Wetenschappelijke publicaties van het Deventer Ziekenhuis, RISO, Dimence en Solis

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1 Wetenschappelijke publicaties van het Deventer Ziekenhuis, RISO, Dimence en Solis Deventer, november 2011

2 Inhoud Voorwoord 3 Deventer Ziekenhuis 5 Anesthesiologie 6 Cardiologie 7 Dermatologie 11 Fysiotherapie 15 Gynaecologie, Verloskunde 16 Heelkunde 23 Intensive Care 38 Interne Geneeskunde 39 Keel-, Neus- en Oorheelkunde 44 Kindergeneeskunde 47 Klinische Chemie 50 Klinische Fysica 51 Klinische Pathologie 52 Longziekten 53 Maag-, Darm- en Leverziekten 54 Medische Microbiologie 62 Nucleaire Geneeskunde 63 Oogheelkunde 64 Orthopedie 66 Radiologie 73 Urologie 75 Ziekenhuisfarmacie 76 Opleidingsinstituut 87 Radiotherapeutisch Instituut Stedendriehoek (RISO) 89 Ouderengeneeskunde Zorggroep Solis 95 State-of-the-Art Lectures 97 Voorwoord Onderzoek doen is een mooie evenwichtsoefening. Aan de ene kant ligt onze primaire focus natuurlijk bij de directe patiëntenzorg. Aan de andere kant maken we zoveel mogelijk tijd vrij voor onderzoek, een essentieel onderdeel waarmee onze organisaties inmiddels in een rijke traditie staan. Onze organisaties hebben veel te bieden, zeker op het gebied van toegepast onderzoek. Inzet hierbij is altijd dat meer patiënten kunnen profiteren van nieuwe inzichten en nieuwe behandelingen. Daarbij is het goed dat we steeds meer samenwerken, niet alleen met elkaar maar ook met onderzoeksinstituten uit de regio en op landelijk en internationaal niveau. Die focus helpt om state-of-the-art te blijven en om goede medisch-specialisten op te leiden én om ze uit te kunnen dagen om onze zorg nog beter te maken. Het doet mij deugd u dit overzichtsboekje aan te mogen bieden. Het biedt een overzicht van al het onderzoek dat in 2010 heeft plaatsgevonden in het Deventer Ziekenhuis, het Radiotherapeutisch Instituut Stedendriehoek en Omstreken en Dimence. Het gaat om publicatie van wetenschappelijke artikelen in nationale en internationale (wetenschappelijke) tijdschriften. Maar ook om boekbijdragen, voordrachten, posters en om promoties. Altijd is er een heldere band met de patiëntenzorg waar het Deventer Ziekenhuis, Dimence, Zorggroep Solis en het RISO voor staan en waarmee ze zich onderscheiden. Dit boekje laat als geen andere uitgave zien dat wij ook het voorbije jaar ervoor hebben gezorgd dat we naast het verlenen van gastvrije, veilige en effectieve zorg ook een mooie bijdrage hebben kunnen leveren aan wetenschap en innovatie. Tineke Hirschler, Voorzitter Raad van Bestuur, Deventer Ziekenhuis Presentaties Wetenschapsavond Impact Factors 101 Auteursindex

3 Opleidingsinstituut Deventer Ziekenhuis 4

4 Anesthesiologie Posters Incidence of Transient Neurologic Symptoms (TNS) Using Hyperbaric Articaine for Spinal Anesthesia. Arjanne Stemerdink, Jan Hein M.G. Cobben, Pim W.E.A. Rutten, Götz J.K. Wietasch, Michel M.R.F. Struys Annual Meeting of the American Society of Anesthesiologists San Diego, California, USA, October 18, 2010 Cardiologie Publicaties The effects of the PPAR-gamma agonist pioglitazone on plasma concentrations of circulating vasoactive factors in type II diabetes mellitus. De Boer RA, Martens FMAC, Kuipers I, Boomsma F, Visseren FLJ J Hum Hypertens Jan;24(1):74-6. Lenient versus strict rate control in patients with atrial fibrillation. Van Gelder IC, Groenveld HF, Crijns HJ, Tuininga YS, Tijssen JG, Alings AM, Hillege HL, Bergsma-Kadijk JA, Cornel JH, Kamp O, Tukkie R, Bosker HA, Van Veldhuisen DJ, Van den Berg MP; RACE II Investigators. N Engl J Med Apr 15;362(15): Epub 2010 Mar 15. BACKGROUND: Rate control is often the therapy of choice for atrial fibrillation. Guidelines recommend strict rate control, but this is not based on clinical evidence. We hypothesized that lenient rate control is not inferior to strict rate control for preventing cardiovascular morbidity and mortality in patients with permanent atrial fibrillation. METHODS: We randomly assigned 614 patients with permanent atrial fibrillation to undergo a lenient rate-control strategy (resting heart rate <110 beats per minute) or a strict rate-control strategy (resting heart rate <80 beats per minute and heart rate during moderate exercise <110 beats per minute). The primary outcome was a composite of death from cardiovascular causes, hospitalization for heart failure, and stroke, systemic embolism, bleeding, and life-threatening arrhythmic events. The duration of follow-up was at least 2 years, with a maximum of 3 years. RESULTS: The estimated cumulative incidence of the primary outcome at 3 years was 12.9% in the lenient-control group and 14.9% in the strict-control group, with an absolute difference with respect to the lenient-control group of -2.0 percentage points (90% confidence interval, -7.6 to 3.5; P<0.001 for the prespecified noninferiority margin). The frequencies of the components of the primary outcome were similar in the two groups. More patients in the lenientcontrol group met the heart-rate target or targets (304 [97.7%], vs. 203 [67.0%] in the strict-control group; P<0.001) with fewer total visits (75 [median, 0], vs. 684 [median, 2]; P<0.001). The frequencies of symptoms and adverse events were similar in the two groups. CONCLUSIONS: In patients with permanent atrial fibrillation, lenient rate control is as effective as strict rate control and is easier to achieve. (ClinicalTrials.gov number, NCT ) 6 7

5 Prognostic value of galectin-3, a novel marker of fibrosis, in patients with chronic heart failure: data from the DEAL-HF study. Lok DJ, Van Der Meer P, De la Porte PW, Lipsic E, Van Wijngaarden J, Hillege HL, Van Veldhuisen DJ Clin Res Cardiol May;99(5): Epub 2010 Feb 4. AIMS: Biomarkers are increasingly being used in the management of patients with chronic heart failure (HF). Galectin-3 is a recently developed biomarker associated with fibrosis and inflammation, and it may play a role in cardiac remodeling in HF. We determined its prognostic value in patients with chronic HF. METHODS AND RESULTS: Patients with chronic HF (New York Heart Association functional class III or IV) who participated in the Deventer-Alkmaar heart failure study were studied. Galectin-3 levels were determined at baseline using a novel optimized enzyme-linked immunosorbent assay. Univariate and multivariate analyses were used to determine the prognostic value of this biomarker. We studied 232 patients; their mean age was 71 +/- 10 years, 72% were male, and 96% were in NYHA class III. During a follow-up period of 6.5 years, 98 patients died. Galectin-3 was a significant predictor of mortality risk after adjustment for age and sex, and severity of HF and renal dysfunction, as assessed by NT-proBNP and estimated glomerular filtration rate, respectively (hazard ratio per standard deviation 1.24, 95% CI , P = 0.026). CONCLUSION: Plasma galectin-3 is a novel prognostic marker in patients with chronic HF. Its prognostic value is independent of severity of HF, as assessed by NT-proBNP levels, and it may potentially be used in the management of such patients. Congenital circumflex artery - coronary sinus fistula in an adult female associated with severe mitral regurgiation and myelodysplasy - case report and review of the literature. Saïd SAM, Van der Sluis A, Koster K, Sie H, Shahin GMM Congenit Heart Dis Nov-Dec;5(6): BACKGROUND: Coronary artery fistulas are uncommon anomalies. They occur in % of patients undergoing coronary arteriography. The origin of the fistulas is the right coronary artery followed by the left anterior descending and lastly by the circumflex artery (17%). Termination into the right heart side occurs in 90% of cases. Termination into the coronary sinus is rare in 3% of cases. Circumflex artery-coronary sinus fistulas are even rarer. DESIGN: A single case report and literature review between 1993 and RESULTS: We describe a 76-year-old female, who was analyzed for dyspnea on exertion (DOE) and chronic fatigue, with known myelodysplastic syndrome and an aneurysmal circumflex coronary artery-coronary sinus fistulous connection associated with severe mitral regurgitation. Mitral valve replacement using a bioprosthesis was performed as well as ligation of the fistula. The postoperative course was complicated with cardiac tamponade, which was successfully drained. CONCLUSION: Our patient presented with chronic fatigue and DOE and was found to have a coronary artery fistula and severe mitral regurgitation associated with known myelodysplasia. Conventional coronary angiography failed to demonstrate the entire fistula characteristics (origin, pathway, and outflow). Multidetector computed tomography was complementary to demonstrate the complex anatomy of the fistula. The fistula was surgically ligated in combination with mitral valve replacement. She remains well. Management of chronic heart failure guided by individual N-terminal pro-b-type natriuretic peptide targets: results of the PRIMA (Can PRo-brainnatriuretic peptide guided therapy of chronic heart failure IMprove heart failure morbidity and mortality?) study. Eurlings LW, van Pol PE, Kok WE, Van Wijk S, Lodewijks-van der Bolt C, Balk AH, Lok DJ, Crijns HJ, Van Kraaij DJ, De Jonge N, Meeder JG, Prins M, Pinto YM J Am Coll Cardiol Dec 14;56(25): OBJECTIVES: The purpose of this study was to assess whether management of heart failure (HF) guided by an individualized N-terminal pro-b-type natriuretic peptide (NT-proBNP) target would lead to improved outcome compared with HF management guided by clinical assessment alone. BACKGROUND: Natriuretic peptides may be attractive biomarkers to guide management of heart failure (HF) and help select patients in need of more aggressive therapy. The PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart failure morbidity and mortality?) study is, to our knowledge, the first large, prospective randomized study to address whether management of HF guided by an individualized target NT-proBNP level improves outcome. METHODS: A total of 345 patients hospitalized for decompensated, symptomatic HF with elevated NT-proBNP levels at admission were included. After discharge, patients were randomized to either clinically-guided outpatient management (n = 171), or management guided by an individually set NT-proBNP (n = 174) defined by the lowest level at discharge or 2 weeks thereafter. The primary end point was defined as number of days alive outside 8 9

