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Doeksen A.,Diakonessen Hospital | Van Lanschot J.J.B.,Erasmus Medical Center
Canadian Journal of Surgery | Year: 2013

Background: There is a lack of outcome data beyond local recurrence rates after primary treatment in rectal cancer, despite more information being necessary for clinical decision-making. We sought to determine patient selection, therapeutic modalities and outcomes of locally recurrent rectal cancer treated with curative intent. Methods:We searched MEDLINE (1990-2010) using the medical subject headings "rectal neoplasms" and "neoplasm recurrence, local." Selection of cohort studies was based on the primary intention of treatment and availability of at least 1 outcome variable. Results:We included 55 cohort studies comprising 3767 patients; 8 studies provided data on the rate of intentionally curative treatment from an unselected consecutive cohort of patients (481 of 1188 patients; 40%). Patients were symptomatic with pain in 50% (796 of 1607) of cases. Overall, 3088 of 3767 patients underwent resection. The R0 resection rate was 56% (1484 of 2637 patients). The rate of external beam radiotherapy was 100% in 9 studies, 0% in 5 studies, and ranged from 12% to 97% in 37 studies. Overall postoperative mortality was 2.2% (57 of 2515 patients). Five-year survival was at least 25%, with an upper limit of 41% in 11 of 18 studies including at least 50 resections. We found a significant increase in reported survival rates over time (r2 = 0.214, p = 0.007). Conclusion: More uniformity in treatment protocols and reporting on outcomes for locally recurrent rectal cancer is warranted. The observed improvement of reported survival rates in time is probably related to better patient selection and optimized multimodality treatment in specialized centres. © 2013 Canadian Medical Association.


De Smet A.M.G.A.,University Utrecht | Kluytmans J.A.J.W.,Amphia Hospital | Kluytmans J.A.J.W.,VU University Amsterdam | Blok H.E.M.,University Utrecht | And 16 more authors.
The Lancet Infectious Diseases | Year: 2011

Background: Previously, we assessed selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) on survival and prevention of bacteraemia in patients in intensive-care units. In this analysis, we aimed to assess effectiveness of these interventions for prevention of respiratory tract colonisation and bacteraemia with highly resistant microorganisms acquired in intensive-care units. Methods: We did an open-label, clustered group-randomised, crossover study in 13 intensive-care units in the Netherlands between May, 2004, and July, 2006. Participants admitted to intensive-care units with an expected duration of mechanical ventilation of more than 48 h or an expected stay of more than 72 h received SOD (topical tobramycin, colistin, and amphotericin B in the oropharynx), SDD (SOD antibiotics in the oropharynx and stomach plus 4 days' intravenous cefotaxime), or standard care. The computer-randomised order of study regimens was applied by an independent clinical pharmacist who was masked to intensive-care-unit identity. We calculated crude odds ratios (95% CI) for rates of bacteraemia or respiratory tract colonisation with highly resistant microorganisms in patients who stayed in intensive-care units for more than 3 days (ie, acquired infection). This trial is registered at http://isrctn.org, number ISRCTN35176830. Findings: Data were available for 5927 (>99%) of 5939 patients, of whom 5463 (92%) were in intensive-care units for more than 3 days. 239 (13%) of 1837 patients in standard care acquired bacteraemia after 3 days, compared with 158 (9%) of 1758 in SOD (odds ratio 0·66, 95% CI 0·53-0·82), and 124 (7%) of 1868 in SDD (0·48, 0·38-0·60). Eight patients acquired bacteraemia with highly resistant microorganisms during SDD, compared with 18 patients (with 19 episodes) during standard care (0·41, 0·18-0·94; rate reduction [RR] 59%, absolute risk reduction [ARR] 0·6%) and 20 during SOD (0·37, 0·16-0·85; RR 63%, ARR 0·7%). Of the patients staying in intensive-care units for more than 3 days, we obtained endotracheal aspirate cultures for 881 (49%) patients receiving standard care, 886 (50%) receiving SOD, and 828 (44%) receiving SDD. 128 (15%) patients acquired respiratory tract colonisation with highly resistant microorganisms during standard care, compared with 74 (8%) during SDD (0·58, 0·43-0·78; RR 38%, ARR 5·5%) and 88 (10%) during SOD (0·65, 0·49-0·87; RR 32%, ARR 4·6%). Acquired respiratory tract colonisation with Gram-negative bacteria or cefotaxime-resistant and colistin-resistant pathogens was lowest during SDD. Interpretation: Widespread use of SDD and SOD in intensive-care units with low levels of antibiotic resistance is justified. Funding: None. © 2011 Elsevier Ltd.


