Since a decade, Clostridium difficile infection (CDI) has increased progressively in incidence and severity of disease. Currently, CDI is considered the leading cause of nosocomial diarrhoea,... Show moreSince a decade, Clostridium difficile infection (CDI) has increased progressively in incidence and severity of disease. Currently, CDI is considered the leading cause of nosocomial diarrhoea, associated with an increased duration of hospitalization, healthcare expenses, morbidity and mortality. This thesis describes our findings with outbreak control, diagnosis, identification of specific risk factors and treatment of CDI after the discovery of the emergence of C. difficile PCR-ribotype 027 in the Netherlands. The studies illustrate the role of antibiotics in relation to persistence, severeness and spreading of CDI. Antibiotics are shown to be a primary risk factor for the development of (ribotype-specific) CDI and an essential part of the outbreak control measures (__bundle-approach__), namely antibiotic stewardship. The use of antibacterials is a risk for selection of novel endemic C. difficile strains in e.g. animals, which introduce an increasing risk of alternative zoonotic transmission routes. Except for very mild CDI, which is clearly induced by usage of specific antibiotics, antibacterial treatment is advised. This thesis reviews the comparative effectiveness of the currently available treatment modalities, thereby providing evidence-based recommendations for CDI remedies. Treatment options include: oral and non-oral antibiotics, toxin-binding resins and polymers, immunotherapy, probiotics, faecal or bacterial intestinal transplantation. Show less
In contrast with the intuitive feeling of physicians many worrisome MRI findings do not correlate with patient outcome in patients with sciatica. Physicians should for example not automatically... Show moreIn contrast with the intuitive feeling of physicians many worrisome MRI findings do not correlate with patient outcome in patients with sciatica. Physicians should for example not automatically ascribe persistent or recurrent symptoms of sciatica to the presence of abnormalities visible on MRI. This thesis enables physicians to reshape the mindset of many persons thinking that knowing imaging findings can only be good. Seeing MRI abnormalities of patients with sciatica should not always be believing. Show less
Fagerli, K.M.; Lie, E.; Heijde, D. van der; Heiberg, M.S.; Kalstad, S.; Rodevand, E.; ... ; Kvien, T.K. 2013
This thesis describes the outcomes an possibilities of drug-tapering in rheumatoid arthritis (RA) patients treated to target. Data from the BeSt cohort were used, in which early RA patients were... Show moreThis thesis describes the outcomes an possibilities of drug-tapering in rheumatoid arthritis (RA) patients treated to target. Data from the BeSt cohort were used, in which early RA patients were randomized to 4 treatment arms: initial monotherapy, sequential or step-up, or initial combination therapy, with prednisone or TNF-blocker infliximab. The disease activity score (DAS) was measured every three months and treatment was changed or added to in case of insufficient response (DAS >2.4). This thesis shows that continued low disease activity steered treatment is possible and leads to maintenance of good functional ability in the majority of patients during 8 years of follow-up. Initial combination therapy is beneficial in the first months of treatment but is not associated with better longer-term results, except in anti-citrullinated protein antibodies positive patients. Initial combination therapy with TNF-blo cker infliximab can be successfully discontinued in over 50% of early RA patients, and in around 20% of all patients, all medication can be stopped when prolonged remission is achieved. Show less
Tack, G.J.; Water, J.M.W. van de; Bruins, M.J.; Kooy-Winkelaar, E.M.C.; Bergen, J. van; Bonnet, P.; ... ; Koning, F. 2013
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