6 the hospital after index admission. RESULTS: HF management guided by this individualized NT-proBNP target increased the use of HF medication (p = 0.006), and 64% of HF-related events were preceded by an increase in NT-proBNP. Nevertheless, HF management guided by this individualized NT-proBNP target did not significantly improve the primary end point (685 vs. 664 days, p = 0.49), nor did it significantly improve any of the secondary end points. In the NT-proBNP-guided group mortality was lower, as 46 patients died (26.5%) versus 57 (33.3%) in the clinically-guided group, but this was not statistically significant (p = 0.206). CONCLUSIONS: Serial NT-proBNP measurement and targeting to an individual NT-proBNP value did result in advanced detection of HF-related events and importantly influenced HF-therapy, but failed to provide significant clinical improvement in terms of mortality and morbidity. (Effect of NT-proBNP Guided Treatment of Chronic Heart Failure [PRIMA]; NCT ) Broad QRS complex tachycardia: looking for clues. YS Tuininga, JK Jongman, PJ Perik Neth Heart J. 2010;18(7): Voordrachten Galectin-3, een nieuwe marker in hartfalen. D.J.A. Lok Challenge Symposium Apeldoorn, 22 januari 2010 Galectin-3 predicts remodeling of the left ventricle in heart failure. D.J.A. Lok American College of Cardiology (ACC) Atlanta, USA, March 3, 2010 Klinische betekenis HS-tropT in de cardiologische praktijk D.J.A. Lok Pro-cardio symposium Amsterdam, 16 april, 2010 New antitrombotic therapy D.J.A. Lok Warcef investigators New York, May 15, 2010 Dermatologie Publicaties Resorcinol peels as a possible self-treatment of painful nodules in hidradenitis suppurativa. Boer J, Jemec GBE Clin Exp Dermatol Jan; 35(1): Epub 2009 Jun 22 BACKGROUND: Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease characterized by abscess formation localized to apocrine sweat gland-bearing skin. The most important factor in patients overall assessment of disease severity is pain. The duration of abscesses takes days to weeks and are always painful. AIM: To assess the efficacy of self-treatment with topical 15% resorcinol in an open study. METHODS: The case notes of 12 women with stage 1 or 2 HS treated with topical resorcinol and followed up for at least 1 year were reviewed. The patients rated the efficacy of treatment on global maximum pain of nodules and abscesses on a visual analogue scale (VAS) and by self-report of the mean duration (days) of a painful lesion. RESULTS: All patients experienced a significant decrease in pain as assessed by VAS and reported a reduction in mean duration of the painful abscesses. CONCLUSIONS: Topical treatment with 15% resorcinol reduced pain from painful nodules in all patients with HS. Further trials are warranted to confirm these results. Pseudo-food allergy caused by carry-over of latex proteins from gloves to food: need for prevention? Van Drooge AM, Knulst AC, De Groot H, Van Ginkel CJW, Pasmans SG Allergy Apr;65(4): Epub 2009 Oct 15. Deroofing: A tissue-saving surgical technique for the treatment of mild to moderate hidradenitis suppurativa lesions. Zee van der HH, Prens EP, Boer J J Am Acad Dermatol Sep;63(3): BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease, often refractory to treatment. Patients with HS and dermatologists are in need of an effective, fast surgical intervention technique. Deroofing is a tissue-saving technique, whereby the roof of an abscess, cyst, or sinus tract is electrosurgically removed. The use of a probe is mandatory to explore the full extent of a lesion

7 OBJECTIVE: We sought to evaluate the efficacy and patient satisfaction of the deroofing technique for recurrent Hurley I (mild) or II (moderate) graded HS lesions at fixed locations. METHODS: An open study consisted of 88 deroofed lesions in 44 consecutive patients with HS, treated by a single clinician with a follow-up time of up to 5 years. RESULTS: Fifteen of 88 (17%) treated lesions showed a recurrence after a median of 4.6 months. In all, 73 treated lesions (83%) did not show a recurrence after a median follow-up of 34 months. The median patient satisfaction with the procedure rated 8 on a scale from 0 to 10. Of the treated patients, 90% would recommend the deroofing technique to other patients with HS. One side effect occurred in the form of postoperative bleeding. LIMITATIONS: Some patients were lost to follow-up. CONCLUSIONS: The deroofing technique is an effective, simple, minimally invasive, tissue-saving surgical intervention for the treatment of mild to moderate HS lesions at fixed locations and it is suitable as an office procedure. Navelstaren met Sister Mary Joseph : Een nattende navel als eerste uiting van een gynaecologische maligniteit. Maathuis MHJ, Scholte AL, Boer J Huisarts Wet. 2010;53(4): Samenvatting De nattende navel bij volwassenen berust vaak op een intertrigineus eczeem, psoriasis inversa of dermatomycose en is relatief eenvoudig te behandelen. In een zeer klein percentage van de gevallen is deze huidafwijking een voorbode van ernstige pathologie. In deze klinische les presenteren wij een casus van een nattende navel die bleek te berusten op een metastase van een endometriumcarcinoom. Het eponiem van deze aandoening leidt terug naar een oplettende Amerikaanse verpleegkundige uit de vorige eeuw: de Sister Mary Joseph s nodule. Master Thesis Hidradenitis suppurativa. Investigations into the application of Neotigason (acitretin). Nazary M (farmacoloog i.o.) Utrecht University, Graduate School of Life Schience, department of pharmaceutical sciences. Begeleiders: J. Boer, G. Folkerts Hidradenitis suppurativa (HS) is a distressing chronic skin disorder which affects body areas rich in apocrine glands such as groins and axillae. It is a common disease with an estimated prevalence of 1% in the unselected population and 4.1% among younger adults. The aetiology is unknown, but several factors seem to play a role such as genetics, smoking and obesity. Women are affected more often than men and are younger than the general population. The diagnosis is mainly based on the patients history of recurrent inflammatory lesions in the inverse areas. In addition, deep seated nodules which develop from non-inflamed nodules to inflamed nodules, sinus formations and scarring with intermittent suppuration are key disease hallmarks of HS It was thought to be a disease of the apocrine glands, but recent histological findings have specified that HS is a disease of the hair follicles. More specifically, follicular dilatation and occlusion in combination with hyperkeratinization have been shown to be the early events occurring in HS. HS is related to acne due to the element of poral occlusion and visible infrainfundibular inflammation, but is different from acne in epidemiology, sebaceous gland involvement and therapeutical response. Thus, the term acne inversa should be utilized more cautiously. It is contemplated that the pathogenic mechanisms such as the disruption of abnormal hair follicles in the inverse areas are triggered by mechanical factors. Moreover, continuous skin friction of already predisposed individuals may lead to disruption of the hair follicles and subsequent lesion formation. The clinical management of HS is tremendously challenging because no standard and effective therapy is currently at hand. However, HS has been treated with combinations of topical and systemic antibiotics, retinoids, immunosuppressives and more recently the biologics. Surgical interventions such as deroofing is still the method of choice when drugs fail to achieve the desired results. The effectiveness of a certain therapeutical option strongly depends on the patients disease severity. Frequently, HS patients are treated with a combination of the above options. Among the retinoids, isotretinoin, etretinate and acitretin have been used in the treatment of HS. Isotretinoin has been shown to be of extremely high value in the treatment of acne. However, no positive results have been noted when used in the treatment of HS. On the other hand, successful cases of HS treatment with etretinate and acitretin have been reported. Recently, Dr. Jurr Boer has treated 12 HS patients with acitretin at Deventer Hospital, The Netherlands. An overall improvement was noticed in all the patients

