Derde wetenschapsboek van het Amphia Ziekenhuis Breda/Oosterhout

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1 Derde wetenschapsboek van het Amphia Ziekenhuis Breda/Oosterhout

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3 Derde wetenschapsboek van het Amphia Ziekenhuis Breda/Oosterhout Najaar 2011

4 2011 Amphia Ziekenhuis Breda Oosterhout Alle rechten voorbehouden. Niets uit deze uitgave mag worden verveelvoudigd, opgeslagen in een geautomatiseerd gegevensbestand, of openbaar gemaakt, in enige vorm of op enige wijze, hetzij elektronisch, mechanisch, door fotokopieën, opnamen, of enige andere manier, zonder voorafgaande toestemming van de uitgever. Voor zover het maken van kopieën uit deze uitgave is toegestaan op grond van artikel 16B Auteurswet 1912 j o het Besluit van 20 juni 1974, St.b. 351, zoals gewijzigd bij Besluit van 23 augustus 1985, St.b. 471 en artikel 17 Auteurswet 1912, dient men de daarvoor wettelijk verschuldigde vergoedingen te voldoen aan de Stichting Reprorecht. Voor het overnemen van gedeelte(n) uit deze uitgave in bloemlezingen, readers en andere compilatie- of andere werken (artikel 16 Auteurswet 1912), in welke vorm dan ook, dient men zich tot de samenstellers/uitgever te wenden. De inzichten in de geneeskunde en wetenschap zijn voortdurend aan verandering onderhevig als gevolg van onderzoek en ervaring. De auteurs en uitgever zijn uiterst zorgvuldig te werk gegaan, om ervoor te zorgen dat de in dit boek verstrekte informatie, in overeenstemming is met de huidige kennis van zaken. Dit ontslaat de gebruiker van het boek echter niet van de verplichting om aan de hand van bestaande richtlijnen, protocollen en wetenschappelijke informatie te controleren of de daar verstrekte informatie afwijkt van de gegevens in dit boek en daarmee vast te stellen of de inhoud nog in overeenstemming is met de huidige stand van zaken ten aanzien van kennis en handelen. Ondanks alle aan de samenstelling van deze uitgave bestede zorg, zullen noch de samenstellers, noch de uitgever aansprakelijkheid aanvaarden voor eventuele schade die zou kunnen voortvloeien uit enige fout die in deze uitgave zou kunnen voorkomen.

5 Woord vooraf Een van de nieuwste beleidsvisies van de STZ, de samenwerkende Topklinische Ziekenhuizen van Nederland, benadrukt de mogelijkheden én noodzaak van wetenschappelijk onderzoek in de Topklinische Ziekenhuizen. De mogelijkheden zijn enorm. Door de omvang van de ziekenhuizen, de goede samenwerking met Universitaire Centra en de breedte van de vakgebieden zijn juist Topklinische ziekenhuizen uitstekende werkplaatsen voor onderzoek. Daarnaast kan geconstateerd worden dat voor veel wetenschappelijk onderzoek grote patiëntenpopulaties nodig zijn. Ook daarin kunnen dit soort ziekenhuizen voorzien, daar waar Academische ziekenhuizen, door hun topreferentiële functie, deze grote populaties vaak ontberen. Het Amphia zet zich daarom al jaren in voor hoogwaardig klinisch onderzoek in de geneeskunde. De infrastructuur voor dit onderzoek neemt jaar na jaar in omvang en kracht toe. Het verrichten van onderzoek is een van de speerpunten van het opleidings- en wetenschapsbeleid van het Amphia. 5 Ook in 2010 heeft er weer een breed scala aan onderzoek plaatsgevonden. Vrijwel alle vakgebieden hebben onderzoek verricht en velen hebben daarover gepubliceerd. Dit derde wetenschapsboek geeft enerzijds een overzicht van dat onderzoek, en anderzijds een blik op de mensen áchter dat onderzoek. Namens het Directiecomité van het Amphia Ziekenhuis dank ik iedereen die direct of indirect bijgedragen heeft aan al het wetenschappelijk onderzoek. Ik wens u veel leesplezier! Dr. J.J. Meij, Directeur Innovatie Lid Directiecomité Dr. J.J. Meij, directeur Woord vooraf

