Canisius Wilhelmina Ziekenhuis

Nijmegen, Netherlands

Canisius Wilhelmina Ziekenhuis

Nijmegen, Netherlands

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Sedelaar J.P.M.,Radboud University Nijmegen | Vergunst H.,Canisius Wilhelmina Ziekenhuis | Futterer J.J.,University of Twente
Radiology | Year: 2013

Purpose: To assess the feasibility of magnetic resonance (MR) imaging- guided focal cryoablation in patients with locally recurrent prostate cancer after radiation therapy. Materials and Methods: This was a prospective study, and informed consent was obtained from all patients. Ten consecutive patients with histopathologically proved recurrent prostate cancer after radiation therapy, without evidence of distant metastases, were treated while under general anesthesia in a 1.5-T MR unit. A urethral warmer was inserted. Cryoneedles were transperineally inserted under real-time MR imaging. Then, a rectal warmer was inserted. Ice ball growth was continuously monitored under MR imaging guidance. Two freeze-thaw cycles were performed. Follow-up consisted of a visit to the urologist, measurement of prostatespecific antigen level, and multiparametric MR imaging at 3, 6, and 12 months. Potential complications were recorded. Results: All patients were successfully treated. In one patient, the urethral warmer could not be inserted and the procedure was cancelled. Two months later, the procedure was successfully repeated. Another patient had urinary retention. Follow-up data were available for all patients. A local recurrence or remnant tumor was found in two patients after ±months and in another patient after 12 months. These three patients underwent successful retreatment with MR imaging-guided focal cryoablation. Conclusion: MR imaging-guided focal cryoablation of recurrent prostate cancer after radiation therapy is feasible and safe. Initial results are promising; however, longer follow-up is needed and more patients must be studied. © 2013 RSNA.


van der Marck M.A.,Radboud University Nijmegen | Munneke M.,Radboud University Nijmegen | Mulleners W.,Canisius Wilhelmina Ziekenhuis | Hoogerwaard E.M.,Rijnstate Ziekenhuis | And 7 more authors.
The Lancet Neurology | Year: 2013

Background: A multidisciplinary approach is thought to be the best way to manage the motor and non-motor symptoms of Parkinson's disease, but how such care should be delivered is unknown. To address this gap in knowledge, we assessed the effectiveness of an integrated multidisciplinary approach compared with usual care. Methods: We recruited patients for our non-randomised controlled trial from six community hospitals in the Netherlands (two in regions where the integrated care intervention was available and four in control regions that administered usual care). Eligible patients were those with Parkinson's disease, aged 20-80 years, and without severe cognitive impairment or comorbidity. Patients in the intervention group were offered an individually tailored comprehensive assessment in an expert tertiary referral centre and subsequent referrals to a regional network of allied health professionals specialised in Parkinson's disease. Primary outcomes were activities of daily living (Academic Medical Center linear disability score [ALDS]) and quality of life (Parkinson's disease quality of life questionnaire [PDQL]) measured at 4, 6, and 8 months. Secondary outcomes included motor functioning (unified Parkinson's disease rating scale, part III [UPDRS III], at 4 months), caregiver burden (belastungsfragebogen Parkinson angehörigen-kurzversion [BELA-A-k] at 4 and 8 months), and costs (during whole study period). Primary analysis was by intention to treat and included scores over 4, 6, and 8 months, with correction for baseline score. The trial is registered at Clinicaltrials.gov, number NCT00518791. Findings: We recruited 301 patients (150 patients in the intervention group and 151 in the control group) between August, 2007, and December, 2009, of whom 285 completed follow-up (last follow-up was July, 2010). 101 (67%) patients in the intervention group visited the expert centre; 49 (33%) opted not to visit the expert centre. The average ALDS score from months 4, 6, and 8, with correction for baseline score, was greater in the intervention group than in the control group (difference 1·3 points, 95% CI -2·1 to 2·8; corresponding raw logit score difference 0·1, 95% CI 0·003 to 0·2) as was the average PDQL score (difference 3·0 points, 0·4 to 5·6). Secondary analysis with correction for baseline disease severity showed no differences between groups for ALDS (difference 0·9 points, 95% CI -0·6 to 2·4; corresponding raw logit score difference 0·1, -0·02 to 0·3) or PDQL (difference 1·7 points, -1·2 to 4·6). Secondary outcomes did not differ between groups (UPDRS III score difference 0·6 points, 95% CI -1·4 to 2·6; BELA-A-k score difference 0·8 points, -0·2 to 1·8; cost difference €742, -€489 to €1950). Interpretation: This integrated care approach offered only small benefits to patients with Parkinson's disease, and these disappeared after correction for baseline disease severity. These results suggest that different approaches are needed to achieve more substantial health benefits. Funding: NutsOhra Foundation, Stichting Parkinson Nederland, National Parkinson Foundation. © 2013 Elsevier Ltd.