8 Fysiotherapie Furthermore, the level of pain, as was assessed by VAS, was significantly reduced in all the patients. No serious side-effects were noticed. Thus, acitretin may become part of the medical arsenal of dermatologists in the therapy of HS. This should be further confirmed by conducting randomized clinical trials. Posters Knieproprioceptie : de relatie tussen bewegingsgevoel en positiegevoel bij gezonde ouderen. E.D. Wind, S.B. Zoethout, M. van der Esch, T. Takken, M. Steultjens, J. Dekker KNGF Congres (Koninklijk Nederlands Genootschap voor Fysiotherapie) Amsterdam, 2 december

9 Gynaecologie & Verloskunde Publicaties Chronic kidney disease after vesico-vaginal stone formation around a migrated intrauterine device Karsmakers R, Weis-Potters AE, Buijs G, Joustra EB BMJ Case Reports Published 1 January 2010;published online 26 July 2010 : zie Urologie Are patient characteristics associated with the accuracy of hysterosalpingography in diagnosing tubal pathology? An individual patient data meta-analysis. Broeze KA, Opmeer BC, Van Geloven N, Coppus SF, Collins JA, Den Hartog JE, Van der Linden PJ, Marianowski P, Ng EH, Van der Steeg JW, Steures P, Strandell A, Van der Veen F, Mol BW. Hum Reprod Update May-Jun;17(3): Epub 2010 Dec 8 BACKGROUND: Conventional meta-analysis has estimated the sensitivity and specificity of hysterosalpingography (HSG) to be 65% and 83%. The impact of patient characteristics on the accuracy of HSG is unknown. The aim of this study was to assess by individual patient data meta-analysis whether the accuracy of HSG is associated with different patient characteristics. METHODS: We approached authors of primary studies reporting on the accuracy of HSG using findings at laparoscopy as the reference. We assessed whether patient characteristics such as female age, duration of subfertility and a clinical history without risk factors for tubal pathology were associated with the accuracy of HSG, using a random intercept logistic regression model. RESULTS: We acquired data of seven primary studies containing data of 4521 women. Pooled sensitivity and specificity of HSG were 53% and 87% for any tubal pathology and 46% and 95% for bilateral tubal pathology. In women without risk factors, the sensitivity of HSG was 38% for any tubal pathology, compared with 61% in women with risk factors (P = 0.005). For bilateral tubal pathology, these rates were 13% versus 47% (P = 0.01). For bilateral tubal pathology, the sensitivity of HSG decreased with age [factor 0.93 per year (P = 0.05)]. The specificity of HSG was very stable across all subgroups. CONCLUSIONS: The accuracy of HSG in detecting tubal pathology was similar in all subgroups, except for women without risk factors in whom sensitivity was lower, possibly due to false-positive results at laparoscopy. HSG is a useful tubal patency screening test for all infertile couples. Patients attitude towards residents participation during gynaecological surgery. Versluis MA, Van der Linden PJ. Eur J Obstet Gynecol Reprod Biol Dec;153(2): Epub 2010 Aug 21 OBJECTIVE: To evaluate patients attitude towards participation of residents in training in gynaecological surgery and patients understanding of resident position. STUDY DESIGN: An observational survey study was performed between July and February in an outpatient clinic of a department of obstetrics and gynaecology of a teaching hospital. Patients planned for gynaecological surgery were concerned eligible. 247 questionnaires were handed out of which 204 were returned (response rate 82.6%). Primary outcome measure was level of confidence in a resident performing hysterectomy in various operative settings. Secondary, patients understanding of the medical education system was tested. RESULTS: There was no difference between confidence in a specialist performing a hysterectomy compared to an experienced resident considered competent and under supervision of a specialist. Respondents have significantly less confidence in less experienced residents operating under supervision and in all residents operating without supervision (P<0.001). From the respondents, 85.6% believes a resident in training has received less education than a resident not in training. 38.6% believes a resident received less training than a medical student. Statistical analysis was done in SPSS 16.0 (SSPS Inc., Chicago, IL, USA) using a Wilcoxon signed-rank test. CONCLUSIONS: Respondents have confidence in a resident in training performing an operation under supervision when it concerns an experienced resident that is considered competent. A majority of respondents does not understand the position of a resident in training. Patient education on resident participation should be improved and the certainty that an operating resident is competent should be emphasized. Well being of obstetric patients on minimal blood transfusions (WOMB trial). Prick BW, Steegers EA, Jansen AJ, Hop WC, Essink-Bot ML, Peters NC, Uyl-de Groot CA, Papatsonis DN, Akerboom BM, Metz GC, Bremer HA, Van Loon AJ, Stigter RH, Van der Post JA, Van Alphen M, Porath M, Rijnders RJ, Spaanderman ME, Schippers DH, Bloemenkamp KW, Boers KE, Scheepers HC, Roumen FJ, Kwee A, Schuitemaker NW, Mol BW, Van Rhenen DJ, Duvekot JJ BMC Pregnancy Childbirth Dec 16;10:

10 BACKGROUND: Primary postpartum haemorrhage is an obstetrical emergency often causing acute anaemia that may require immediate red blood cell (RBC) transfusion. This anaemia results in symptoms such as fatigue, which may have major impact on the health-related quality of life. RBC transfusion is generally thought to alleviate these undesirable effects although it may cause transfusion reactions. Moreover, the postpartum haemoglobin level seems to influence fatigue only for a short period of time. At present, there are no strict transfusion criteria for this specific indication, resulting in a wide variation in postpartum policy of RBC transfusion in the Netherlands. METHODS/DESIGN: The WOMB trial is a multicentre randomised non-inferiority trial. Women with acute anaemia due to postpartum haemorrhage, hours after delivery and not initially treated with RBC transfusion, are eligible for randomisation. Patients with severe physical complaints are excluded. Patients are randomised for either RBC transfusion or expectant management. Health related quality of life (HRQoL) will be assessed at inclusion, at three days and one, three and six weeks postpartum with three validated measures (Multi-dimensional Fatigue Inventory, ShortForm-36, EuroQol-5D). Primary outcome of the study is physical fatigue three days postpartum. Secondary outcome measures are general and mental fatigue scores and generic health related quality of life scores, the number of RBC transfusions, length of hospital stay, complications and health-care costs. The primary analysis will be by intention-to-treat. The various longitudinal scores will be evaluated using Repeated Measurements ANOVA. A costs benefit analysis will also be performed. The power calculation is based on the exclusion of a difference in means of 1.3 points or greater in favour of RBC transfusion arm regarding physical fatigue subscale. With missing data not exceeding 20%, 250 patients per arm have to be randomised (one-sided alpha = 0.025, power = 80%). DISCUSSION: This study will provide evidence for a guideline regarding RBC transfusion in the postpartum patient suffering from acute anaemia. Equivalence in fatigue score, remaining HRQoL scores and physical complications between both groups is assumed, in which case an expectant management would be preferred to minimise transfusion reactions and costs. An economic analysis of induction of labour and expectant monitoring in women with gestational hypertension or pre-eclampsia at term (HYPITAT trial). Vijgen SM, Koopmans CM, Opmeer BC, Groen H, Bijlenga D, Aarnoudse JG, Bekedam DJ, Van den Berg PP, De Boer K, Burggraaff JM, Bloemenkamp KW, Drogtrop AP, Franx A, De Groot CJ, Huisjes AJ, Kwee A, Van Loon AJ, Lub A, Papatsonis DN, Van der Post JA, Roumen FJ, Scheepers HC, Stigter RH, Willekes C, Mol BW, Van Pampus MG; HYPITAT study group. BJOG Dec;117(13): Epub 2010 Sep 14. OBJECTIVE: To assess the economic consequences of labour induction compared with expectant monitoring in women with gestational hypertension or pre-eclampsia at term. DESIGN: An economic analysis alongside the Hypertension and Pre-eclampsia Intervention Trial At Term (HYPITAT). SETTING: Obstetric departments of six university and 32 teaching and district hospitals in the Netherlands. POPULATION: Women diagnosed with gestational hypertension or preeclampsia between 36(+0) and 41(+0) weeks of gestation, randomly allocated to either induction of labour or expectant monitoring. METHODS: A trial-based cost-effectiveness analysis was performed from a societal perspective during a 1-year time horizon. MAIN OUTCOME MEASURES: One-year costs were estimated and health outcomes were expressed as the prevalence of poor maternal outcome defined as either maternal complications or progression to severe disease. RESULTS: The average costs of induction of labour (n = 377) were 7077 versus 7908 for expectant monitoring (n = 379), with an average difference of (95% CI to - 144). This 11% difference predominantly originated from the antepartum period: per woman costs were 1259 for induction versus 2700 for expectant monitoring. During delivery, more costs were generated following induction ( 2190) compared with expectant monitoring ( 1210). No substantial differences were found in the postpartum, follow-up and for non-medical costs. CONCLUSION: In women with gestational hypertension or mild pre-eclampsia at term, induction of labour is less costly than expectant monitoring because of differences in resource use in the antepartum period. As the trial already demonstrated that induction of labour results in less progression to severe disease without resulting in a higher caesarean section rate, both clinical and economic consequences are in favour of induction of labour in these women. TRIAL REGISTRATION: The trial has been registered in the clinical trial register as ISRCTN NHG-standaard subfertiliteit. Van Asselt KM, Hinloopen RJ, Silvius AM, Van der Linden PJQ, Van Oppen CCAN, Van Balen JAM Huisarts en Wet. 2010; 53(4):