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7 Inhoud Anesthesiologie Apotheek Cardiologie Cardiothoracale chirurgie Chirurgie Dermatologie Gynaecologie Interne geneeskunde en Maag- darm- levergeneeskunde Kaakchirurgie Kindergeneeskunde Laboratorium voor Microbiologie en Infectiepreventie Longgeneeskunde Neurologie Oogheelkunde Orthopedie Psychiatrie Radiologie Reumatologie Revalidatie Seksuologie Urologie Publicaties Medisch Specialisten Publicaties Arts-assistenten Inhoud

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9 Anesthesiologie Kerngegevens zorgkern Anesthesiologie 26 anesthesiologen: J. Bach Kolling, mw. A. Besselink, S.F. de Boer, H.P. van Driel, M.J.P.G. van Eerd, F.E.A. Geisler, G. van Gelder, dr. B.M. Gerritse, dr. V.L.H. Hoffmann, L.H. Jacobs, A. van Keeken, J. Konings, E.B. Lachitjaran, F. de Loos, P.P.M. Maas, dr. B.J.M. van der Meer, R.J. Meulemans, F.X. O Connor, T.A. Rijpstra, P.M.J. Rosseel, dr. R. van Seventer, C.M.P. Theunissen, dr. W.A. Visser, M.A.J. Voets, E. Winters, mw. S.I.M. van Zijll Langhout-Kokke 8 assistenten niet in opleiding subspecialismen: cardio-anesthesiologie, pijnbestrijding, algemene anesthesiologie 9 Samenvattingen gepubliceerde artikelen Visser WA, Kolling JB, Groen GJ, Tetteroo E, van Dijl R, Rosseel PM, van der Meer NJ. Persistent cortical blindness after a thoracic epidural test dose of bupivacaine. Anesthesiology Feb;112(2): Thoracic epidural anesthesia is considered as an essential component of the perioperative care for patients undergoing lung resection. Although neurologic adverse events have been associated with this technique, permanent injury is rare. These events primarily involve the peripheral nervous system; for example, nerve root injury. We present a case of persistent cortical blindness after a test dose of bupivacaine was administered into an uneventfully placed thoracic epidural catheter. PMID: [PubMed - indexed for MEDLINE] Gerritse BM, Schalkwijk A, Pelzer BJ, Scheffer GJ, Draaisma JM. Advanced medical life support procedures in vitally compromised children by a helicopter emergency medical service. BMC Emerg Med Mar 8;10:6. Anesthesiologie

10 10 BACKGROUND: To determine the advanced life support procedures provided by an Emergency Medical Service (EMS) and a Helicopter Emergency Medical Service (HEMS) for vitally compromised children. Incidence and success rate of several procedures were studied, with a distinction made between procedures restricted to the HEMS-physician and procedures for which the HEMS is more experienced than the EMS. METHODS: Prospective study of a consecutive group of children examined and treated by the HEMS of the eastern region of the Netherlands. Data regarding type of emergency, physiological parameters, NACA scores, treatment, and 24- hour survival were collected and subsequently analysed. RESULTS: Of the 558 children examined and treated by the HEMS on scene, 79% had a NACA score of IV-VII. 65% of the children had one or more advanced life support procedures restricted to the HEMS and 78% of the children had one or more procedures for which the HEMS is more experienced than the EMS. The HEMS intubated 38% of all children, and 23% of the children intubated and ventilated by the EMS needed emergency correction because of potentially lethal complications. The HEMS provided the greater part of intraosseous access, as the EMS paramedics almost exclusively reserved this procedure for children in cardiopulmonary resuscitation. The EMS provided pain management only to children older than four years of age, but a larger group was in need of analgesia upon arrival of the HEMS, and was subsequently treated by the HEMS. CONCLUSIONS: The Helicopter Emergency Medical Service of the eastern region of the Netherlands brings essential medical expertise in the field not provided by the emergency medical service. The Emergency Medical Service does not provide a significant quantity of procedures obviously needed by the paediatric patient. PMID: [PubMed - indexed for MEDLINE] PMCID: PMC Van Zaane B, Nierich AP, Brandon Bravo Bruinsma GJ, Rosseel PM, Ramjankhan FZ, de Waal EE, Buhre WF, Moons KG. Diagnostic accuracy of modified transoesophageal echocardiography for pre-incision assessment of aortic atherosclerosis in cardiac surgery patients. Br J Anaesth Aug;105(2): Epub 2010 Jun 10. BACKGROUND: Epiaortic ultrasound scanning (EUS) is regarded as the reference standard for detecting atherosclerosis in the ascending aorta (AA). Combined with appropriate surgical modifications, EUS use can significantly reduce the incidence of postoperative stroke when detecting severe AA atherosclerosis. A recently introduced modification of conventional transoesophageal echocardiography (TOE), known as the A-View method, has proven capable of inspecting the distal AA. The objective of this study was to quantify the diagnostic accuracy of modified TOE in assessing atherosclerosis of the distal AA. METHODS: After approval by the institutional medical ethical committee and after obtaining written informed consent, 465 consecutive patients above 65 yr old, undergoing elective cardiac surgery with a median sternotomy, were included. The study followed a cross-sectional diagnostic design. Derde wetenschapsboek van het Amphia Ziekenhuis Breda/Oosterhout