Cannon C.P.,Harvard University | Blazing M.A.,Duke Clinical Research Institute DCRI | Giugliano R.P.,Harvard University | McCagg A.,Harvard University | And 17 more authors.
New England Journal of Medicine | Year: 2015

BACKGROUND: Statin therapy reduces low-density lipoprotein (LDL) cholesterol levels and the risk of cardiovascular events, but whether the addition of ezetimibe, a nonstatin drug that reduces intestinal cholesterol absorption, can reduce the rate of cardiovascular events further is not known. METHODS: We conducted a double-blind, randomized trial involving 18,144 patients who had been hospitalized for an acute coronary syndrome within the preceding 10 days and had LDL cholesterol levels of 50 to 100 mg per deciliter (1.3 to 2.6 mmol per liter) if they were receiving lipid-lowering therapy or 50 to 125 mg per deciliter (1.3 to 3.2 mmol per liter) if they were not receiving lipid-lowering therapy. The combination of simvastatin (40 mg) and ezetimibe (10 mg) (simvastatin-ezetimibe) was compared with simvastatin (40 mg) and placebo (simvastatin monotherapy). The primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, unstable angina requiring rehospitalization, coronary revascularization (≥30 days after randomization), or nonfatal stroke. The median follow-up was 6 years. RESULTS: The median time-weighted average LDL cholesterol level during the study was 53.7 mg per deciliter (1.4 mmol per liter) in the simvastatin-ezetimibe group, as compared with 69.5 mg per deciliter (1.8 mmol per liter) in the simvastatin-monotherapy group (P<0.001). The Kaplan-Meier event rate for the primary end point at 7 years was 32.7% in the simvastatin-ezetimibe group, as compared with 34.7% in the simvastatin-monotherapy group (absolute risk difference, 2.0 percentage points; hazard ratio, 0.936; 95% confidence interval, 0.89 to 0.99; P = 0.016). Rates of pre-specified muscle, gallbladder, and hepatic adverse effects and cancer were similar in the two groups. CONCLUSIONS: When added to statin therapy, ezetimibe resulted in incremental lowering of LDL cholesterol levels and improved cardiovascular outcomes. Moreover, lowering LDL cholesterol to levels below previous targets provided additional benefit. Copyright © 2015 Massachusetts Medical Society.


Geutjes P.,Canisius Wilhelmina Ziekenhuis
Huisarts en Wetenschap | Year: 2015

Abstract: Geutjes PJ, Van den Ouweland JMW. Combination screening for vitamin B12 deficiency. HuisartsWet 2015;58(5):234-7. Objective: The diagnosis of vitamin B12 screening deficiency rests on the measurement of the total vitamin B12 concentration in blood, but this method has its limitations. The additional measurement of methylmalonic acid (MMA), a marker of functional vitamin B12 status, may improve the diagnosis of vitamin B12 deficiency. However, the two assays in combination are rarely used in clinical practice. The aim of this study was to investigate the diagnostic yield of the combined measurement in primary care. Design: Observational study. In 2012 a new screening scheme was introduced in the blood analysis service Rivierenland Gelre, by which MMA levels are measured when vitamin B12 concentrations are between 100 and 200 pmol/L (1752 of 8246 samples submitted in this study). Patients with a vitamin B12 concentration < 100 pmol/L or an MMA concentration of > 0.34 µmol/L are considered to be vitamin B12 deficient regardless of their clinical background. Results: The prevalence of vitamin B12 deficiency was 8[%] in this study: 1[%] with a serum vitamin B12 concentration < 100 pmol/L and 7[%] with an MMA concentration > 0.34 µmol/L. Of the samples screened with both assays, 27[%] that had a ‘normal’ vitamin B12 concentration (150-200 pmol/L) had a raised level of MMA (> 0.34 µmol/L). Of the samples with a ‘low’ vitamin B12 concentration (100-150 pmol/L), 59[%] had a normal MMA concentration and thus a normal vitamin B12 status. Conclusion: Measurement of MMA in addition to vitamin B12 levels changes the classification of patients with intermediate concentrations of vitamin B12, which could lead to over- or under-diagnosis and treatment of vitamin B12 deficiency. © 2015, Bohn, Stafleu van Loghum.