Baijens L.W.J.,Maastricht University | Speyer R.,James Cook University | Passos V.L.,Maastricht University | Pilz W.,Maastricht University | And 3 more authors.
Laryngoscope | Year: 2013

Objectives/Hypothesis A new treatment for oropharyngeal dysphagia in Parkinson's disease was evaluated in the present study. Study Design Prospective randomized controlled trial. Methods The study describes the effects of surface electrical stimulation (SES) of the neck (submental region) in dysphagic Parkinson patients using different intensities of electrical current. Quasi-random allocation was performed when assigning patients to treatment groups. Three groups consisting of dysphagic patients with idiopathic Parkinson's disease (N = 90) received daily treatment for 15 days with periods of no treatment during the weekend. All three received traditional logopedic dysphagia treatment. In addition, two groups received SES, either motor-level or sensory-level stimulation. A standardized measurement protocol, including fiber optic endoscopic evaluation of swallowing (FEES) and videofluoroscopy of swallowing (VFS), was performed before and after therapy. A team of experienced raters was blinded to the treatment group and to the moment of measurement. Intrarater and interrater reliability were calculated. Results Using proportional odds models (POMs), some of the visuoperceptual ordinal outcome variables showed significant improvement in all groups following treatment. Following 15 days of SES of the submental region, few significant effects were found, suggesting a therapy effect of traditional logopedic dysphagia treatment without any additional influence of SES. Conclusions On the grounds of this study, it is concluded that further research is needed on the exact mechanism of SES and its effects on the neural pathways involved in swallowing. Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.


Engel M.F.,University Utrecht | Van Velzen M.,University Utrecht | Hoepelman A.I.M.,University Utrecht | Thijsen S.,Diakonessen Hospital | Oosterheert J.J.,University Utrecht
European Journal of Clinical Microbiology and Infectious Diseases | Year: 2013

A positive pneumococcal urinary antigen test (PUAT) for Streptococcus pneumoniae allows an early switch from empiric to targeted treatment in hospitalised community-acquired pneumonia (CAP) patients. The economic and treatment consequences of this widespread implemented test are, however, unknown. We retrospectively evaluated all tests performed since its introduction in two teaching hospitals. Data on patient characteristics, treatment, admission and outcome were retrieved from the electronic patient files. Test benefits were expressed as the number of days that targeted therapy (i.e. penicillin) was administered to hospitalised CAP patients due to a positive PUAT. This calculation was based on the timing of the PUAT and the initiation of targeted therapy. Subsequently, we performed two direct cost analyses from a hospital perspective, first including tests performed for CAP only, and second including costs of all (excessive) tests. Between 2005 and 2012, 3,479 PUATs were performed, of which 1,907 (55 %) were for CAP. A total of 1,638 PUATs (86 %) were negative and 269 (14 %) were positive. Fifty-two (19 %) positive tests were excluded. In 75 (35 %) of the 217 remaining positive tests, a positive PUAT led to targeted treatment during 293 cumulative admission days. Testing costs for CAP only were €131 per targeted treatment day. These costs were €257 if local protocol dictated PUAT use for all CAP cases, as opposed to €72 if the test was reserved for severe cases only. When including all tests, PUAT costs were €254 per targeted treatment day. Therefore, improving the selective use of the PUAT in hospitalised CAP patients may lead to increased (cost-)efficiency. © 2012 Springer-Verlag Berlin Heidelberg.


Datema F.R.,Diakonessen Hospital | Datema F.R.,Erasmus Medical Center | Lohuis P.J.F.M.,Diakonessen Hospital
Aesthetic Plastic Surgery | Year: 2015

Background: Overprojection of the nasal tip is a common problem in aesthetic Caucasian and Mediterranean rhinoplasty patients. In these patients, shortening of the conjoined medial crura frequently plays an important part in deprojection of the nasal tip. The combination of vertical incision maneuvers of the medial crura and tongue-in-groove (TIG) allows the surgeon to achieve significant control over projection, rotation and shape of the nasal tip. In this article we present our graduated approach towards nasal tip deprojection in aesthetic Caucasian and Mediterranean rhinoplasty together with a statistical analysis of overall success.Methods: This retrospective study based on 22 consecutive Caucasian or Mediterranean patients who had aesthetic, open deprojection rhinoplasty combining TIG with either footplate resection or medial crural overlay by one surgeon between 2009 and 2011. Aesthetical success was determined by statistical analysis of change in subjective body image in relation to nasal appearance, scored on five aesthetic 5-point Likert Scale questions and a 10 cm visual analog scale. Change in projection was calculated using a modified Goode method, applied on standardized pre- and postoperative photographs which were also used to measure change in rotation.Results: Subjective body image in relation to nasal appearance improved from 15.14 to 6.55 (p < 0.01). The mean aesthetic VAS score improved from 3.32 to 7.91 (p < 0.01). Substantial deprojection was measured in 19 patients (86.4 %) with a mean deprojection ratio of 0.06 [range 0.02–0.16]. An increased projection ratio of 0.03 was encountered in one patient and in two patients projection was unchanged.Conclusions: Analysis of objective and subjective aesthetic outcome data suggest that our deprojection algorithm helps to deliver consistently good results in Caucasian and Mediterranean patients who require open deprojection rhinoplasty.Level of Evidence IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. © 2014, Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery.