11 All consecutive patients underwent modified TOE followed by EUS (reference standard) to assess the severity of distal AA atherosclerosis. We constructed contingency tables to compare the presence (and severity) of atherosclerosis, detected by the two techniques. RESULTS: The positive predictive value of modified TOE for the detection of clinically significant atherosclerosis was 67%, and the negative predictive value was 97%. The sensitivity was 95% and the specificity was 79%. One patient suffered a pulmonary haemorrhage, although he recovered without further sequelae. We did not observe any clinical significant haemodynamic or ventilatory effects. CONCLUSIONS: The high negative predictive value and sensitivity show that modified TOE yields adequate diagnostic accuracy for excluding clinically relevant aorta atherosclerosis without significant cardiopulmonary side-effects, provided that the A-View catheter is introduced carefully. PMID: [PubMed - indexed for MEDLINE] Chu K, Rosseel P, Trelles M, Gielis P. Surgeons without borders: a brief history of surgery at Médecins Sans Frontières. World J Surg Mar;34(3): Médecins Sans Frontières (MSF) is a humanitarian organization that performs emergency and elective surgical services in both conflict and non-conflict settings in over 70 countries. In 2006 MSF surgeons departed on approximately 125 missions, and over 64,000 surgical interventions were carried out in some 20 countries worldwide. Historically, the majority of MSF surgical projects began in response to conflicts or natural disasters. During an emergency response, MSF has resources to set up major operating facilities within 48 h in remote areas. One of MSF strengths is its supply chain. Large pre-packaged surgical kits, veritable operating theatres to go, can be readied in enormous crates and quickly loaded onto planes. In more stable contexts, MSF has also strengthened the delivery of surgical services within a country s public health system. The MSF surgeon is the generalist in the broadest sense and performs vascular, obstetrical, orthopaedic, and other specialized surgical procedures. The organization aims to provide surgical services only temporarily. When there is a decrease in acute needs a program will be closed, or more importantly, turned over to the Ministry of Health or another non-governmental organization. The long-term solution to alleviating the global burden of surgical disease lies in building up a domestic surgical workforce capable of responding to the major causes of surgery-related morbidity and mortality. However, given that even countries with the resources of the United States suffer from an insufficiency of surgeons, the need for international emergency organizations to provide surgical assistance during acute emergencies will remain for the foreseeable future. PMID: [PubMed - indexed for MEDLINE] 11 Rosseel P, Trelles M, Guilavogui S, Ford N, Chu K. Ten years of experience training nonphysician anesthesia providers in Haiti. World J Surg Mar;34(3): Anesthesiologie

