervangende therapie, levende donatie en de impact die dit heeft op de kwaliteit van leven van de patiënt. De voorlichting vindt plaats in de thuissituatie van de patiënt. Om het effect van de voorlichting op kennis en communicatie te toetsen, wordt er voor- en na de bijeenkomsten een enquête afgenomen. Kennis wordt gemeten op een schaal van 0-30. UITKOMSTEN: Van oktober 2011 t/m februari 2012 zijn 19 patiënten benaderd, waarvan 14 patiënten hebben deelgenomen aan de voorlichting. Het kennisniveau van de patiënten die de nefroloog hebben bezocht in het SFG ligt gemiddeld op 17.4 (SD=3.6). Dit geeft aan dat er behoefte is aan informatie in een eerder stadium. De voorlichting wordt door de patiënten als positief ervaren (Gemiddeld 1,25 ± 0,45 range 0-7). Zij zijn tevreden over de inhoud van de voorlichting en de bijdrage van de medisch maatschappelijk werker (Gemiddeld 1,25 ± 0,45 range 0-7). Ze vinden de voorlichting duidelijk (Gemiddeld 1,17 ± 0,39 range 0-7). Gemiddeld zijn er 5 genodigden bij de voorlichting aanwezig (range 2-11). De medisch maatschappelijk werker evalueert de bijeenkomsten als positief. Er werden veel vragen gesteld en er was veel interactie. Als nadeel werd ervaren dat de voorlichting minder gestructureerd werd als er veel mensen aanwezig waren.

Complement receptor type 1 is involved in the binding of LDL to erythrocytes: an anti-atherogenic mechanism.


Boudewijn Klop1, Pieter van der Pol2, Gert-Jan M. van de Geijn3, Yanan Wang4, Tjin L. Njo3, Hans W. Janssen3, Erwin Birnie5, Addy van Miltenburg6, J. Wouter Jukema7, Ton J. Rabelink2, C. van Kooten2, Manuel Castro Cabezas1 Dpts. of Internal Medicine1, Clinical Chemistry and Haematology3, Education and Statistics5 and Cardiology6, Sint Franciscus Gasthuis, Rotterdam, the Netherlands. Dpts. of Nephrology2, Endocrinology4 and Cardiology7, Leiden University Medical Center, Leiden, the Netherlands

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INTRODUCTION: Binding of apolipoprotein (apo) B containing lipoproteins to erythrocytes may be an atheroprotective mechanism. The binding mechanism remains speculative since erythrocytes do not have LDL-receptors. However, erythrocytes are known for their immune adherence and transport of C3b-opsonised ligands by the complement receptor type 1 (CR1). We investigated erythrocyte-bound apoB (ery-apoB) in relation to carotid intima media thickness (IMT) in a large population and carried out experiments to investigate the role of CR1 in binding apoB-containing lipoproteins using an in vitro model. METHODS: Ery-apoB was measured by flowcytometry using polyclonal anti-apoB antibodies. A carotid IMT of more than 0.70 mm was considered increased, reflecting (subclinical) atherosclerosis. Transfected Chinese hamster ovarian (CHO) cells, which expressed CR1 (CHO-CR1), and control CHO cells (CHO-R) were used for in vitro experiments to investigate isolated LDL binding to CR1. RESULTS: Subjects with increased carotid IMT (>0.70 mm) (N=145) had a lower ery-apoB (0.89 ± 0.83 a.u.) compared to those with normal IMT (N=254) (1.16 ± 0.92; N=254, P=0.007). Ery-apoB was inversely correlated with IMT (Spearman r: -0.116, P=0.021). CHO-CR1 significantly bound more apoB containing lipoproteins from serum compared to CHO-R (8.1±2.0 a.u. versus 5.2±1.1 a.u., P<0.001). Binding of isolated LDL was significantly higher to CHO-CR1 compared to CHO-R, but only when LDL was opsonised. Native LDL


bound similarly to both cell types, suggesting the presence of an alternative binding site, most likely the LDL receptor. Binding of LDL to CR1 could be diminished in a dose response by using heat inactivated serum, which disrupts the function of the complement system, instead of normal human serum. CONCLUSION: This study provides further proof of a protective effect of apoB containing lipoproteins bound to erythrocytes on atherosclerosis. The presence of apoB on erythrocytes can be explained by the capacity of CR1 to bind LDL after opsonisation by complement factors. Immune adherence of apoB-containing lipoproteins to erythrocytes may be operational in vivo.