Ton E.,University Utrecht | Bakker M.F.,University Utrecht | Verstappen S.M.M.,University Utrecht | Ter Borg E.J.,Sint Antonius Hospital | And 5 more authors.
Journal of Rheumatology | Year: 2012

Objective. To explore the influence of tender points (TP) on the Disease Activity Score assessing 28 joints (DAS28) in patients with rheumatoid arthritis (RA). Methods. In 200 consecutive patients with RA from the outpatient clinic, DAS28 and its components, tender and swollen joint counts (TJC, SJC, respectively), visual analog scale (VAS) for patient's general health (GH), and erythrocyte sedimentation rate (ESR), along with a tender point count (TPC) were assessed. Patients were categorized according to 4 TPC classes: zero, 1-5, 6-10, and ≥ 11 TP. The influence of TPC classes on DAS28 and its individual components was determined with Kruskal-Wallis tests and correlations between TP and DAS28 and its components were calculated. Results. In 196 eligible patients, 70% were female, mean age was 59 years, and median disease duration was 3.9 years; median DAS28 was 3.1; and 49% had active disease, defined as DAS28 > 3.2. In 15% of patients, the TPC was ≥ 11, in 12% 6-10, in 30% 1-5, and in 43% zero. TPC significantly influenced the DAS28 and its less objective components TJC and VAS-GH (i.e., based on patient's report), but not the more objective DAS28 components SJC and ESR (i.e., observer- and laboratory-based). Conclusion. DAS28 is influenced by tender points, even in the non-fibromyalgia range, falsely suggesting higher disease activity and decreasing the sensitivity of the DAS28 criterion of low disease activity or remission. When applying DAS28-guided "tight control" or "treat-to-target" treatment strategies in RA, evaluation of not only the DAS28, but also its individual components along with a full joint and physical evaluation including assessment of TP is required to reliably estimate the individual's disease activity, which guides therapeutic decisions. The Journal of Rheumatology Copyright © 2012. All rights reserved.


Bruijning-Verhagen P.,University Utrecht | Mangen M.-J.J.,University Utrecht | Felderhof M.,Spaarne Hospital | Hartwig N.G.,Sint Franciscus Hospital | And 4 more authors.
BMC Medicine | Year: 2013

Background: The cost-effectiveness of universal rotavirus (RV) vaccination is controversial in developed countries. As a result, RV vaccination programs do not currently exist in most European countries. Hospitalization is the main driver of RV disease costs, and prematurity, low birth weight (LBW) and underlying medical conditions have been associated with RV hospitalization and complications. We investigated the cost-effectiveness of targeted RV vaccination of high-risk infants and universal RV vaccination versus no vaccination. Methods: Disease burden, mortality and healthcare costs of RV hospitalization for children with and without prematurity, LBW and congenital pathology were quantified in two hospital-based observational studies in the Netherlands. Cost-effectiveness analysis was based on an age-structured stochastic multi-cohort model of the Dutch population comparing universal RV vaccination and targeted vaccination of high-risk infants to no vaccination. The primary endpoint was the incremental cost-effectiveness ratio (ICER), with a threshold of €35,000/quality-adjusted life year (QALY) from the healthcare provider perspective. Sensitivity analyses included vaccine price and coverage, herd-immunity and QALY losses. Results: A total of 936 children with RV infection were included. Prematurity, LBW and congenital pathology were associated with increased risks of RV hospitalization (relative risks (RR) ranging from 1.6 to 4.4), ICU admission (RR ranging from 4.2 to 7.9), prolonged hospital stay (1.5 to 3.0 excess days) and higher healthcare costs (€648 to €1,533 excess costs). Seven children succumbed due to RV complications, all belonging to the high-risk population. Targeted RV vaccination was highly cost-effective and potentially cost-saving from the healthcare provider perspective with ICERs below €20,000/QALY in all scenarios with total (undiscounted) annual healthcare costs between -€0.1 and €0.5 million/year. Results were most sensitive to mortality rates, but targeted vaccination remained highly cost-effective up to reductions of 90% compared to observed mortality. Universal RV vaccination was not considered cost-effective (mean ICER: €60,200/QALY) unless herd-immunity and caretaker QALY losses were included and vaccine prices were €60 at most (mean ICER: €21,309/QALY). Conclusion: We recommend targeted RV vaccination for high-risk infants in developed countries. © 2013 Bruijning-Verhagen et al.; licensee BioMed Central Ltd.