12 12 Surgery is increasingly recognized as an effective means of treating a proportion of the global burden of disease, especially in resource-limited countries. Often non-physicians, such as nurses, provide the majority of anesthesia; however, their training and formal supervision is often of low priority or even non-existent. To increase the number of safe anesthesia providers in Haiti, Médecins Sans Frontières has trained nurse anesthetists (NAs) for over 10 years. This article describes the challenges, outcomes, and future directions of this training program. From 1998 to 2008, 24 students graduated. Nineteen (79%) continue to work as NAs in Haiti and 5 (21%) have emigrated. In 2008, NAs were critical in providing anesthesia during a post-hurricane emergency where they performed 330 procedures. Mortality was 0.3% and not associated with lack of anesthesiologist supervision. The completion rate of this training program was high and the majority of graduates continue to work as nurse anesthetists in Haiti. Successful training requires a setting with a sufficient volume and diversity of operations, appropriate anesthesia equipment, a structured and comprehensive training program, and recognition of the training program by the national ministry of health and relevant professional bodies. Preliminary outcomes support findings elsewhere that NAs can be a safe and effective alternative where anesthesiologists are scarce. Training non-physician anesthetists is a feasible and important way to scale up surgical services resource limited settings. PMID: [PubMed - indexed for MEDLINE] Heijnen EB, Bentala M, van der Meer NJ. Purpura in a patient receiving vancomycin: a leukoclastic vasculitis? J Cardiothorac Vasc Anesth Apr;25(2): Epub 2010 Apr 27. PMID: [PubMed - in process] Jongerden IP, de Smet AM, Kluytmans JA, te Velde LF, Dennesen PJ, Wesselink RM, Bouw MP, Spanjersberg R, Bogaers-Hofman D, van der Meer NJ, de Vries JW, Kaasjager K, van Iterson M, Kluge GH, van der Werf TS, Harinck HI, Bindels AJ, Pickkers P, Bonten MJ. Physicians and nurses opinions on selective decontamination of the digestive tract and selective oropharyngeal decontamination: a survey. Crit Care. 2010;14(4):R132. Epub 2010 Jul 13. INTRODUCTION: Use of selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) in intensive care patients has been controversial for years. Through regular questionnaires we determined expectations concerning SDD (effectiveness) and experience with SDD and SOD (workload and patient friendliness), as perceived by nurses and physicians. METHODS: A survey was embedded in a group-randomized, controlled, cross-over multicenter study in the Netherlands in which, during three 6-month periods, SDD, SOD or standard care was used in random order. At the end of each study period, all nurses and physicians from participating intensive care units received study questionnaires. Derde wetenschapsboek van het Amphia Ziekenhuis Breda/Oosterhout

13 RESULTS: In all, 1024 (71%) of 1450 questionnaires were returned by nurses and 253 (82%) of 307 by physicians. Expectations that SDD improved patient outcome increased from 71% and 77% of respondents after the first two study periods to 82% at the end of the study (P = 0.004), with comparable trends among nurses and physicians. Nurses considered SDD to impose a higher workload (median 5.0, on a scale from 1 (low) to 10 (high)) than SOD (median 4.0) and standard care (median 2.0). Both SDD and SOD were considered less patient friendly than standard care (medians 4.0, 4.0 and 6.0, respectively). According to physicians, SDD had a higher workload (median 5.5) than SOD (median 5.0), which in turn was higher than standard care (median 2.5). Furthermore, physicians graded patient friendliness of standard care (median 8.0) higher than that of SDD and SOD (both median 6.0). CONCLUSIONS: Although perceived effectiveness of SDD increased as the trial proceeded, both among physicians and nurses, SOD and SDD were, as compared to standard care, considered to increase workload and to reduce patient friendliness. Therefore, education about the importance of oral care and on the effects of SDD and SOD on patient outcomes will be important when implementing these strategies. TRIAL REGISTRATION: ISRCTN PMID: [PubMed - indexed for MEDLINE] PMCID: PMC Zaludik J, Schuitemaker F, DeWaal R, Veldhuijzen B, van der Meer N. Severe lactate acidosis and cardiogenic shock: a rare manifestation of a phaeochromocytoma. Anaesth Intensive Care May;38(3): PMID: [PubMed - indexed for MEDLINE] 13 Tolsma M, Kröner A, van den Hombergh CL, Rosseel PM, Rijpstra TA, Dijkstra HA, Bentala M, Schultz MJ, van der Meer NJ. The clinical value of routine chest radiographs in the first 24 hours after cardiac surgery. Anesth Analg Jan;112(1): Epub 2010 Nov 3. BACKGROUND: Chest radiographs (CXRs) are obtained frequently in the intensive care unit (ICU). Whether these CXRs should be performed routinely or on clinical indication only is often debated. The aim of our study was to investigate the incidence and clinical significance of abnormalities found on routine postoperative CXRs in cardiac surgery patients and whether a restricted use of CXRs would influence the number of significant findings. METHODS: We prospectively included all consecutive patients who underwent cardiac surgery during a 2-month period. Two or three CXRs were performed in the first 24 hours of ICU stay. After ICU admission and after drain removal, a clinical assessment was performed before a CXR was obtained. All CXR abnormalities were noted and it was also noted whether they led to an intervention. For the admission CXR and the drain removal CXR, a comparison was made between CXRs clinically indicated by the physician and those not clinically indicated. RESULTS: Two hundred fourteen patients were included. The majority of patients underwent coronary arterial bypass grafting Anesthesiologie

