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Port Alfred, South Africa

Labrie J.,University Utrecht | Berghmans B.L.C.M.,Maastricht University | Fischer K.,University Utrecht | Milani A.L.,Reinier de Graaf Gasthuis | And 14 more authors.
New England Journal of Medicine | Year: 2013

BACKGROUND: Physiotherapy involving pelvic-floor muscle training is advocated as first-line treatment for stress urinary incontinence; midurethral-sling surgery is generally recommended when physiotherapy is unsuccessful. Data are lacking from randomized trials comparing these two options as initial therapy. METHODS: We performed a multicenter, randomized trial to compare physiotherapy and midurethral-sling surgery in women with stress urinary incontinence. Crossover between groups was allowed. The primary outcome was subjective improvement, measured by means of the Patient Global Impression of Improvement at 12 months. RESULTS: We randomly assigned 230 women to the surgery group and 230 women to the physiotherapy group. A total of 49.0% of women in the physiotherapy group and 11.2% of women in the surgery group crossed over to the alternative treatment. In an intention-to-treat analysis, subjective improvement was reported by 90.8% of women in the surgery group and 64.4% of women in the physiotherapy group (absolute difference, 26.4 percentage points; 95% confidence interval [CI], 18.1 to 34.5). The rates of subjective cure were 85.2% in the surgery group and 53.4% in the physiotherapy group (absolute difference, 31.8 percentage points; 95% CI, 22.6 to 40.3); rates of objective cure were 76.5% and 58.8%, respectively (absolute difference, 17.8 percentage points; 95% CI, 7.9 to 27.3). A post hoc per-protocol analysis showed that women who crossed over to the surgery group had outcomes similar to those of women initially assigned to surgery and that both these groups had outcomes superior to those of women who did not cross over to surgery. CONCLUSIONS: For women with stress urinary incontinence, initial midurethral-sling surgery, as compared with initial physiotherapy, results in higher rates of subjective improvement and subjective and objective cure at 1 year. Copyright © 2013 Massachusetts Medical Society. Source

When two successive pregnancies end in intra-uterine fetal death (IUFD), the question of whether it is coincidental or if there is an underlying abnormality arises. Although diagnostic investigations into the underlying cause are not always carried out after IUFD, they are recommended by the professional body. A 28-year-old female attended our gynaecology outpatient clinic for a second opinion following two intra-uterine fetal deaths. Her own treating physician was of the opinion that there was no connection between the two IUFDs. After a multidisciplinary evaluation, the phenotype fetal akinesia deformation sequence (FADS) was diagnosed in both cases. This is a rare, clinically and aetiologically heterogeneous group of disorders. Thereafter the patient and her husband were offered specific pre-conception counseling. Every IUFD justifies systemic and multidisciplinary investigation to determine any underlying aetiology such as FADS. This may contribute to better pre-conception advice and prenatal individualised diagnostics in a subsequent pregnancy. Source

ter Bals E.,Onze Lieve Vrouwe Gasthuis | Odekerken D.A.M.,Spaarne Ziekenhuis | Somsen G.A.,Onze Lieve Vrouwe Gasthuis
Netherlands Heart Journal | Year: 2014

We describe a 76-year-old patient with takotsubo cardiomyopathy complicated by cardiac tamponade. Pericardial effusion in takotsubo cardiomyopthy is common but a cardiac tamponade is very rare. The use of anticoagulants may increase the risk of pericardial effusion and should be considered with care. © The Author(s) 2014. Source

Postma D.F.,University Utrecht | Van Werkhoven C.H.,University Utrecht | Van Elden L.J.R.,Diakonessenhuis Utrecht | Thijsen S.F.T.,Diakonessenhuis Utrecht | And 8 more authors.
New England Journal of Medicine | Year: 2015

Background: The choice of empirical antibiotic treatment for patients with clinically suspected community-acquired pneumonia (CAP) who are admitted to non-intensive care unit (ICU) hospital wards is complicated by the limited availability of evidence. We compared strategies of empirical treatment (allowing deviations for medical reasons) with beta-lactam monotherapy, beta-lactam-macrolide combination therapy, or fluoroquinolone monotherapy. Methods: In a cluster-randomized, crossover trial with strategies rotated in 4-month periods, we tested the noninferiority of the beta-lactam strategy to the beta-lactam-macrolide and fluoroquinolone strategies with respect to 90-day mortality, in an intention- to-treat analysis, using a noninferiority margin of 3 percentage points and a two-sided 90% confidence interval. Results: A total of 656 patients were included during the beta-lactam strategy periods, 739 during the beta-lactam-macrolide strategy periods, and 888 during the fluoroquinolone strategy periods, with rates of adherence to the strategy of 93.0%, 88.0%, and 92.7%, respectively. The median age of the patients was 70 years. The crude 90-day mortality was 9.0% (59 patients), 11.1% (82 patients), and 8.8% (78 patients), respectively, during these strategy periods. In the intention-to-treat analysis, the risk of death was higher by 1.9 percentage points (90% confidence interval [CI], -0.6 to 4.4) with the betalactam- macrolide strategy than with the beta-lactam strategy and lower by 0.6 percentage points (90% CI, -2.8 to 1.9) with the fluoroquinolone strategy than with the beta-lactam strategy. These results indicated noninferiority of the beta-lactam strategy. The median length of hospital stay was 6 days for all strategies, and the median time to starting oral treatment was 3 days (interquartile range, 0 to 4) with the fluoroquinolone strategy and 4 days (interquartile range, 3 to 5) with the other strategies. Conclusions: Among patients with clinically suspected CAP admitted to non-ICU wards, a strategy of preferred empirical treatment with beta-lactam monotherapy was noninferior to strategies with a beta-lactam-macrolide combination or fluoroquinolone monotherapy with regard to 90-day mortality. Copyright © 2015 Massachusetts Medical Society. All rights reserved. Source

Emanuel M.H.,Spaarne Ziekenhuis
Best Practice and Research: Clinical Obstetrics and Gynaecology | Year: 2013

Diagnostic and operative hysteroscopy have become standards in gynaecologic practice. Many hysteroscopic procedures have replaced old, invasive techniques, such as dilatation and curettage. As instruments have reduced in size, office hysteroscopy has begun to replace operating-room procedures. New instruments and techniques continue to emerge, and the prospects for improvement seem unlimited. Discussed are hysteroscopic sterilisation, bipolar electrosurgery, hysteroscopic morcellation, and virtual hysteroscopy. Furthermore, the evidence for supporting the vaginoscopic approach, cervical preparation, pain medication and the use of local anaesthetics is presented. Main hysteroscopic procedures, such as polypectomy, myomectomy, adhesiolysis, metroplasty, and the role of hysteroscopy before embryo transfer, are reviewed, and what has been proven is further discussed. © 2013 Published by Elsevier Ltd. Source

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