11 P-505 Can hysterosalpingography predict spontaneous pregnancy in patients with tubal pathology? Opmeer BC, Broeze KA, Coppus SF, Collins JA, Den Hartog JE, Land JA, Van der Linden PJ, Marianowski P, Ng E, Van der Steeg JW, Steures P, Strandell A, Mol BW. Hum Reprod. 2010;25(suppl 1):i285-i Academic Medical Centre, Clinical Epidemiology Biostatistics and Bioinformatics, Amsterdam ZO, The Netherlands 2. 2 Academic Medical Centre, Obstetrics and gynaecology, Amsterdam ZO, The Netherlands 3. 3 McMaster University, Obstetrics and gynaecology, Hamilton, Canada 4. 4 VieCuri Hospital, Obstetrics and gynaecology, Venlo, The Netherlands 5. 5 University Medical Centre, Obstetrics and gynaecology, Groningen, The Netherlands 6. 6 Deventer Hospital, Obstetrics and gynaecology, Deventer, The Netherlands 7. 7 Medical University of Warsaw, Obstetrics and gynaecology, Warsaw, Poland 8. 8 Queen Mary Hospital, Obstetrics and gynaecology, Hong Kong, China 9. 9 Sahlgrenska University Hospital, Obstetrics and gynaecology, Goteborg, Sweden INTRODUCTION: Hysterosalpingography (HSG) and diagnostic laparoscopy are the most common tests to diagnose tubal pathology. The prognostic capacity of these tests in the predicton of spontaneous pregnancy has been investigated previously by Mol et al. in This study was based on aggregated data, restricting the estimation of the prognostic value to the complete group of patients. Individual patient data (IPD) meta-analysis provides the possibility to analyse prognostic values at the individual patient level. This will result in a more individualized prognosis for subfertility patients. The aim of this study is to assess the prognostic capacity of HSG in patients with tubal pathology using IPD meta-analysis. MATERIAL AND METHODS: We approached authors of primary studies on hysterosalpingography and diagnostic laparoscopy for tubal pathology and requested their original data. The individual patient data on HSG and laparoscopy were linked with follow-up data on pregnancy outcome. The association between spontaneous pregnancy, defined as a viable pregnancy at a gestational age of 12 weeks and HSG findings was estimated by Chi square statistic. Since time to event data were not yet available, a logistic regression model was used to predict spontaneous pregnancy. Patient characteristics that influence pregnancy rates, such as age, duration and type of subfertility, history of pelvic inflammatory disease and anovulation, were assessed and included into the model. We used a random intercept term to account for the heterogeneity between studies. RESULTS: We obtained data of seven studies reporting on 7,220 subfertile women. For 5,210 women data on ongoing pregnancy were available, for 3,640 of them HSG findings were available (78%) patients showed no tubal pathology on HSG, 447 (12%) had a unilateral tubal pathology, and 356 (10%) had a bilateral tubal pathology. The overall ongoing pregnancy rate was 24 %. There was a non significant association between any tubal pathology as detected by HSG and ongoing pregnancy, as estimated by Chi-square statistic. The model showed a non significant prognostic value of unilateral HSG findings (OR 0.94, 95% CI ) and a significant prognostic value of bilateral HSG findings (OR 0.20, 95% CI ). CONCLUSION: Unilateral tubal pathology detected on HSG has limited prognostic significance for spontaneous pregnancy, whereas bilateral tubal pathology detected on HSG reduces fertility prospects considerably. Wetenschappelijke stages Auteur: A. ter Haar Studentnummer: Vakgroep: Gynaecologie, Voortplantingsgeneeskunde & Verloskunde, Deventer Ziekenhuis Begeleider: P.J.Q. van der Linden Periode: 30 november april 2010 Remifentanil for maternal pain relief in labour: efficacy and maternal satisfaction Objectives: Our aim was to investigate the efficacy and de maternal satisfaction of remifentanil in a patient-controlled analgesia device for labour. Methods: In a partly retrospective, partly prospective observational study, 70 women received remifentanil intravenously given as patient-controlled analgesia (PCA). Remifentanil was available in constant boluses (bolus doses 15-25μg depending on the women s weight before the pregnancy) and a background infusion starting at 0,025 μg/kg/min. A lock-out time of 4 minutes was used. There was a possibility of increasing the background infusion to a maximum of 0,05 μg/kg/min when a lower dose could not relief the pain satisfactorily. Pain severity was assessed on a scale 0-3 (0=no pain, 3=severe pain) in the retrospective part of de study. In the prospective part a visual analog scale was used to asses the severity of the pain. Satisfaction and ease 20 21

12 Heelkunde of the administration were assessed by women after termination of the labour by means of a survey. Secondary goals were to investigate maternal and neonatal side effects and possible effects on the duration and termination of the labour. Results: There was a significant reduction in pain scores from baseline scores (P<0,05) in the first and second hour following the start of the remifentanil. After the first two hours it seemed like pain scores returned towards baseline, but there were too little data to make this certain. 91% of the women was satisfied with the analgesic effects given by remifentanil. More than 60% of the women had problems with timing of the bolus doses. There were mild maternal side effects. The most common side effect mentioned by women was drowsiness (in 60%). There was no evidence of side effects in the new-borns, de median apgarscore after 1 minute was 9 and after 5 minutes was 10. Conclusions: Remifentanil PCA with background infusion may especially be adequate for women who are just a few hours away from delivery. The pain relief given by remifentanil PCA may not be as good as epidural analgesia but it gives women a satisfactorily relief of pain, without severe side effects for mother and child. More investigation needs to be done to find out the most effective and safe balance between background infusion and boluses. Publicaties Limited value of digital subtraction angiography in the evaluation of cell-based therapy in patients with limb ischemia. Van Tongeren RB, Hamming JF, Le Cessie S, Van Erkel AR, Van Bockel JH Int J Cardiovasc Imaging Jan;26(1): Epub 2009 Sep 16. Cell-based therapy has been proposed as a novel strategy for patients with severe peripheral arterial disease by stimulating vascular growth. In clinical studies of this therapy, the emphasis has been on demonstrating recovery of clinical parameters, rather than on evaluation of blood flow recovery. Angiography is still the gold standard for the assessment of lower leg arteries. Therefore, we studied the usefulness of angiography in the evaluation of cell-based therapy. Sixteen patients with critical leg ischemia (ischemic rest pain or ulcers), or persistent (>12 months) profound disabling claudication were unilaterally treated with autologous bone marrow-derived mononuclear cells. Pre- and 6 months post-treatment digital subtraction angiographies (DSA) were assessed and compared in a blinded fashion twice by a panel of seven vascular surgeons and interventional radiologists. Inter- and intraobserver variability on qualitative (poor/moderate/rich) and semiquantitative (increase/no difference/decrease) assessment of collateral circulation were evaluated. Agreement was expressed inter- and intraclass correlation coefficients (CC). Inter- and intraobserver agreement was moderate for the qualitative grading of collateral extent (CC = 0.46 and 0.60, respectively). Agreement was moderate (inter-cc = 0.60) to good (intra-cc = 0.73) for comparing pre- and post-treatment DSA. Clinical response was based on limb salvage, pain-free walking distance, ankle-brachial pressure index and pain scores. No difference was observed in the extent of collateral circulation between pre- and post treatment DSA after separate analysis of clinical responding and non-responding patients (P = 0.92). DSA is not a suited modality for the evaluation of therapeutic angiogenesis. Elective laparoscopic recto-sigmoid resection for diverticular disease is suitable as a training operation. Bosker R, Hoogenboom F, Groen H, Hoff C, Ploeg R, Pierie JP Int J Colorectal Dis Apr;25(4): Epub 2010 Feb 10. Source: Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands. PURPOSE: Some authors state that elective laparoscopic recto-sigmoid 22 23