14 (60%), heart valve surgery (21%), or a combination of these (14%). In total, 534 CXRs were performed (2.5 per patient). Abnormalities were found on 179 CXRs (33.5%) and 13 CXR results led to an intervention (2.4%). The association between clinically indicated CXRs and the presence of CXR abnormalities was poor. For 32 (10%) of the 321 admission and drain removal CXRs, clinical indications were stated by the physician beforehand. If these CXRs would not have been performed routinely, 68 abnormalities would have been missed, of which 5 led to an intervention. CONCLUSIONS: Partial elimination of routine CXRs in the first 24 hours after cardiac surgery seems possible for the majority of patients, but it is limited by the insensitivity of clinical assessment in predicting clinically important abnormalities detectable by CXRs. PMID: [PubMed - indexed for MEDLINE] 14 Complete publicatielijst Gerritse BM, Schalkwijk A, Pelzer BJ, Scheffer GJ, Draaisma JM. Advanced medical life support procedures in vitally compromised children by a helicopter emergency medical service. BMC Emerg Med Mar 8;10:6. De Vries J, Rijpstra TA, van der Meer NJM. Cardiac tamponade as a result of pericardial effusion in pneumococcal infections. Neth J Crit Care 2010:14(2): Van Zaane B, Nierich AP, Brandon Bravo Bruinsma GJ, Rosseel PM, Ramjankhan FZ, de Waal EE, Buhre WF, Moons KG. Diagnostic accuracy of modified transoesophageal echocardiography for pre-incision assessment of aortic atherosclerosis in cardiac surgery patients. Br J Anaesth Aug;105(2): Epub 2010 Jun 10. Visser WA, Kolling JB, Groen GJ, Tetteroo E, van Dijl R, Rosseel PM, van der Meer NJ. Persistent cortical blindness after a thoracic epidural test dose of bupivacaine. Anesthesiology Feb;112(2): Jongerden IP, de Smet AM, Kluytmans JA, te Velde LF, Dennesen PJ, Wesselink RM, Bouw MP, Spanjersberg R, Bogaers-Hofman D, van der Meer NJ, de Vries JW, Kaasjager K, van Iterson M, Kluge GH, van der Werf TS, Harinck HI, Bindels AJ, Pickkers P, Bonten MJ. Physicians and nurses opinions on selective decontamination of the digestive tract and selective oropharyngeal decontamination: a survey. Crit Care. 2010;14(4):R132. Epub 2010 Jul 13. Gerritse BM, Dirven PJ, Draaisma JMT, Scheffer GJ. Prehospitale echografie in Nederland door het Mobiel Medisch Team. Nederlands Tijdschrift voor Anesthesiologie. Ned Tijdschr voor Anesthesiologie. 2010;22(2): Heijnen EB, Bentala M, van der Meer NJ. Purpura in a patient receiving vancomycin: a leukoclastic vasculitis? J Cardiothorac Vasc Anesth Apr;25(2): Epub 2010 Apr 27. Zaludik J, Schuitemaker F, DeWaal R, Veldhuijzen B, van der Meer N. Severe lactate acidosis and cardiogenic shock: a rare manifestation of a phaeochromocytoma. Anaesth Intensive Care May;38(3): Derde wetenschapsboek van het Amphia Ziekenhuis Breda/Oosterhout

15 Chu K, Rosseel P, Trelles M, Gielis P. Surgeons without borders: a brief history of surgery at Médecins Sans Frontières. World J Surg Mar;34(3): Rosseel P, Trelles M, Guilavogui S, Ford N, Chu K. Ten years of experience training nonphysician anesthesia providers in Haiti. World J Surg Mar;34(3): Tolsma M, Kröner A, van den Hombergh CL, Rosseel PM, Rijpstra TA, Dijkstra HA, Bentala M, Schultz MJ, van der Meer NJ. The clinical value of routine chest radiographs in the first 24 hours after cardiac surgery. Anesth Analg Jan;112(1): Epub 2010 Nov 3. Gerritse BM, Pelzer B, Draaisma JMT, Scheffer GJ. The deployment of a Helicopter Emergency Medical Service for vitally compromised children in the Netherlands. Internet Journal of Aeromedical Transportation. 2010;2:1. 15 Anesthesiologie