Snijders S.L.,Canisius Wilhelmina Ziekenhuis
Nederlands tijdschrift voor geneeskunde | Year: 2010

A 70-year-old woman was admitted to hospital with fever and signs of bronchopneumonia following a recent visit to Southeast Asia. She was diagnosed with melioidosis and treated with ceftazidime i.v. for two weeks, followed by oral co-trimoxazol and folinic acid. She recovered and had no recurring disease in the first year following recovery. Melioidosis is caused by an infection with Burkholderia pseudomallei. Clinical presentation can vary, but pneumonia is present in most patients. The diagnosis should be considered in patients with reduced immunological resistance who have been in endemic areas such as Southeast Asia, especially during the rainy season. It is important to determine which countries have been visited by patients who have recently returned from tropical areas. In addition, the time of onset, the duration of symptoms and a detailed physical examination are essential in the assessment of patients presenting with exotic diseases.


Mulleners W.M.,Canisius Wilhelmina Ziekenhuis
Nederlands tijdschrift voor geneeskunde | Year: 2010

Migraine patients who experience an average of 2 or more attacks per month are eligible for preventive treatment as well as treatment for acute attacks. The decision to offer preventative treatment is also made on the basis of the average attack duration, severity of the attacks, and response to attack treatment. Prior to initiating preventive treatment, the average attack frequency per month should be assessed, preferably by means of a headache diary over a number of months, as attack frequency is extremely variable. None of the currently available preventive drugs, such as beta-blockers, sodium valproate, topiramate and candesartan, were developed specifically for treating migraine, but were all originally intended for other indications. 50% of the migraine patients receiving preventive treatment can expect a 50% reduction in attacks, and the remaining attacks often seem to be less severe. The effects of the drugs are often unpredictable per individual, and side-effects frequently lead to early discontinuation of treatment. Drugs usually prescribed for cardiovascular disorders are often used. In the case of a disorder such as migraine with a high burden of disability, patients with cardiovascular or pulmonary comorbidity should receive medication that is optimally adjusted for both indications.


Mulleners W.M.,Canisius Wilhelmina Ziekenhuis | McCrory D.C.,Duke University | McCrory D.C.,Center for Health Services Research in Primary Care | Linde M.,Norwegian University of Science and Technology | Linde M.,St Olavs University Hospital
Cephalalgia | Year: 2015

Introduction: The efficacy of several antiepileptics in the preventive treatment of episodic migraine in adults has been systematically reviewed. Because many trial reports have been published since then, an updated systematic review was warranted. Methods: We searched the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE (1966 to January 15, 2013), MEDLINE In-Process (current week, January 15, 2013), and EMBASE (1974 to January 15, 2013) and handsearched Headache and Cephalalgia through January 2013. Prospective, controlled trials of antiepileptics taken regularly to prevent the occurrence of migraine attacks, to improve migraine-related quality of life, or both, were selected. Results: Mean headache frequency on topiramate and sodium valproate is significantly lower than placebo. Likewise, topiramate and divalproex demonstrated favorable results for the proportion of subjects with ≥50% reduction of migraine attacks. For topiramate, 100 mg and 200 mg outperformed 50 mg, but this was paralleled by a higher adverse event rate. For valproate/divalproex, a dose-effect correlation could not be established. There was no unequivocal evidence of efficacy for any of the other antiepileptics. Conclusion: Topiramate, sodium valproate and divalproex are effective prophylactic treatments for episodic migraine in adults. In contrast to previous reports, there is insufficient evidence to further support the use of gabapentin. © International Headache Society 2014.