13 resection is more difficult for diverticular disease as compared with malignancy. For this reason, starting laparoscopic surgeons might avoid diverticulitis, making the implementation phase unnecessary long. The aim of this study was to determine whether laparoscopic resection for diverticular disease should be included during the implementation phase. METHODS: All consecutive patients who underwent an elective laparoscopic recto-sigmoid resection in our hospital for diverticulitis or cancer from 2003 to 2007 were analysed. RESULTS: A total of 256 consecutive patients were included in this prospective cohort study. One hundred and fifty-one patients were operated on for diverticulitis and 105 for cancer. There was no significant difference in operation time (168 vs. 172 min), blood loss (189 vs. 208 ml), conversion rates (9.9% vs. 11.4%), hospital stay (8 vs. 8 days), total number of peroperative (2.3% vs. 1.6%) or postoperative complications (21.9% vs. 26.9%). The occurrence of anastomotic leakages was associated with higher American Society of Anesthesiologists (ASA) classification, which differed between the groups (86.8% vs. 64.8% ASA I-II, p < 0.001). CONCLUSION: Since there are no differences in operation time, blood loss, conversion rate and total complications, there is no need to avoid laparoscopic recto-sigmoid resection for diverticular disease early in the learning curve. Initial promising results of the dynamic locking blade plate, a new implant for the fixation of intracapsular hip fractures: results of a pilot study. Roerdink WH, Aalsma AM, Nijenbanning G, Van Walsum AD Arch Orthop Trauma Surg Apr;131(4): Epub 2010 Oct 21. Source: Department of Traumatology, Medisch Spectrum Twente, PO BOX , 7500 KA Enschede, The Netherlands. INTRODUCTION: The osteosynthesis of intracapsular hip fractures results in a 19-48% failure rate. Only when the anatomical reduction is secured by stable fixation, revascularisation of the femoral head can take place and the fracture can heal by primary osteonal reconstruction. The common implants lack rotational and/or angular stability. Also the relative large volume of the implants within the femoral head compromises the (re)vascularisation. The combination of an anatomical reduction and a low volume, dynamic implant, providing angular and rotational stability seem to be crucial factors in the treatment of intracapsular hip fractures. This assumption formed the starting point for the development of the dynamic locking blade plate (DLBP), a new implant for the internal fixation of intracapsular hip fractures. This report describes the first clinical results of the new implant. PATIENTS AND METHODS: Internal fixation with the DLBP was performed in 25 consecutive patients with an intracapsular hip fracture within 24 h from admission. Failure of fixation, due to non-union, avascular necrosis, implant failure or secondary displacement of the fracture, was the primary outcome measurer. Functional outcome was assessed by the Harris Hip Score. RESULTS: Following internal fixation of intracapsular hip fractures with the DLBP, a failure rate of 2 out of 25 patients and excellent functional results were seen after a follow-up of more than 2 years. CONCLUSION: The initial clinical results of the DLBP are promising and justify the start of a randomised controlled trial. Current surgical treatment of diverticular disease in The Netherlands. Morks AN, Klarenbeek BR, Flikweert ER, Van der Peet DL, Karsten TM, Eddes EH, Cuesta MA, De Graaf PW World J Gastroenterol Apr 14;16(14): Source: Department of Surgery, Reinier de Graaf Gasthuis, PO Box 5011, 2600 GA Delft, The Netherlands. AIM: To evaluate the development of diagnostic tools, indications for surgery and treatment modalities concerning diverticular disease (DD) in The Netherlands. METHODS: Data were collected from 100 patients who underwent surgery for DD in three Dutch hospitals. All hospitals used the same standardized database. The collected data included patient demographics, patient history, type of surgery and complications. Patients were divided into two groups, one undergoing elective surgery (elective group) and the other undergoing acute surgery (acute group). RESULTS: Two hundred and ninety-nine patients were admitted between 2000 and One hundred and seventy-eight patients underwent acute surgery and 121 patients received elective operations. The median age of the 121 patients was 69 years (range: years), significantly higher in acute patients (P = 0.010). Laparoscopic resection was performed in 31% of elective patients. In the acute setting, 61% underwent a Hartmann procedure. The overall morbidity and mortality were 51% and 10%, and 60% and 16% in the acute group, which were significantly higher than in the elective group (36% and 1%). Only 35% of the temporary ostomies were restored. CONCLUSION: This study gives a picture of current surgical practice for DD in The Netherlands. New developments are implemented in daily practice, resulting in acceptable morbidity and mortality rates 24 25

14 Primary hemiarthroplasty versus conservative treatment for comminuted fractures of the proximal humerus in the elderly (ProCon): a multicenter randomized controlled trial. Den Hartog D, Van Lieshout EM, Tuinebreijer WE, Polinder S, Van Beeck EF, Breederveld RS, Bronkhorst MW, Eerenberg JP, Rhemrev S, Roerdink WH, Schraa G, Van der Vis HM, Van Thiel TP, Patka P, Nijs S, Schep NW BMC Musculoskelet Disord May 25;11:97. Source : Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, P,O, Box 2040, 3000 CA Rotterdam, the Netherlands. BACKGROUND: Fractures of the proximal humerus are associated with a profound temporary and sometimes permanent, impairment of function and quality of life. The treatment of comminuted fractures of the proximal humerus like selected three-or four-part fractures and split fractures of the humeral head is a demanding and unresolved problem, especially in the elderly. Locking plates appear to offer improved fixation; however, screw cut-out rates ranges due to fracture collapse are high. As this may lead to higher rates of revision surgery, it may be preferable to treat comminuted fractures in the elderly primarily with a prosthesis or non-operatively. Results from case series and a small-sample randomized controlled trial (RCT) suggest improved function and less pain after primary hemiarthroplasty (HA); however these studies had some limitations and a RCT is needed. The primary aim of this study is to compare the Constant scores (reflecting functional outcome and pain) at one year after primary HA versus non-operative treatment in elderly patients who sustained a comminuted proximal humeral fracture. Secondary aims include effects on functional outcome, pain, complications, quality of life, and cost-effectiveness. METHODS/DESIGN: A prospective, multi-center RCT will be conducted in nine centers in the Netherlands and Belgium. Eighty patients over 65 years of age, who have sustained a three-or four part, or split head proximal humeral fracture will be randomized between primary hemiarthroplasty and conservative treatment. The primary outcome is the Constant score, which indicates pain and function. Secondary outcomes include the Disability of the Arm and Shoulder (DASH) score, Visual Analogue Scale (VAS) for pain, radiographic healing, health-related quality of life (Short-form-36, EuroQol-5D) and healthcare consumption. Cost-effectiveness ratios will be determined for both trial arms. Outcome will be monitored at regular intervals over the subsequent 24 months (1, 3 and 6 weeks, and 3, 6, 12, 18, and 24 months). Data will be analyzed on an intention to treat basis, using univariate and multivariable analyses. DISCUSSION: This trial will provide level-1 evidence on the effectiveness of the two mostly applied treatment options for three-or four part and split head proximal humeral fractures in the elderly. These data may support the development of a clinical guideline for treatment of these traumatic injuries. TRIAL REGISTRATION: Netherlands Trial Register (NTR2040). A comparison of the Doppler-derived maximal systolic acceleration versus the ankle-brachial pressure index or detecting and quantifying peripheral arterial occlusive disease in diabetic patients. Van Tongeren RB, Bastiaansen AJ, Van Wissen RC, Le Cessie S, Hamming JF, Van Bockel JH J Cardiovasc Surg (Torino) Jun;51(3): Source: Departments of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands. AIM: The aim of this study was to assess the diagnostic accuracy of the Doppler derived maximal systolic acceleration (ACCmax) as a novel technique for evaluating peripheral arterial occlusive disease (PAOD) in patients with diabetes mellitus, who are known for a falsely elevated ankle-brachial index (ABI). METHODS: In this retrospective analysis ACCmax was measured at ankle level in a series of 163 consecutive patients referred to the vascular laboratory for initial assessment of PAOD. Patients were classified according to the presence or absence of diabetes. In the non-diabetic patients PAOD was defined as ABI < or =0.90. This group was used to establish the association between ACCmax and ABI in a linear regression model. The result was then used to predict the presence or absence of PAOD in the diabetic patients. RESULTS: The authors examined 301 lower limbs. The study group consisted of 166 limbs of patients without diabetes and 135 limbs of patients with diabetes. PAOD was present in 52% of limbs in the nondiabetic group versus 59% of limbs in the diabetic group (ABI < or =0.90, or in case of non-compliant vessels toe-brachial index (TBI) < or =0.70). An ACCmax cut-off value of >10 m/s2 was found to be highly predictive for the exclusion of PAOD (negative predictive value 95%). In addition, the ACCmax cut-off value of <6.5 m/s2 was highly predictive for the detection of PAOD (positive predictive value 99%). A strong quadratic association was found between ACCmax and ABI in the non-diabetic group (R2=0.85). In the diabetic patients R2 values were 0.81 and 0.79 after ABI and TBI measurement respectively. CONCLUSION: DUS-derived ACCmax is an accurate marker that could offer significant benefits for the diagnosis of PAOD, especially in diabetic patients