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17 Apotheek Kerngegevens Apotheek 6 ziekenhuisapothekers: P.R.M. van Hattum, mw. V.S. Koster, P.A.O. Smithuis, N.E. van t Veer, mw. R.R.E.C.M. Verzijl-Zeegers, mw. M.H.G. Winters 2 assistenten in opleiding 17 Samenvattingen gepubliceerde artikelen Ter Laak MA, Temmink AH, Koeken A, van t Veer NE, van Hattum PR, Cobbaert CM. Recognition of impaired atomoxetine metabolism because of low CYP2D6 activity. Pediatr Neurol. 2010Sep;43(3): Ten out of 100 children treated for attention deficit hyperactivity disorder with standard doses of atomoxetine were selected by a neurologist for cytochrome P450 2D6 and cytochrome P450 2C19 genotyping, based on late response (>9 weeks) and adverse effects (gastrointestinal problems, sleeping disorders, malaise, inactivity, and mood instabilities). After genotyping, eight children were confirmed to have compromised cytochrome P450 2D6 activity because of at least one nonfunctional or less functional allele. Cytochrome P450 C19 is a minor pathway in atomoxetine metabolism and therefore of less importance. Tailored therapeutic advice was given to the neurologist. Four children with compromised cytochrome P450 2D6 activity responded better after decreasing their atomoxetine dose. The other four ceased treatment because of initial adverse effects. These cases indicate that compromised atomoxetine metabolism can be recognized, based on adverse effects and late response to atomoxetine. Physicians should be aware of the typical pattern of adverse effects and late response in atomoxetine treatment, possibly indicating compromised cytochrome P450 2D6 activity. Cytochrome P450 2D6 genotyping before atomoxetine treatment may be beneficial in preventing overdosing or early cessation. Further research is needed to establish the cost versus benefit ratio of prospective Apotheek

18 cytochrome P450 2D6 genotyping in atomoxetine treatment. Copyright 2010 Elsevier Inc. All rights reserved. PMID: [PubMed - indexed for MEDLINE] Willemsen I, Cooper B, van Buitenen C, Winters M, Andriesse G, Kluytmans J. Improving quinolone use in hospitals by using a bundle of interventions in an interrupted time series analysis. Antimicrob Agents Chemother Sep;54(9): Epub 2010 Jun The objectives of the present study were to determine the effects of multiple targeted interventions on the level of use of quinolones and the observed rates of resistance to quinolones in Escherichia coli isolates from hospitalized patients. A bundle consisting of four interventions to improve the use of quinolones was implemented. The outcome was measured from the monthly levels of use of intravenous (i.v.) and oral quinolones and the susceptibility patterns for E. coli isolates from hospitalized patients. Statistical analyses were performed using segmented regression analysis and segmented Poisson regression models. Before the bundle was implemented, the annual use of quinolones was 2.7 defined daily doses (DDDs)/100 patient days. After the interventions, in 2007, this was reduced to 1.7 DDDs/100 patient days. The first intervention, a switch from i.v. to oral medication, was associated with a stepwise reduction in i.v. quinolone use of 71 prescribed daily doses (PDDs) per month (95% confidence interval [CI] = 47 to 95 PDDs/month, P < 0.001). Intervention 2, introduction of a new antibiotic guideline and education program, was associated with a stepwise reduction in the overall use of quinolones (reduction, 107 PDDs/month [95% CI = 58 to 156 PDDs/month). Before the interventions the quinolone resistance rate was increasing, on average, by 4.6% (95% CI = 2.6 to 6.1%) per year. This increase leveled off, which was associated with intervention 2 and intervention 4, active monitoring of prescriptions and feedback. Trends in resistance to other antimicrobial agents did not change. This study showed that the hospital-wide use of quinolones can be significantly reduced by an active policy consisting of multiple interventions. There was also a stepwise reduction in the rate of quinolone resistance associated with the bundle of interventions. PMID: [PubMed - indexed for MEDLINE] PMCID: PMC Complete publicatielijst Willemsen I, Cooper B, van Buitenen C, Winters M, Andriesse G, Kluytmans J. Improving quinolone use in hospitals by using a bundle of interventions in an interrupted time series analysis. Antimicrob Agents Chemother Sep;54(9): Epub 2010 Jun 28. Ter Laak MA, Temmink AH, Koeken A, van t Veer NE, van Hattum PR, Cobbaert CM. Recognition of impaired atomoxetine metabolism because of low CYP2D6 activity. Pediatr Neurol Sep;43(3): Derde wetenschapsboek van het Amphia Ziekenhuis Breda/Oosterhout