Case report: a spinal epidural abscess. BACKGROUND: A spinal epidural abscess (SEA) is an uncommon condition with an incidence of 0.2 to 2 per 10.0000 hospital admissions per year. Classical symptoms of SEA are spinal pain, fever and neurological deficit. In most cases this triad is not present. Most common complaints are not specific; these include back pain, neck pain and radicular pain. Fever is not always present. For this reason, the diagnosis SEA can be easily overlooked. If not treated early in development, a SEA is a life threatening condition. Therapy of choice is early neurosurgical intervention together with long term antibiotics. In the majority of cases infection is caused by S. Aureus. Choice of antibiotic treatment should be adjusted accordingly. CASE DESCRIPTION: We present a 56-year-old woman who visited the emergency department because she had progressive back pain, radiating into the left leg which started six days before presentation. She also had loss of motor function of the upper leg. Fever was not present, nor were there any other signs of internal or neurologic deficit. Laboratory findings showed highly elevated C-reactive protein (>500 mg/l) and leukocytosis (>20 x 109/l). Imaging studies showed multiple abscesses. There was a spinal epidural abscess ranging from L2-L4, an abscess in the left psoas muscle and in the paravertebral muscles. There was also severe infiltration in both lungs. Puncture of the paravertebral muscle abscess showed infection with Staphylococcus Aureus. The patient was treated with parental flucloxacillin and oral rifampicin together with CT-guided needle aspiration of the psoas muscle abscess. The patient responded very well to this therapy and after two weeks the parenteral antibiotics were replaced by oral clindamycin. The total duration of treatment was seven weeks. CONCLUSION: A spinal epidural abscess is a potentially life threatening condition. Mortality rates are still substantial, because there is a delay in early recognition. Outcome depends mainly on the patient’s neurological status and the duration of symptoms. Therapy of choice is neurosurgical. We presented a patient who was successfully treated with CT guided needle aspiration combined with antimicrobial therapy, without neurosurgical intervention.

Een pasgeborene met congenitale anemie.

J. van der Weijde, J. van Oossanen, A.K.E. Hoffmann-Haringsma, M.H. Beunis. CASUS: Een jongen geboren bij een amenorroeduur van 39 2/7 week met een geboortegewicht van 3660gram, Apgarscore van 6 en 6 na respectievelijk 1 en 5 minuten met een anemie. Moeder was gravida 3 para 2 met een blanco voorgeschiedenis en een ongecompli-


R. Hanewinckel, T. den Heijer, afd. Neurologie.

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ceerde zwangerschap. Twee dagen voor de partus voelde zij minder leven en een dag voor de partus werd zij door een gynaecoloog gezien. Vanwege een weinig acceleratief CTG werd zij doorgeleid en beviel zij een dag later van een zoon. Er was sprake van een snelle bevalling en een matige start waarbij hij kortdurend is bijgeblazen met 100% FiO2. Er werd bloed afgenomen en er bleek sprake te zijn van een anemie (Hb 4.2, Ht 0.22). Hij kreeg hiervoor een erytrocytentransfusie. Vanwege een matige circulatie werd hij gevuld met NaCl 0.9%. Daarnaast krijg hij een bolus glucose bij een eerste glucose van 1.1 mmol/l. Er werden bij moeder o.a. TORCHES en parvo B19 ingezet, een Kleihauer test gedaan en antistoffen bepaald. Post transfusie steeg het Hb van het kind tot 7.5 mmol/l. Het LDH is op dag 1 (na 24 u) 5370 U/l en is 3 dagen na de geboorte nog 2483 u/l. Bilirubine steeg tot maximaal 228 µmol/l op dag 4. Het percentage reticulocyten was na 24u 5,7 % en na 48u 15,6 %. Op dag 6 is het jongetje ontslagen met een Hb van 6,9. Het Hb op dag 10 is 6,6 mmol/l. RESULTATEN: De Kleihauertest was positief (2% foetale cellen, wat overeenkomt met 100 ml foetaal bloed bij de moeder). Bij de moeder werden irregulaire antistoffen aangetoond anti Jk(a). De directe antiglobuline test bij kind en moeder waren negatief (Diamed). Omdat de DAT van moeder en kind negatief waren (Diamed), maar zwak positief met Immucor, werd van beiden een eluaat ingezet. In het eluaat zowel van moeder als van kind, werden Jk(a) antistoffen geëlueerd. De herhaling van de screening van de 12e week was negatief. De moeder was homozygoot Jk(b) positief , de vader was homozygoot Jk(a) positief. Het kind was heterozygoot Jk(a) Jk(b). CONCLUSIE: De Kleihauertest toont een sterk verhoogd aantal foetale erytrocyten van het kind bij de moeder aan. Het lage Hb en het hoog aantal reticulocyten bij de geboorte passen ook bij een langer bestaande foetomaternale transfusie. De foetomaternale transfusie heeft bij moeder een versnelde productie van anti Jk(a) antistoffen geïnduceerd, waardoor erytrocyten van het kind werden gehemolyseerd.

Een prematuur met huidafwijkingen.


J. Kok-van der Weijde, A.K.E. Hoffmann-Haringsma. Sint Franciscus Gasthuis, afdeling Kindergeneeskunde, Kleiweg 500, 3045 PM Rotterdam. Trefwoorden: Staphyloccocal scalded skin syndroom, Impetigo bullosa, exfoliatief toxine.