Chronicle E.P.,University of Hawaii at Manoa | Mulleners W.M.,Canisius Wilhelmina Ziekenhuis
Cochrane Database of Systematic Reviews | Year: 2016

Background: This review has been split and updated in a series of four new reviews, all with the author byline Linde M, Mulleners WM, Chronicle EP, McCrory DC. The new titles are: 1. Topiramate for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010610. DOI: 10.1002/14651858.CD010610. 2. Valproate (valproic acid or sodium valproate or a combination of the two) for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010611. DOI: 10.1002/14651858.CD010611. 3. Gabapentin or pregabalin for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010609. DOI: 10.1002/14651858.CD010609. 4. Antiepileptics other than gabapentin, pregabalin, topiramate, and valproate for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010608. DOI: 10.1002/14651858.CD010608. Readers are referred to those reviews for updated results. Anticonvulsant drugs seem to be useful in clinical practice for the prophylaxis of migraine. This might be explained by a variety of actions of these drugs in the central nervous system. Objectives: To describe and assess the evidence from controlled trials on the efficacy and tolerability of anticonvulsants for preventing migraine attacks in adult patients with migraine. Search methods: We searched PubMed (1966-December 2005), EMBASE (1974-December 2005) and the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2005), and handsearched Headache and Cephalalgia through April 2006. Selection criteria: Studies were required to be prospective, controlled trials of anticonvulsant drugs taken regularly to prevent the occurrence of migraine attacks and/or to reduce the intensity of those attacks. Data collection and analysis: Studies were selected and data extracted by two independent reviewers. For migraine frequency data, standardized mean differences (SMDs) were calculated for individual studies and pooled across studies. For dichotomous data on significant reduction in migraine frequency, odds ratios (ORs) and numbers-needed-to-treat (NNTs) were similarly calculated. Adverse events were analyzed by calculating numbers-needed-to-harm (NNHs) for studies using similar agents. Main results: Twenty-three papers met the inclusion criteria. In total, data from 2927 patients were considered. Analysis of data from 10 trials (n = 902) demonstrates that anticonvulsants, considered as a class, reduce migraine frequency by about 1.3 attacks per 28 days as compared to placebo (WMD -1.31; 95% confidence interval [CI] -1.99 to -0.63). Data from 13 trials (n = 1773) show that anticonvulsants, considered as a class, also more than double the number of patients for whom migraine frequency is reduced by 50% or more relative to placebo (RR 2.25; 95% CI 1.79 to 2.84; NNT 3.9; 95% CI 3.4 to 4.7). For six trials of sodium valproate and divalproex sodium, NNHs for five clinically important adverse events ranged from 7.0 to 18.8. For six trials of topiramate, NNHs for seven adverse events (100 mg dose) ranged from 2.4 to 31.2. Authors' conclusions: Anticonvulsants appear to be both effective in reducing migraine frequency and reasonably well tolerated. There is noticeable variation among individual agents, but there are insufficient data to know whether this is due to chance or variation in true efficacy. Acetazolamide, clonazepam, lamotrigine and vigabatrin were not superior to placebo (one trial each). Relatively few robust trials are available for agents other than sodium valproate/divalproex sodium and topiramate; gabapentin in particular needs further evaluation. Trials designed with sufficient power to compare different drugs are also necessary. © 2016 The Cochrane Collaboration.


A laparoscopic tubectomy in the lithotomy position was performed on a healthy 31-year-old woman, as treatment following an extra-uterine pregnancy. The operation proceeded without complications and took 60 minutes. However, on the third day following surgery the woman was diagnosed with compartment syndrome, which was treated with three-compartment fasciotomy. Compartment syndrome is a rare but dangerous complication of an operation in the lithotomy position. Since pressure on leg compartments increases with time spent in the lithotomy position, regardless of the type of stirrups used, it is important to maintain the position only as long as is necessary for the procedure. The patient's legs should be taken out of the lithotomy position as soon as possible, and the position resumed if necessary at a later stage in the procedure. This can easily be achieved with pneumatic stirrups.


Two infants with congenital toxoplasmosis are presented. A girl born prematurely was treated postnatally after the mother had received antimicrobial treatment during pregnancy for acute toxoplasmosis. Apart from being small for gestational age, she remained without symptoms and treatment was ceased after 13 months. A 2-month-old boy presented with hydrocephalus and chorioretinitis, consistent with congenital toxoplasmosis. Despite antimicrobial treatment, at 12 months of age he suffered from epilepsy, cerebral palsy and vision impairment. Most infants with congenital toxoplasmosis (2 per 1000 live births in the Netherlands) are asymptomatic at birth. The education of pregnant women is crucial for the prevention of congenital toxoplasmosis. Awareness of antenatal and postnatal presenting signs and symptoms is important for clinicians, because early diagnosis and treatment may minimize sequelae. Untreated, the majority of affected infants will develop chorioretinitis, deafness and/or neurological symptoms.

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