19 Cardiologie Grenzen verleggen, technieken verbeteren om patiëntvriendelijker te werken De cardiologiemaatschap in het Amphia Ziekenhuis is een van de grootste van Nederland. Vooral de verrichtingen op het gebied van percutane hartkleppen zijn bijzonder, omdat deze in eerste instantie in slechts enkele Nederlandse ziekenhuizen werden uitgevoerd en het Amphia het eerste niet-academische ziekenhuis was dat de ingreep verrichtte. 19 Dr. M. Meuwissen Het vakgebied cardiologie is in vijf hoofdtakken te verdelen: algemene cardiologie (hart- en vaatziekten in brede zin), beeldvorming (echocardiografie, cardiale CT en MRI), interventiecardiologie (stent- en dotterbehandelingen, vervanging hartklep), Cardiologie

20 congenitale cardiologie (aangeboren hartgebreken) en elektrofysiologie (behandeling van hartritmestoornissen). In het Amphia Ziekenhuis vinden behalve harttransplantaties alle behandelingen plaats. Hartritmestoornissen We doen veel, qua volume en qua mogelijkheden, constateert cardioloog dr. Martijn Meuwissen, en vooral ook veel bijzondere verrichtingen. Hij verwijst hiermee onder andere naar de elektrofysiologische behandelingen bij hartritmestoornissen, zoals katheterablatie, pacemakers en ICD s (implanteerbare cardioverter-defibrillators). Bij een katheterablatie brengt een cardioloog via een katheter die via de lies(slag)ader naar het hart wordt opgevoerd kleine littekens aan in het hartspierweefsel. Die littekens blokkeren prikkels die zijn ontstaan op een verkeerde plaats of schakelen deze prikkels uit. Hiermee doven de soms levensbedreigende hartritmestoornissen uit. 20 Subcutane ICD Als deze levensbedreigende hartritmestoornissen oncontroleerbaar zijn wordt er meestal een ICD geïmplanteerd. Een ICD is een inwendige defibrillator. Dit apparaatje zorgt voor een constante controle van het hartritme. Zo nodig vindt een schokje plaats om het ritme weer te normaliseren. Meuw issen: Nieuw bij deze techniek is de ICD die net onder de huid geplaatst wordt (subcutane ICD), wat veel voordelen kan bieden bij bijvoorbeeld jonge mensen, die dit device noodzakelijkerwijs tientallen jaren dragen. De toekomst zal ons waarschijnlijk ICD s en pacemakers brengen die draadloos hun werk verrichten. Nu vindt het uitlezen van de ICD al wel op afstand plaats; de zogenaamde home monitoring. Wij cardiologen doen een extra fellowship elektrofysiologie om dit soort ingrepen te mogen en kunnen verrichten. Minimaal invasieve ingrepen Er is ook innovatie op het gebied van de interventiecardiologie. Naast de percutane aortaklepimplantatie kunnen ook andere kleppen percutaan (minimaal invasief) worden gerepareerd. Een ernstig lekkende (mitralis)klep komt in de praktijk het meest voor. Niet alle patiënten kunnen zware ingrepen doorstaan. Daarom is het fijn als je met een incisie in de lies een tube in de ader kunt inbrengen die een clipje bevat. Je schuift dat clipje op de goede plaats onder de lekkende mitraalklep en via het echoapparaat kun je zien dat de lekkage stopt. Enkele uren later is de patiënt alweer mobiel. Meuwissen toont een filmpje van de leverancier, waarbij het plaatsen van een MitraClip nauwkeurig is te volgen. Op een vergelijkbare manier, via de lies, zijn onderzoeken gedaan naar het plaatsen van betere stents in de kransslagader. Dit zijn kleine zeefjes die in uitgezette vorm een verstopte kransslagader openhouden om met een goede bloedstroom de hartspier van de benodigde zuurstof te voorzien. Deze zogenoemde dottertechniek bestaat sinds 1966 en is in 1976 Derde wetenschapsboek van het Amphia Ziekenhuis Breda/Oosterhout