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INLEIDING: Staphylococcal scalded skin syndrome (SSSS) is een gegeneraliseerde ernstige huidinfectie. Het wordt veroorzaakt door een Staphylococcus Aureus stam die exfoliatieve toxines (ET) produceert (incidentie 5%). Ongeveer 30% van de neonaten is binnen een week na geboorte gekoloniseerd met S.Aureus en in ziekenhuizen verloopt kolonisatie meest waarschijnlijk via de verpleegkundige. Het begint vaak met symptomen als koorts, lethargie, prikkelbaarheid en voedingsproblemen. Daarna ontwikkelt zich een erythemateus huidbeeld meestal beginnend in het gelaat en de nek welke zich in enkele dagen over de rest van het lichaam uit kan breiden. Er worden dunne blaren gevormd die snel kapot gaan waardoor de epidermis van de onderhuid kan loslaten (positief Nikolsky sign). Vanwege het gegeneraliseerde huiddefect is er een verhoogd risico op dehydratie, een verhoogde vochtbehoefte, temperatuurschommelingen en bestaat er een risico op secundaire infectie. CASUS: Een meisje geboren bij een amenorrhoeduur van 31 3/7 week, eerste van een dichoriale-diamniotische gemelli graviditeit, lag op de afdeling neonatologie. Zij kreeg respiratoire ondersteuning door middel van CPAP. Op dag 23 werd voor het eerst een huidbeschadiging op de wang geconstateerd, nadat de CPAP was gestaakt. In eerste instantie werd gedacht aan huidbeschadiging door de CPAP kap die met pleisters op de wang was vast geplakt. Echter binnen een dag breidde de huidafwijking zich uit over het lichaam.


Bij lichamelijk onderzoek werd een pijnlijke, echter niet zieke neonaat gezien. De huid was grotendeels erythemateus, vertoonde uitgebreide nattende leasies met een gelige rand en in het gelaat daarbij enkele gele crustae. Er was sprake van een positief Nikolsky sign. Er werd gedacht aan een secundaire huidinfectie via de open plekken op de wangen of aan een SSSS. Er werd materiaal afgenomen voor kweken en gestart met Floxapen iv. Om de wonden te behandelen werd in eerste instantie Fucidine zalf en zinkolie gebruikt en later Omiderm®. In de kweken werd een S. Aureus geisoleerd welke exofoliatief toxine A en B produceerde. De diagnose SSSS werd bevestigd. Zij werd twee weken behandeld met antibiotica, kreeg extra vocht toediening en pijnbestrijding. Na start van de behandeling knapte het huidbeeld snel op. Twee dagen nadat bij dit meisje huidafwijkingen waren geconstateerd kreeg de moeder zelfde soort huidafwijkingen op haar armen en vervolgens een dag later werd bij haar tweelingbroer huidafwijking op zijn rechterwang gezien. Zij werden eveneens behandeld met antibiotica nadat kweken waren afgenomen. De kweken lieten tevens een S.Aureus zien die exofoliatief toxine A en B produceerde. CONCLUSIE: De prognose van SSSS is goed indien tijdig wordt behandeld met antibiotica. Daarbij een goede ondersteuning van de vitale functies en voorkomen van secundaire infecties is van belang. Snelle herkenning is essentieel. Tevens altijd de ouders en siblings vervolgen in verband met mogelijk dragerschap of kolonisatie.

Longfunctie is gerelateerd aan complicaties van bariatrische chirurgie.

ACHTERGROND: Morbide obese patiënten hebben een grotere kans op complicaties, met name bij buikchirurgie. DOELSTELLING: De relatie tussen longfunctie en complicaties van bariatrische chirurgie onderzoeken. METHODEN: Een retrospectieve studie van patiënten die bariatrische chirurgie ondergingen, waarbij complicaties tot 30 dagen na de operatie werden gescoord. Spirometrie werd pre-operatief verricht. Patiënten met en zonder complicaties werden met elkaar vergeleken. RESULTATEN: 485 patiënten werden geïncludeerd (304 gastric sleeve resecties, 181 gastric bypass operaties). Er vonden 52 complicaties (8 pulmonaal, 26 chirurgisch, 14 infectieus, 4 overig) plaats bij 50 patiënten (=10%). Er waren 35 heropnames (=7.2%), en 17 relaparoscopieen (=3.5%). Er was geen verschil in demografische parameters tussen patiënten met en zonder complicaties, in het bijzonder in gewicht, BMI, buikomtrek of vetpercentage, of in type ingreep (sleeve resectie/ gastric bypass). Patiënten met complicaties hadden een significant lagere FEV1 (gemiddeld 86.9 % voorspeld ± 13.5) en FVC (95.6 % voorspeld ± 13.0) dan patiënten zonder complicaties (respectievelijk 95.9 % voorspeld ± 14.3, p=0.005; 100.1 % voorspeld ± 14.9, p=0.045). Patiënten met complicaties hadden significant vaker FEV1≥12% (18.4%) of FEV1/FVC<70% (20%) dan patiënten zonder complicaties (respectievelijk 7.2 %, p=0.007; 8.1%, p=0.006). Er was geen verschil in comorbiditeiten zoals reflux of slaap apneu syndroom. Bij backward logistische regressie analyse bleven


Astrid van Huisstede1, Ulas Biter2, Erwin Birnie3, Guido Mannaerts2, Ronald Luitwieler4, Pieter Hiemstra5, Gert-Jan Braunstahl1 1 Afdeling Longziekten, Sint Franciscus Gasthuis 2 Afdeling Chirurgie, Sint Franciscus Gasthuis 3 Afdeling Leerhuis, Sint Franciscus Gasthuis 4 Afdeling Anesthesie, Sint Franciscus Gasthuis 5 Afdeling Longziekten, Leids Universitair Medisch Centrum

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FEV1≥12% (adj OR 2.2; 95%CI 0.944-5.322) en FEV1/FVC<70% (adj OR 2.3; 95%CI 1.012-5.290) over als voorspellende factoren. CONCLUSIE: Patiënten met een luchtwegobstructie of reversibiliteit hebben een verhoogde kans op complicaties na bariatrische chirurgie. DISCUSSIE: Prospectief gerandomiseerd onderzoek is nodig om te kunnen concluderen of pre-operatief longfunctie onderzoek bijdraagt aan vermindering van complicaties van bariatrisch onderzoek.