Lohuis P.J.F.M.,Diakonessen Hospital | Hakim S.,Leiden University | Duivesteijn W.,Leiden University | Knobbe A.,Leiden University | Tasman A.-J.,Leiden University
Plastic and Reconstructive Surgery | Year: 2013

BACKGROUND: The authors tested a short, practically designed questionnaire to assess changes in subjective perception of nasal appearance in patients before and after aesthetic rhinoplasty. METHODS: A prospective cohort study was conducted in a group of 121 patients who desired aesthetic rhinoplasty and were operated on by one surgeon. The questionnaire contained five questions (E1-E5) based on a five-point Likert scale and a visual analogue scale (range, 0 to 10). Two questions were designed as trick questions to help the surgeon screen for signs of body dysmorphic disorder. RESULTS: All patients rated the appearance of their nose as improved after surgery. The visual analogue scale revealed a Gaussian curve of normal distribution (range, 0.5 to 10) around a significant improvement (mean, 4.36 points, p = 0.018). Also, question E1, question E2, and the sum of questions E1 through E5 showed a statistically significant improvement after surgery (p = 1.74 × 10, p = 4.29 × 10, and p = 9.23 × 10, respectively). The authors found a linear relationship between preoperative score on the trick questions and postoperative increase in visual analogue scale score. Test-retest reliability could be investigated in 74 of 121 patients (61 percent) and showed a positive correlation between postoperative (1 year after surgery) and repostoperative response (2 to 4 years after surgery). CONCLUSIONS: The authors concluded that a surgeon performing aesthetic rhinoplasty can benefit from using this questionnaire. It is simple, takes no more than 2 minutes to complete, and provides helpful subjective information regarding patients' preoperative nasal appearance and postoperative surgical outcome. Copyright © 2013 by the American Society of Plastic Surgeons.


Datema F.R.,Erasmus Medical Center | Lohuis P.J.F.M.,Diakonessen Hospital
Facial Plastic Surgery | Year: 2016

The tongue-in-groove (TIG) is a conservative but powerful surgical suture technique to control tip rotation and projection, to set an appropriate alar-columellar relationship, to straighten a caudal septal deviation, and to stabilize the nasal base. TIG is suitable in primary and most revision cases and is easily combined with other surgical techniques. Seventeen years after its popularization, the TIG technique is embedded in modern-day rhinoplasty literature and teaching material. This article describes indications and considerations during external primary and revision rhinoplasty, based on clinical experience and the available literature. © 2016 by Thieme Medical Publishers.


Bouwman J.J.M.,Diakonessen Hospital Utrecht | Thijsen S.F.T.,Diakonessen Hospital Utrecht | Bossink A.W.,Diakonessen Hospital
Journal of Infection | Year: 2012

Vacutainer CPT tubes require blood samples for TSPOT.TB to be processed within 8h. In this study we evaluated the ability of T-Cell Xtend to maintain the number and function of lymphocytes after 24 and 48h of blood storage, giving similar test results as in freshly isolated specimens. Methods: Whole blood specimens from 59 individuals were collected in Vacutainer CPT tubes (CPT) and lithium heparin (LH) tubes. CPT tubes were processed within 8h. T-Cell Xtend was added to LH tubes after 24 or 48h. We also left LH tubes untreated for 48h. Total number of white blood cells (WBC) and proportions of lymphocytes and granulocytes were determined in the isolated Peripheral Blood Mononuclear Cells (PBMC). We also evaluated the performance of T-Cell Xtend in the TSPOT.TB assay. Results: PBMC yields from T-Cell Xtend treated LH samples did not differ from PBMC yields from CPT tubes, but T-Cell Xtend had a pronounced effect on the proportions of lymphocytes and granulocytes. The mean lymphocyte percentage in PBMCs isolated from fresh CPT blood was 84.31±1.14% (at t=48h), but was decreased to 52.72±3.34% (p<0.05) in untreated LH blood (at t=48h). This effect was neutralized by T-Cell Xtend (85.44±0.74%). We observed a similar but opposite effect on granulocytes: The mean proportion in untreated LH blood was increased to 40.9±3.67% (p<0.001) compared to CPT blood (8.26±0.89%). Treatment of LH samples with T-Cell Xtend (48h) restored the proportion of granulocytes to 8.47±0.61%. Enumeration of spots in the TSPOT.TB assay demonstrated good agreement between CPT and T-Cell Xtend results, even after 48 h. Conclusions: T-Cell Xtend efficiently removes granulocytes from PBMC suspensions and increases the proportion of lymphocytes. TSPOT.TB results from T-Cell Xtend treated blood samples are at least comparable to the results obtained from the current CPT method. Use of standard lithium heparin blood combined with T-Cell Xtend allows up to 48h storage of blood samples for batched processing and may further decrease the rate of indeterminate TSPOT.TB results. © 2011 The British Infection Association.

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