15 Results of 244 consecutive patients with hemorrhoids treated with Doppler-guided hemorrhoidal artery ligation. Pol RA, Van der Zwet WC, Hoornenborg D, Makkinga B, Kaijser M, Eeftinck Schattenkerk M, Eddes EH Dig Surg. 2010;27(4): Epub 2010 Jul 31. AIM: This study was designed to determine the effect of treating hemorrhoids with the Doppler-guided hemorrhoidal artery ligation (DG-HAL) procedure. METHODS: From June 2005 to March 2008, 244 consecutive hemorrhoidal patients underwent hemorroidal artery ligation performed with the DG-HAL system from AMI. All patients were evaluated postoperatively with a proctologic examination and interview. Further follow-up was performed by telephone with a standardized questionnaire. When indicated, patients revisited the clinic for further examination and treatment. RESULTS: 244 patients were treated with DG-HAL. The mean follow-up time was 18.4 months (range ). Sixty-seven percent of the patients had an improvement of symptoms after one treatment. Fifty-three patients (22%) underwent a second procedure because of persisting symptoms. Thirteen patients (25%) underwent a second DG-HAL and 40 (75%) underwent rubber band ligation. In total, 69% of the patients had a good response using the DG-HAL technique. Multivariate logistic regression analysis revealed prolapse to be an independent risk factor for persistent symptoms (OR = 2.38, 95% CI ). Patients with grades 3 and 4 hemorrhoids had a higher risk of developing recurrent disease (OR = 4.94, 95% CI ). CONCLUSION: DG-HAL seems to be an effective procedure for treating low-grade hemorrhoids. A resection procedure should be the treatment for patients with recurrent disease. Improving quality of cancer care through surgical audit. van Gijn W, van de Velde CJ; members of the EURECCA consortium. Collaborators (13) Dziki A, Eddes EH, Laurberg S, Mroczkowski P, Ortiz H, Pahlman L, Pavalkis D, Penninckx F, Romano G, Smith J, Valentini V, Van de Velde CJ, Wibe A Eur J Surg Oncol Sep;36 Suppl 1:S23-6. Epub 2010 Jul 7. Source: Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands. Quality of healthcare is a hot topic and this is especially true for cancer care. New surgical techniques and effective neoadjuvant treatment regimens have significantly improved colorectal cancer outcome. Nevertheless, there seem to be substantial differences in quality of care between European countries, hospitals and doctors. To reduce hospital variation, most initiatives aim on selective referral, encouraging patients to seek care in high-volume hospitals, where cancer care is concentrated to site-specialist multidisciplinary teams. As an alternative to volume-based referral, hospitals and surgeons can also improve their results by learning from their own outcome statistics and those from colleagues treating a similar patient group. European national audit registries in surgical oncology have led to improvements with a greater impact on survival than any of the adjuvant therapies currently under study. Moreover, they offer the possibility to perform research on patient groups that are usually excluded from clinical trials. Nevertheless, between European countries remain differences in outcome and treatment schedules that cannot be easily explained. The European CanCer Organisation (ECCO) has recognised these importances and created the European Registration of Cancer Care (EURECCA) framework to develop a European colorectal audit structure. EURECCA will advance future treatment improvements and spread these to all European cancer patients. It provides opportunities to treat elderly and comorbid patients evidence based while it offers an unique insight in socialeconomical healthcare matters such as the consequences of commercialisation, treatment availability and screening initiatives. As such, ECCO has established the basis for a strong, multidisciplinary audit structure with the commitment to improve cancer care for every European cancer patient. Internal fixation of intracapsular hip fractures with a dynamic locking plate: initial experience and results for 83 patients treated with a new implant. Roerdink WH, Van Walsum AD Injury Oct;41(10):1095-6; author reply Epub 2010 Jan 6. Functional treatment versus plaster for simple elbow dislocations (FuncSiE): a randomized trial. De Haan J, Den Hartog D, Tuinebreijer WE, Iordens GI, Breederveld RS, Bronkhorst MW, Bruijninckx MM, De Vries MR, Dwars BJ, Eygendaal D, Haverlag R, Meylaerts SA, Mulder JW, Ponsen KJ, Roerdink WH, Roukema GR, Schipper IB, Schouten MA, Sintenie JB, Sivro S, Van den Brand JG, Van der Meulen HG, Van Thiel TP, Van Vugt AB, Verleisdonk EJ, Vroemen JP, Waleboer M, Willems WJ, Polinder S, Patka P, Van Lieshout EM, Schep NW 28 29

16 BMC Musculoskelet Disord Nov 12;11:263. Source: Department of Surgery-Traumatology, AR Hoorn, The Netherlands. BACKGROUND: Elbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures. After reduction of a simple dislocation, treatment options include immobilization in a static plaster for different periods of time or so-called functional treatment. Functional treatment is characterized by early active motion within the limits of pain with or without the use of a sling or hinged brace. Theoretically, functional treatment should prevent stiffness without introducing increased joint instability. The primary aim of this randomized controlled trial is to compare early functional treatment versus plaster immobilization following simple dislocations of the elbow. METHODS/DESIGN: The design of the study will be a multicenter randomized controlled trial of 100 patients who have sustained a simple elbow dislocation. After reduction of the dislocation, patients are randomized between a pressure bandage for 5-7 days and early functional treatment or a plaster in 90 degrees flexion, neutral position for pro-supination for a period of three weeks. In the functional group, treatment is started with early active motion within the limits of pain. Function, pain, and radiographic recovery will be evaluated at regular intervals over the subsequent 12 months. The primary outcome measure is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford elbow score, pain level at both sides, range of motion of the elbow joint at both sides, rate of secondary interventions and complication rates in both groups (secondary dislocation, instability, relaxation), healthrelated quality of life (Short-Form 36 and EuroQol-5D), radiographic appearance of the elbow joint (degenerative changes and heterotopic ossifications), costs, and cost-effectiveness. DISCUSSION: The successful completion of this trial will provide evidence on the effectiveness of a functional treatment for the management of simple elbow dislocations. TRIAL REGISTRATION: The trial is registered at the Netherlands Trial Register (NTR2025). Twee nieuwe behandelingen van hemorrhoiden, dopplergeleide ligering van hemorrhoidale arterien en geniete anopexie. J.W.A. Burger, E.H. Eddes, M.F. Gerhards, P.G. Doornebosch, E.J.R. de Graaf Ned Tijdschr Geneeskd. 2010; 154 (3): Samenvatting Hemorroïden komen bij ongeveer 30% van de bevolking voor. Veel voorkomende klachten zijn bloedverlies, jeuk, hygiëneproblemen en soiling. Een vezelrijk dieet, eventueel met vezelsuppletie, verhelpt vaak de klachten. Bij onvoldoende resultaat is de volgende stap rubberbandligering: een veilige en eenvoudige behandeling. Op lange termijn is het resultaat van rubberbandligering vaak onvoldoende. Vroeger was dan hemorroïdectomie het enige alternatief. De hemorroïdectomie kan gepaard gaan met ernstige complicaties, zoals invaliderende pijn en incontinentie. Hemorroïdectomie werd daarom in de CBO-consensus van 1994 als obsoleet beschouwd. Tegenwoordig zijn nieuwe operatietechnieken beschikbaar: dopplergeleide ligering van hemorroïdale arteriën (DG-HAL) en geniete anopexie. Beide technieken zijn veilig en de resultaten zijn goed. Bovendien veroorzaken deze technieken weinig postoperatieve pijn. DG-HAL en geniete anopexie bieden een alternatief aan patiënten die niet uitkomen met vezelsuppletie en rubberbandligering. Nieuwe richtlijn acute appendicitis: routinematige preoperatieve beeldvorming is te simpel. van Laarhoven S, Eeftinck Schattenkerk M Ned Tijdschr Geneeskd. 2010;154:A1571 Dutch Surgical Colorectal Audit Jaarrapportage 2009 Uitkomst van zorgregistratie: transparantie, keuzes en kwaliteit van zorg. Analyses en eindredactie; M.W.J.M. Wouters, R. Brand, E.H. Eddes, G.A. Gooiker, N.E. Kolfschoten, R.A.E.M. Tollenaar Datum uitgave: april 2010 Samenvatting Er stierven vorig jaar driehonderd patiënten na een darmkankeroperatie. Dat zijn vierhonderd overlijdensgevallen minder dan er voorheen geregistreerd werden. Dit is één van de opvallende uitkomsten van de DSCA Jaarrapportage 2009 van de Dutch Surgical Colorectal Audit (DSCA). Aan dit onderzoek deden alle 84 Nederlandse ziekenhuizen mee. DSCA De DSCA is een uniek registratiesysteem dat vorig jaar is opgezet door 30 31