Effect van bariatrische chirurgie op astma: 3 maanden follow-up.


A. van Huisstede1, M. Castro Cabezas2, H. Zengerink3, R. Luitwieler4, C Taube5, P.S. Hiemstra5, G.J. Braunstahl1 1 Afdeling Longziekten, Sint Franciscus Gasthuis 2 Afdeling Interne Geneeskunde, Sint Franciscus Gasthuis 3 Afdeling Chirurgie, Sint Franciscus Gasthuis 4 Afdeling Anesthesie, Sint Franciscus Gasthuis 5 Afdeling Longziekten, Leids Universitair Medisch Centrum

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ACHTERGROND: Astma in obese patiënten wordt slecht begrepen, en het effect van gewichtsverlies op astma controle is niet goed beschreven. DOEL: De effecten van bariatrische chirurgie op astma controle, kwaliteit van leven en longfunctie onderzoeken. METHODEN: Een prospectieve studie van patiënten met bewezen diagnose astma (FEV1≥12% en/of PD20<1.76mg) en patiënten zonder astma die bariatrische chirurgie ondergingen (BMI >35kg/m2, leeftijd 18-50 jaar). Longfunctie, medicatie gebruik en kwaliteit van leven werden bekeken op baseline en 3 maanden na bariatrische chirurgie. Obese astma patiënten die geen bariatrische chirurgie ondergingen vormden een additionele controle groep. RESULTATEN: 35 patiënten met astma (O+A) en 50 patiënten zonder astma (O-A) ondergingen bariatrische chirurgie, 17 astma patiënten vormden de controle groep (NO+A). Er waren geen verschillen in astma controle vragenlijst (ACQ), astma kwaliteit van leven vragenlijst (AQLQ), FEV1 of FeNO tussen O+A en NO+A op baseline. BMI van NO+A (40 kg/m2) was significant lager vergeleken met O+A (47 kg/m2) en O-A (45 kg/m2) (p=0.005). Na bariatrische chirurgie daalde de BMI naar 38 kg/m2 in de O+A groep (p<0.001) en 36 kg/m2 in de O-A groep (p<0.001), waar de BMI stabiel bleef in de NO+A groep. Na bariatrische chirurgie daalde het percentage patiënten met bronchiale hyperreactiviteit (PD20<1.76mg) significant van 80% naar 34% in de O+A groep (p=0.003). Daarnaast daalde ook het gebruik van inhalatie corticosteroïden met 50%. FEV1 verbeterde alleen in de O+A groep (gemiddelde 85.6 naar 94.6 %voorspeld, p=0.011). Na bariatrische chirurgie verbeterde zowel de ACQ als AQLQ significant in de O+A groep (1.1 naar 0.5, p=0.022, respectievelijk 5.7 naar 6.3, p=0.004), terwijl er geen verschil zichtbaar was na 3 maanden in de NO+A groep. ACQ en AQLQ waren significant beter in de O+A groep vergeleken met NO+A na 3 maanden (ACQ p=0.027, AQLQ p=0.002). Er was geen verbetering in FeNO in een groep. CONCLUSIE: Bariatrische chirurgie verbetert longfunctie, astma controle en kwaliteit van leven in patiënten met astma en morbide obesitas al na 3 maanden. Wellicht dus dat gewichtsverlies een belangrijk onderdeel is van de behandeling van obese astma patiënten.


Case report: Hemolytic anemia caused by a kinked hemodialyis line. M. Burger1, A.P. Rietveld 1 en Y. Schrama1, 1 Interne Geneeskunde 2 Intensive care

Hemodialysis is a widespread form of therapy and it is used by patients with renal insufficiency caused by various conditions (e.g. nephrosclerosis, glomerulonephritis, and intoxications). Hemolysis during hemodialysis and its source must be quickly identified in order to avoid or treat life-threatening complications. Only a few cases have reported this relatively rare event. One critically ill patient is described to illustrate the effect of acute hemolysis during hemodialysis. Our patient was admitted to the intensive care unit due to an astma cardiale and received hemodialysis as part of the treatment course. However during hemodialysis the patient acutely developed a severe hemolysis.

Pituitary Tumour apoplexy in pregnancy.

S. R. Bachasingh, N.M. Janssen, R.M.F. van der Weiden Afdeling Obstetrie en Gynaecologie, Sint Franciscus Gasthuis, Rotterdam. After pregnancy was obtained in a patient with microprolactinoma, bromocriptine therapy was ceased. At 10 weeks’ gestation the patient presented with visual complaints and a prolactin concentration of 5660 µmol/l. Visual field examination and MRI suggested compression of the optic chiasm caused by a macroprolactinoma with pituitary tumor apoplexy. Management with bromocriptine, levothyroxine and hydrocortisone resulted in a decline in tumour size and a further uneventful pregnancy. This report indicates that even in pregnant patients with a major pituitary apoplexy and visual field defects, conservative medical treatment should be considered as the first choice of treatment

Beriberi na bariatrische chirugie

INLEIDING: Bariatrische chirugie is de enige effectieve oplossing voor morbide obesitas, helaas zijn deze operaties niet zonder complicaties. Patienten hebben een sterk verhoogd risico op vitaminetekorten welke vaak neurologische symptomen veroorzaken. Beschouwing: Bij een aanzienlijk deel van de patiënten wordt na gastric bypass en gastric sleeve operaties één of meerdere vitaminetekorten gevonden. [2,3] Risicofactoren voor deficiënties zijn langdurige ziekenhuis opname en postoperatief braken. De meest voorkomende deficiënties zijn ijzer, vitamine B12, vitamine D en calcium. Er wordt een breed spectrum aan neurologische verschijnselen gezien na bariatrische chirurgie. De presentatie varieert van binnen enkele weken na operatie encephalopathie en neuropathie terwijl jaren na de operatie myelopathie voorkomt. [4] Een tekort aan vitamine B1 kan leiden tot Wernicke encephalopathie, Korsakov syndroom en Beriberi. Wernicke encephalopathie wordt gekenmerkt door de trias van oogbolmotoriekstoornissen, ataxie en verwardheid en is een medisch noodgeval. Droge beriberi, zoals gezien bij de patiënt uit de casus, kenmerkt zich door onder andere een acute, vaak pijnlijke, polyneuropathie. Vitamine B1 depletie kan al na 18 dagen zonder inname ontstaan. Indien een patiënt veel braakt, zoals bij onze casus, is het dus van belang snel over te gaan op


Rianne Goselink1, Joris Harlaar2, Ulas Biter2, Frederique Vermeij1, Tom den Heijer1. 1 Afdeling Neurologie, Sint Franciscus Gasthuis, Rotterdam 2 Afdeling Heelkunde, Sint Franciscus Gasthuis, Rotterdam.

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intramusculaire toediening van vitamine B1. BEHANDELING: Vanwege de hoge incidentie van tekorten wordt standaard laboratoriumonderzoek geadviseerd. Preventie speelt een belangrijke rol waarbij een multidisciplinaire aanpak voor deze patiënten zeer belangrijk is. Wanneer een patiënt na bariatrische chirurgie zich presenteert met neurologische verschijnselen danwel andere gevolgen van vitamine deficiënties is het belangrijk om adequaat te suppleren, oraal, intramusculair of intraveneus. CONCLUSIE: Patiënten met in de voorgeschiedenis een bariatrische operatie hebben een ernstig verhoogd risico op deficiënties van vitamine (alle vitamines B, C, A, D, en K), mineralen (calcium) en spoorelementen (ijzer, selenium, zink en koper). Het is van belang om vitamine suppletie tijdig te starten om ernstige complicaties te voorkomen. In de volgende casus presenteren wij een patient met een vitamine B1 deficientie na bariatrische chirurgie. Patiënt beschrijving: Een 49 jarige man met in met in de voorgeschiedenis morbide obesitas (gewicht 129 kg, BMI 42 kg/m2) waarvoor gastric sleeve resectie 4 maanden voor presentatie, bezocht de spoedeisende hulp met aanhoudend braken, dubbelzien en verminderde kracht aan armen en benen. Bij neurologisch onderzoek was er sprake van desoriëntatie, een gestoorde oogbolmotoriek en een verminderde kracht voornamelijk van de bovenbenen. Er werd een sterk verlaagde vitamine B1 spiegel gevonden en op het EMG werd een polyneuropathie gezien. Er werd gestart met vitamine B1 suppletie. Hierop verbeterde de patient maar matig, ondanks een goede vitamine B 1 spiegel. Hij confabuleert, heeft geheugenproblemen (passend bij het syndroom van Korsakov) en de kracht verbetert langzaam, hij verblijft in het revalidatie centrum.

Uterine artery pseudoaneurysm: embolisation during pregnancy.


M.J.W. Samama 1, N.M. Janssen 1, J. Cornette 2, R.M.F. van der Weiden 1 1 Afdeling Obstetrie en Gynaecologie, Sint Franciscus Gasthuis, Rotterdam 2 Afdeling Obstetrie en Gynaecologie, Erasmus MC, Rotterdam.

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Uterine artery pseudoaneurysm is a rare but well described cause of massive and often delayed postpartum hemorrhage. Uterine artery pseudoaneurysm during pregnancy is extremely rare. In this case a pregnant woman presented with vaginal blood loss at a gestational age of 27 weeks. Transvaginal ultrasound disclosed a para-cervical mass with a diameter of 3 x 4 x 4 centimetres, suspicious for endometriosis. Using colour Doppler a classic Yin-Yang sign typical for a pseudoaneurysm was observed. Embolisation of the aneurysm and the proximal uterine artery was performed successfully. However, the patient returned with vaginal blood loss after 3 days. A second attempt for embolisation was performed, resulting in occlusion of the aneurysm and both the proximal (afferent) and distal (efferent) course of the uterine artery. Thereafter vaginal bleeding did not recur. At a gestational age of 37 weeks an elective caesarean section was performed, with a good maternal and fetal outcome. This is the first case reporting prolongation of a pregnancy following embolisation of a uterine artery pseudoaneurysm.