17 darmkankerchirurgen, samen met de betrokken chirurgische beroepsverenigingen. Het heeft als doel informatie te vergaren die aanknopingspunten geeft om de kwaliteit van de zorg te verbeteren. Behalve de nieuwe gegevens over overlijdensgevallen na operaties, kwam naar voren dat darmkankerpatiënten in ons land gemiddeld twaalf dagen in het ziekenhuis liggen. Dat is meer dan artsen dachten. Deze meetmethode kan in alle andere zorgdomeinen worden toegepast, opdat ook daar een scherper beeld van de prestaties kan ontstaan. Operatierisico Na darmkankeroperaties treden regelmatig complicaties op die soms leiden tot het overlijden van de patiënt. Uit de audit-resultaten is nog niet te concluderen of die complicaties deels te vermijden zijn. De sterfte na darmkankeroperaties in Nederland is circa 4 procent. Op basis van de huidige gegevens is er geen enkel statistisch bewijs dat er ziekenhuizen zijn met een overmatig sterfterisico. Wel blijkt dat oudere patiënten, een groep die de komende jaren zal toenemen, een sterk verhoogd risico op overlijden hebben ten opzichte van jongere patiënten. Er is wellicht ruimte voor verbetering in de zorg voor deze kwetsbare groep patiënten. Leeftijd Van de acuut geopereerde darmkankerpatiënten die ouder zijn dan tachtig jaar overlijdt in Nederland 20 procent na de operatie. Alle patiënten met een colorectaal carcinoom die acuut geopereerd moeten worden, lopen een hoger risico op complicaties, op het niet volledig verwijderen van de tumor en op langere ziekenhuisopname. Een deel van deze patiënten was al onder behandeling voordat zij acuut moesten worden geopereerd. Zij zouden baat kunnen hebben bij een versneld preoperatief traject, om te voorkomen dat zij in een acute situatie terecht komen. Dit zou kunnen leiden tot een vermindering van het aantal acute operaties en dus tot minder sterfte. Ook het identificeren van ziekenhuizen die goed scoren in de opvang van acute patiënten met een colorectaal carcinoom, kan leiden tot een lager risico voor alle patiënten die in deze situatie terecht komen. Kijkoperaties In Nederland worden vaker dan in andere landen darmtumoren via een kijkoperatie (laparoscopisch) verwijderd. De patiënten die laparoscopisch geopereerd zijn overlijden minder vaak na de operatie, hebben minder vaak complicaties en moeten minder vaak opnieuw geopereerd worden. In het kader van de recente discussie over de veiligheid van kijkoperaties in Nederland, is dit een zeer positieve bevinding. Toch zijn er ook voor deze groep patiënten nog verbeteringen te bewerkstelligen, vooral wanneer een kijkoperatie alsnog moet worden geconverteerd naar een open. Toekomst DSCA De systematiek waarmee de DSCA gegevens verzamelt, opslaat en analyseert is generiek van opzet, waardoor deze vorm van medical auditing eenvoudig toepasbaar is op andere zorgdomeinen. Dat betekent dat ook andere audits gebruik zouden kunnen maken van de door de DSCA ontwikkelde en beheerde ICT-infrastructuur. De methode van de DSCA biedt niet alleen een analyse op jaarbasis aan de deelnemende ziekenhuizen, maar ook tussentijds een wekelijkse terugkoppeling van hun eigen resultaten in combinatie met de actuele landelijke cijfers. Kwaliteitsverbetering De metingen en terugkoppelingen maken regelmatig benchmarken mogelijk, hetgeen aangetoond een sterk kwaliteitsbevorderend instrument is. Bij uitbreiding van deze audit-structuur naar andere zorgdomeinen zal de focus moeten liggen op aandoeningen die vaak voorkomen, waar verbeteringen te behalen zijn en waarvoor wetenschappelijk onderbouwde richtlijnen beschikbaar zijn. Zulke door de beroepsgroep gedragen richtlijnen zijn noodzakelijk om een zinvolle set van te verzamelen gegevens (gevalideerde dataset) te kunnen bepalen. Een bijkomend voordeel is dat door middel van de audit de richtlijn verder getoetst kan worden. Voordrachten Dutch Surgical Colorectal Audit, Een matrix voor medische registraties. E.H. Eddes Nederlandse Vereniging voor Longchirurgie Bunnik, 28 januari 2010 Dutch Surgical Colorectal Audit E.H. Eddes Nederlandse Vereniging voor Oncologie Utrecht, 28 januari 2010 Stamcellen en vaatchirurgie. R.B.M. van Tongeren Vascular Rounds Nijmegen, 9 maart 2010 Long term results of a self-expanding metallic stent (SEMS) strategy for acute malignant colonic obstruction. H.H. Zwaving, M. Ledeboer, F. ter Borg, E.H. Eddes, R.J.I. Bosker, M. Eefttinck Schattenkerk 32 33

18 Nederlandse Vereniging voor Gastroenterologie Veldhoven, maart 2010 Geen aanvullende chirurgie bij maligne colonpoliepen: de rol van biopten uit het polypectomielitteken. M. Eeftinck Schattenkerk NVGE Veldhoven, 18 maart 2010 Resultaten van de operatieve behandeling van laterale clavicula fracturen in type III AC-luxaties met de Clavicula haakplaat. A. Vogel, R. Pol, A.J. Frima, W.H. Roerdink Chirurgendagen Veldhoven, 21 mei 2010 Dikke darm kanker, hoe meten specialisten elkaar de maat. E.H. Eddes Zorgverzekeraars Nederland Amersfoort, 23 september 2010 Stamcellen en vaatchirurgie. R.B.M. van Tongeren Vascular Rounds VUMC Amsterdam, 5 oktober 2010 Mogelijkheden van de DSCA om nieuwe behandelingen te monitoren. E.H. Eddes NVGE Veldhoven, 7 oktober 2010 Dutch Surgical Colorectal Audit, monitor voor de behandeling van darmkanker, spiegelinformatie en openbaarheid. E.H. Eddes Elsevier congres ter gelegenheid van uitgave Beste Ziekenhuizen Den Haag, 20 oktober 2010 De chirurgische behandeling van darmkanker. Stand van Zaken in Nederland anno E.H. Eddes Nederlandse Fysiotherapie dagen Amsterdam, RAI, 2 december 2010 Colorectale chirurgie. E.H. Eddes Oncologiedagen Nederlandse Vereniging voor Oncologieverpleegkundigen Amsterdam, Jaarbeurs, 16 december 2010 Promotie Experimental strategies in restenosis and critical limb ischemia R.B.M. van Tongeren Leiden, Rijksuniversiteit Leiden, 22 april 2010 Samenvatting Radiotherapie bleek een hype, voor stamcellen is er hoop De studies in het eerste deel concentreren zich op de mogelijkheid om door middel van radiotherapie (re)stenose vorming, veroorzaakt door intima hyperplasie en remodeling, tegen te gaan. Dit werd onderzocht na PTA in het femoropopliteale traject bij patiënten met perifeer vaatlijden en bij patiënten bij wie een kunststof arterio-veneuze (AV) fistel ten behoeve van hemodialyse werd aangelegd. Het tweede deel van dit proefschrift focust op de experimentele behandeling met stamcellen (celtherapie) van patiënten met ernstig perifeer vaatlijden bij wie een reguliere chirurgische of endovasculaire behandeloptie niet mogelijk is. Straling ter preventie van restenose: de verdwijning van de vasculaire radiotherapie In een studie bij 60 patiënten kon na randomisatie geen verschil worden aangetoond tussen PTA plus aanvullende endovasculaire brachytherapie (EBT) of door middel van alleen PTA. Rekening houdend met het type laesie resulteerde een dosis van 14 Gray op de vaatwand gegeven (Iridium 192 ) in een absolute risico reductie van slechts 9% bij patiënten met een stenose, maar in geval van occlusie bedroeg de reductie 32%. Een substantieel aantal patiënten met laag-complexe, de-novo laesies lijkt verklarend voor het beperkte effect. Inmiddels is gebleken dat radiotherapie met name effectief is bij recidief stenosen en langere, complexe afwijkingen. Voorts werd het effect van uitwendige bestraling (EBI) op de doorgankelijkheid van kunststof dialyse fistels onderzocht (AVF trial). De veneuze anastomose werd bij 50 patiënten door middel van loting al dan niet aanvullend bestraald (18 Gy in 2 fracties). Hoewel er geen stralingsgerelateerde bijwerkingen werden waargenomen na 12 maanden follow up, resulteerde de bestraling niet in minder stenosen of reïnterventies. In het veld van de vasculaire radiotherapie heeft een significante ommezwaai plaatsgevonden. Na ongeveer een decade van gestage groei, met name 34 35