A rare case of hepatitis C negative mixed type (type 2) cryoglobulinemia.

J.E.M. Schilders1, A.J.B.W. Brouwers2, H.C.T. van Zaanen3. Sint Franciscus Gasthuis, department of Internal Medicine1, Intensive Care Unit2 and department of Hematology3, Kleiweg 500, 3045 PM Rotterdam, the Netherlands.


Diagnose in beeld: Een anefrische vrouw met ‘urine’-incontinentie. G. Prins en Dr. Y.C.Schrama, Interne Geneeskunde Afdeling nefrologie Sint Franciscus Gasthuis Rotterdam

CASUS: Een 55-jarige vrouw werd opgenomen vanaf de dialyse afdeling in verband met koorts en algehele malaise. Haar voorgeschiedenis vermeldt: chronische nierinsufficiëntie stadium V; dialyse afhankelijkheid bij postrenale problematiek bij congenitaal spina bifida; recidiverende pyelonefritiden bij neurogene blaasstoornissen. Ter voorbereiding op een niertransplantatie, werd in het verleden een bilaterale nefrectomie verricht. Patiënte had bij opname een CRP van 405 mg/ liter en een temperatuur van 38.0. Initieel leek het focus een septische arthritis van haar schouder. Onder therapie hiervoor daalde het CRP gestaag, maar patiënte knapte onvoldoende op.


INTRODUCTION: Cryoglobulinemia is defined as one or more immunoglobulins in the serum which precipitate at temperatures below 37C and dissolve again on rewarming. Criteria for the classification of cryoglobulinemia patients are based on serologic, pathologic and clinical findings. We present a patient with hepatitis C negative mixed type cryoglobulinemia. CASE REPORT: A 58-year old Caucasian man was admitted to the Intensive Care because of an arterial occlusion and was treated with urokinase and stenting. During admission he was successfully treated with clarythromycin because of pneumonia. One month after discharge the patient returned with hypoxemia with massive hemoptysis. He was readmitted to the Intensive Care for intubation and mechanical ventilation. Physical examination showed erythematous lesions on his lower extremities, biopsy showed a leukocytoclastic vasculitis. We found an increased level of creatinine with dysmorphic erythrocytes in the urinanalysis, suggesting glomerulonephritis. Decreased levels of C3, C4 and an elevated C1q-bindingtest suggested activation of the immune system. Over time the patient developed progressive renal failure, all tests for auto-immune diseases (ANA, ENA, ANCA, anti-CCP) were negative except for a positive IgM rheumatoid factor. Also viral tests including hepatitis C RNA were negative. Because of a possible seronegative Wegener granulomatosis he started with prednisone, cyclophosphamide and plasmapheresis, with poor result. Additionally a monoclonal IgM-kappa paraprotein and cryoglobulins were present in the serum. Bone marrow biopsy (performed after initial treatment) showed 1% plasmacells and 15% B-lymphocytes with an increased kappa/lambda ratio of 47, the ratio of kappa/lambda free light chains in the serum was also increased (ratio 23). We concluded that the patient had a hepatitis C virus negative mixed cryoglobulinemia (type 2) with diffuse alveolar haemorrhage, leukocytoclastic vasculitis of the skin and glomerulonephritis. He was treated with prednisone 1mg/kg daily and rituximab 375 mg/m2 weekly for 4 weeks. Currently he is doing well and is treated with prednisone (tapering scheme) and rituximab every three months (for 2 years according to non Hodgkin lymphoma protocols). Kappa/lambda ratios, IgM, complement levels etc. are normalised and cryoglobulins can not be detected anymore. CONCLUSION: Cryoglobulinemia mixed type 2 is an immune complex-mediated systemic vasculitis. In a majority of cases it is induced by B-cell activation by the hepatitis C virus, therefore HCV-negative cryoglobulinemia is very rare. It is unknown what the causative factors are involving HCV-negative cryoglobulinemia mixed type 2, but this diagnosis should always be considered in HCV-negative patients.

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Anamnestisch bleek patiënte bij drukverhogende momenten vocht aan onderzijde te verliezen: vaginaal of urethraal. Aanvullend onderzoek toonde een blaasretentie van 320cc en een CT-abdomen liet een gedeeltelijk gevulde blaas zien met een kleine verkalking passend bij een blaassteen. In verband met deze opmerkelijke bevinding werd de uroloog in consult gevraagd. Cystoscopie toonde een blaasempyeem op basis van een rubberen corpus alienum. Deze werd verwijderd en na het spoelen van de blaas werd gentamicine achtergelaten. Bij nadere bestudering bleek het te gaan om een stukje van een oude blaascatheter. Patiënte bleek twintig jaar geleden voor de laatste keer gecatheteriseerd was. DIAGNOSE: Blaasempyeem op basis van oud stukje blaascatheter bij een anefrische- hemodialyse patiënte.

Haemodynamic instability following bariatric surgery: an unusual complication?


M. Zigenhorn1, S. van de Poll2, J. Wiebolt1, JWF Elte1, AP Rietveld1, G. Mannaerts3, M. Castro Cabezas1 Departments of Internal Medicine1, Cardiology2 and Surgery3, Sint Franciscus Gasthuis, Rotterdam

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INTRODUCTION: Bariatric surgery (BS) is a popular and effective method in the treatment of morbid obesity. In the majority of patients BS results in significant weight loss. Symptoms and signs of orthostatic hypotension following rapid weight loss have been described especially in starvation, but may also occur after BS. We describe three patients with severe orthostatic intolerance after BS. Case report: Three patients (two males and one female; mean age 44.3 ±2.9 years) who had undergone BS and developed clear symptoms of orthostatic intolerance and were admitted to the hospital. On average they lost 54.0 ± 20,2 kg body weight (representing 37.4 ±9.9 % of their original body weight). Their initial BMI was 42.2 ±3.2 kg/m2 which decreased after laparoscopic sleeve resection to 26.1 ±2.9 kg/m2. All three subjects developed new-onset syncope, near-syncope and dizziness within a mean term of 13.3 ±8.1 months after surgery. Their mean systolic blood pressure decreased from 132.5 ±10.6 mmHg to 117.5 ±24.7 and their heart rate decreased from 81.0 ± to 55.5 ±14.8 bpm. ECG, electrocardiography and 24 hrs holter registration were normal. None of the patients had deficiencies of vitamins or minerals and there were no other biochemical abnormalities responsible for their symptoms. Based upon these results all three patients were diagnosed with (postural) orthostatic hypotension following excessive weight loss. DISCUSSION: BS is an effective method to treat (morbid) obesity. Orthostatic hypotension can be a severe side-effect of BS and has been described previously. Its exact incidence and etiology is unknown. The likely mechanism of orthostatic failure is autonomic insufficiency combined with reverse course of obesity-related hypertension. In general, the orthostatic hypotension disappears if the patient regains weight. As BS is getting more popular in the Netherlands, more people presenting with orthostatic intolerance following rapid weight loss are expected. Further investigations will be necessary to determine the exact incidence of orthostatic intolerance and to identify those patients at greater risk for developing orthostatic intolerance following BS.

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ARTIKELENINDEX

ARTIKELENINDEX

ARTIKELENINDEX

Anesthesiologie Apotheek Cardiologie Chirurgie Dermatologie Gynaecologie Intensive Care Interne Geneeskunde Kindergeneeskunde Klinische Chemie Leerhuis Longziekten MDL Neurologie Oogheelkunde Orthopedie Pathologie/ Pathan Psychiatrie Reumatologie Spoedeisende Hulp (SEH) Urologie Verpleegkunde Totaal

PubMed artikelen 3 13 2 6 1 17 1 1 3 7 4 1 1 6 2 68

Overige artikelen 2 1 1 2 1 1 1 2 1 2 2 4 1 2 1 24

Boek

Voordracht

3 3

7 2 19 5

32 9 5 1 4

8 9 6 17 1 125

Abstracts Posters 9 2 11

3 3 2 9 13 6 5 2 4 11 58


Specialisme

129

AUTEURSINDEX

AUTEURSINDEX

AUTEURSINDEX


pagina Albersen A 43, 50, 51, 52, 105, 114 Alipour A 40, 99 Altenburg – Van der Velden S 44 Assen YJ 25 Aydin Z 37, 41, 43 Baars JE 11 Bachasingh SR 123 Bakker CV 24 Bakker R 52, 87 , 113, 114 Bakker SLM 71 Bani L 96 Beunis MH 51, 52, 115, 119 Birnie E 9, 43, 44, 46, 50, 51, 52, 60, 87, 103, 113, 116, 118, 121 Biter LU 13, 14, 20, 60, 121 Blaauw Y 52, 115 Boesten LSM 51, 52 Boevé ER 43, 45, 92, 94, 111 Bonte-Mineur F 85 Bontemps S 22, 99, 112 Boshuizen JJ 97 Bosma MS 9, 44 Braunstahl GJ 46, 50, 51, 52, 57, 58, 59, 60, 61, 101, 102, 116, 121, 122 Brouwers AJ 31 Brouwers AJBW 7, 46, 124 Brown AV, 89, 102 Burger M 112, 123 Castro Cabezas M 14, 35, 36, 40, 41, 43, 44, 46, 58, 59, 60, 87, 103, 113, 118, 122, 126 Chan STJ 25, 110 Christiaansen C 94 Cohen Tervaert JW 54 De Boer B 80 De Feiter P 7, 22, 31, 44, 90, 104, 112 De Jong GJ 97, 112 De Jong PH 82, 83, 84, 87 De Man P 9, 44, 101 De Quelerij M 7, 104 De Ridder VA 21, 22, 89, 102 De Vos tot Nederveen Cappel RJ 14 De Vries SH 94 De Waard J 27 De Waard DE 112 Den Heijer T 7, 69, 70, 71, 72, 119, 123