19 binnen de interventie-cardioologie, volgde een nogal abrupt verval rond Dit werd veroorzaakt door de klaarblijkelijke beperkingen van EBT zoals hierboven genoemd (alleen effectief bij recidief stenosen) en de zeer bewerkelijke aard van de procedure. De gebleken bescheiden lange-termijn resultaten in follow-up studies vormden de genadeslag. Binnen de interventiecadiologie werd EBT in een kort tijdsbestek werd het veld overgenomen door de drug-eluting stents. Celtherapie bij perifeer vaatlijden Het concept van celtherapie kwam voort uit de gedachte dat het toedienen van een cocktail van cytokines, groeifactoren en cellen aanleiding geeft tot een meer fysiologische en effectieve methode om tot vaatgroei te komen in ischemisch weefsel. In de meeste studies is gebruik gemaakt van mononucleaire cellen uit het beenmerg. Bij 30 patiënten bij wie reguliere behandeling door middel van bypass chirurgie of endovasculaire interventie was uitgesloten, werd een 40 ml concentraat autologe beenmergcellen (BMCs) toegediend. Negen van hen ondergingen binnen 3 maanden amputatie van het been vanwege aanhoudende ischemie. In de overige patiënten resulteerde de behandeling in een significante en aanhoudende (>12 maanden) verbetering. Na 6 maanden was de pijnvrije loopafstand verdrievoudigd. De gemiddelde enkel-arm index steeg 23% en pijnscores lieten een reductie van 50% zien. Hoewel deze benadering technisch goed mogelijk is gebleken in dierexperimentele- en enkele klinische studies, weten we nog relatief weinig van het werkingsmechanisme en de klinische effectiviteit. Veel is nog gebaseerd op hypothesen. De huidige topics zijn als volgt: Het ideale celtype Samenvattend zou de ideale celpopulatie om vaatgroei te stimuleren: - moeten kunnen uitgroeien tot rijpe stadia van verschillende weefseltypen en regenereren zonder hun potentie tot differentiatie te verliezen. - bij voorkeur collateralen met een sufficiënte diameter en daardoor een lage weerstand kunnen formeren. Capillairen daar en tegen hebben een hoge weerstand en zijn niet geschikt om de doorbloeding significant te verbeteren. - van autologe origine zijn en in grote aantallen eenvoudig beschikbaar zijn. Ideale toedieningsweg Op dit moment bestaat er geen optimale strategie voor de toediening van de cellen; intramusculair, rechtstreeks in de arterie, of een combinatie van beide? Een belangrijk aspect is het dirigeren van de cellen naar het juiste weefsel ( homing ). Onderzoek naar de verdeling van de geïnjecteerde beenmergcellen in de verschillende weefsels toonde dat maar een paar procent getraceerd kon worden in het ischemische weefsel. Bij diermodellen werd het overgrote deel van de cellenteruggevonden in de lever en de milt. Toekomstige research zal zich ook moeten richten op strategieën om tot een verbeterde homing te komen. Ideale celfunctie Patiënt factoren als leeftijd, diabetes en hypercholesterolemie zijn geassocieerd met een verstoorde respons van het lichaam op ischemie en met een verminderd aantal circulerende stamcellen. Verschillende benaderingen van therapeutische angiogenese zullen wellicht gecombineerd worden. Genetische modulatie van stamcellen zal overexpressie van groeifactoren kunnen geven en daarmee de signaalactiviteit bevorderen, of de levensduur van de getransplanteerde cellen verbeteren. Mechanisme Gezien de delings- en regeneratiemogelijkheden van beenmergcellen is het verleidelijk te suggereren dat celtherapie neovascularisatie stimuleert door directe incorporatie in de vaatwand. Echter, de data over transdifferentiatie van deze cellen zijn controversieel. Anderen trekken deze theorie in twijfel en leveren aannemelijk bewijs voor de hypothese dat beenmergcellen niet of nauwelijks in de vaatwand incorporeren. Daar veel celpopulaties uit het beenmerg een bron zijn van groeifactoren, cytokines en chemokines is een complementaire hypothese dat deze cellen een meer ondersteunende rol spelen. Momenteel is de algemene gedachte dat het potentiële gunstige effect meer is gerelateerd aan een paracrien effect dan aan transdifferentiatie. Mogelijke ongewenste effecten Stamcellen theoretisch tumor vascularisatie stimuleren. Op dezelfde wijze kan retinopathie en bestaande atherosclerose bevorderd worden. Aan de andere kant bestaat er een groeiende hoeveelheid bewijs dat circulerende stamcellen een belangrijke rol spelen bij de regeneratie van endotheel en het verminderen van de atherosclerotische plaque, meer dan bij het bevorderen van atherosclerose. Het uiteindelijke succes van celtherapie zal echter afhangen van het aantonen van klinische effectiviteit, veel meer dan van het volledig ontrafelen van een complex mechanisme. Uiteraard is identificatie van de werkzame (cel)componenten van belang, evenals de vraag of het effect direct wordt bewerkstelligd door de getransplanteerde cellen of indirect door de betrokkenheid van genoemde factoren. Zo kan doelgerichte toediening van essentiële componenten mogelijk worden. Dit is waarschijnlijk een kritieke stap in de verdere realisatie van deze experimentele benadering. Uiteraard veelbelovend, maar de nog vele onbeantwoorde vragen maken dat daadwerkelijke klinische toepassing van celtherapie wellicht nog even op zich laat wachten

20 Intensive Care Publicaties Late fatal bleeding after percutaneous dilatational tracheostomy. Hoiting O, Brule van den JMD, Zwam van PH, Hulsbergen-van de Kaa CA, Fikkers BG Neth J Crit Care 2010;14(5): We present two cases of late fatal bleeding after percutaneous dilatational tracheostomy placement. The first case describes a patient who suffered fatal bleeding after percutaneous dilatational tracheostomy due to a tracheoinnominate fistula. In this patient the percutaneous dilatational tracheostomy was sited too low down. The second case describes a patient who died following venous bleeding after percutaneous dilatational tracheostomy. This patient had had previous neck surgery. We use these two cases to focus attention on two pitfalls of percutaneous dilatational tracheostomy placement in ICU patients, namely: low tracheostomy placement may lead to tracheoinnominate fistula, and patients with previous neck surgery may have aberrant vasculature. Posters A cluster controlled implementation project of Intensive Insulin Therapy (IIT) improves blood glucose control. R.E. Harmsen, F. van Braam Houckgeest, J.P. van de Sluijs, H. van den Oever, L. Hofstra, M. Kuiper, A. Abu-Hanna, P.E. Spronk, M.J. Schultz International Symposium on Intensive Care and Emergency Medicine Brussel, 9-12 maart 2010 Interne Geneeskunde Publicaties A case of ATRA-induced isolated myocarditis in the absence of circulating malignant cells: demonstration of the t(15;17) translocation in the inflammatory infiltrate by in situ hybridisation. Van Rijssel RH, Wegman J, Oud ME, Pals ST, Van Oers MH. Leuk Res Jul;34(7):e Epub 2010 Jan 8. Artifactual measurement of low serum HDL-cholesterol due to paraproteinemia. Van Gorselen EO, Diekman T, Hessels J, Verhorst PM, Von Birgelen C. Clin Res Cardiol Sep;99(9): Epub 2010 Jul 1. Quality of care in patients with chronic kidney disease is determined by hospital specific factors. Van Zuilen AD, Blankestijn PJ, Van Buren M, ten Dam MA, Kaasjager KA, Ligtenberg G, Sijpkens YW, Sluiter HE, Van de Ven PJ, Vervoort G, Vleming LJ, Bots ML, Wetzels JF. MASTERPLAN Study Group. Nephrol Dial Transplant Nov;25(11): Epub 2010 Apr 9 Source: Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands. BACKGROUND: Guidelines have set goals for risk factor management in chronic kidney disease (CKD) patients. These goals are often not met. In this analysis, we set out to assess the quality of risk factor management in CKD and to identify factors that determine the quality of care (QoC). For that purpose, baseline data of the MASTERPLAN (Multifactorial Approach and Superior Treatment Efficacy in Renal Patients with the Aid of Nurse practitioners) study have been used. MASTERPLAN is a multicentre study which evaluates the effect of a multifactorial intervention in prevalent CKD patients on cardiovascular (CV) events and progression of kidney failure. METHODS: QoC was quantified using a score based on the number of 11 defined treatment goals on target. The maximum score per patient was 11. RESULTS: The average (±SD) QoC score was 6.7 (±1.5). The average score per centre ranged from 5.9 to 6.9. In a multivariable analysis, centre proved to be a significant, independent determinant of QoC with a difference up to 0.7 between centres. This difference remained when adjustments were made for those risk factors primarily treated by pharmacotherapy. Other factors that were significantly related to the QoC were estimated glomerular filtration rate, 38 39