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132

Denker S 50, 51, 52, 116 Doornaar M 7 Eggink-Meester BJ 48 Eskes SA 33 Fransens F 59 Gadiot RPM 7, 14, 44, 104, 107, 111 Geerlings CJC 9, 22, 44, 90, 101, 112 Goselink RJ 69, 72, 123 Grewal S 41 Grimbergen YAM 112 Grotenhuis BA 13, 15, 19, 20 Hajdarbegovic E 25, 109 Halilovic M 94 Hamberg AP 38, 42, 43, 44, 45, 105, 111 Hanewinckel R 72, 119 Hanselaar WE 39, 61 Harlaar JJ 69, 72, 123 Hartog H 16 Heetman-Meijer CFM 9 Herman E 25 Hoffman-Haringsma AKE 119, 120 Hoedemaeker RF 11, 27 Holtslag I 16 Huisman AM 46, 87, 99 Immerzeel J 96 in ‘t Veen JC 58, 59 Janssen NM 123, 124 Janssen JW 40, 43, 44, 46, 51, 52, 87, 103, 113, 114, 115, 118 Kamerbeek A 9 Kamping MA 28 Karsdorp VHM 27 Kats S 80 Kerver AJH 13, 14, 17, 20, 21, 22 Klem TMAL 13, 15, 20, 21 Klop B 35, 36, 43, 44, 46, 87, 103, 113, 118 Koeleman JGM 50, 51, 52, 116 Leeuwenburgh I 39, 45, 66, 67, 99, 109 Loots MAM 25 Luitwieler RL 7, 60, 44, 46, 104, 121 Mannaerts GHH 7, 60, 44, 46, 14, 17, 19, 21, 27, 28, 69, 104, 107, 111, 121, 122, 126 Meijer N 7, 44 Meijer R 52

Mooij MG 9, 48 Nette RW 96, 117 Njo TL 40, 43, 44, 46, 50, 51, 52, 87, 103, 105, 113, 115, 116, 117 Noordhoek Hegt V 24, 25, 78, 109 Nooter RI 92 Oostergo T 39, 45, 66, 109 Paats MS 33, 34, 39, 43, 61 Pasman SA 28 Pennewaard HM 96, 117 Pieters C 11, 110 Polak AA 76, 85, 87 Porcelijn L 43, 50, 51, 105 Prins G 39, 45, 46, 63, 66, 109, 125 Quist RJ 7 Racz E 24 Revet I 51, 52, 114 Rietbergen JBW 9, 28, 40, 41, 46, 93 Rietveld AP 9, 40, 41, 46, 101, 123, 126 Roemeling S 94 Roopram AD 22 Rosendaal A 89 Rudolphus A 56, 59 Samama MJW 124 Schilders J 43, 46, 51, 105, 124 Schönau LE 96, 117 Schoof P 80 Schouten J 63 Schrader AMR 24 Schrama YC 39, 43, 45, 46, 66, 85, 109, 111, 123, 125 Shapiro Koss C 102 Schrauwen SL 85 Snels DGCTM 25 Soema LM 9 Spelbrink M 80 Sukul P 89 Theeuwes HP 17, 22 Touw DJ 44, 9 Van Breukelen-Van der Stoep DF 46, 87, 113 Van Broekhoven S 96 Van Brussel JP 22 Van Casteren-Messidoro C 63, 86, 87, 113 Van Dijck-Van Boetzelaer CWT 9


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pagina

134

Van Dijk M Van Grimbergen YAM Van Hooff MHA Van Huisstede A Van Lith K Van Mechelen R Van Miltenburg AJM Van Oossanen J Van Oosten MJM Van Praag MCG Van Ruyven RL Van Tilburg AJP Van Tuijl SGL Van Velzen C Van Velzen LS Van Waning VH Van Wijk–Van Buuren JJE Van Zaanen HCT. Van Zeben D Van de Geijn GJM Van de Poll SW Van den Oever FJ Van der Ham AC Van der Klooster J Van der Loos ThLJM Van der Meulen N Van der Poel AE Van der Pol P Van der Poll S Van der Snoek EM Van der Spek AM Van der Voet Van der Weiden RMF Van der Weijde J Van der Zwaan HB Vakalopoulos KA Varin DSE Veerhoek R Veltman JD Verbrugge SJC Vergers-Spooren H Verhallen JTCM

52, 115 99 27, 29, 106 46, 56, 58, 59, 60, 102, 113, 121, 122 80 40, 110 11, 46, 118 51, 119 43, 45, 111 24, 25, 109, 110 74 63, 64, 65, 67 9 7, 44, 104 112 31, 51, 52, 116 96 43, 46, 124 46, 86, 82, 83, 87, 113 43, 44, 46, 50, 51, 52, 87, 103, 113, 115, 116, 117 11 9 17, 22 7, 44 , 104 41, 42 43, 40 96, 97 118 126 24 97 104 27, 28, 29, 31, 123, 124 119, 120 43 107, 111 89 90 41 7, 44, 104 106 25, 48

pagina 69, 70, 71, 72, 123 87, 113 11 13, 15, 18, 97 46, 126 16 96 27 63, 67 126 14, 122 42, 43, 50, 51, 105


Vermeij FH Verwer N Visser E Vrijland WW Wiebolt J Wijk IV Wildeman S Yo G Zelinkova Z Zigenhorn M Zengerink HJ Zuetenhorst JM

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