Anorectal disorders are common in general practice and the incidence of chronic anal fissure is 2.5 cases per 1000 persons in the Netherlands. A chronic anal fissure (CAF) refers to a longitudinal... Show moreAnorectal disorders are common in general practice and the incidence of chronic anal fissure is 2.5 cases per 1000 persons in the Netherlands. A chronic anal fissure (CAF) refers to a longitudinal ulcer or tear in the squamous epithelium, generally located in the posterior midline with symptoms present for longer than 4-6 weeks or recurrent fissures. The classical symptom is pain during defecation, which may persist for hours, and has a significant impact on quality of life.Although some debate exists on the pathogenesis of CAF, it is assumed that pain causes an increased anal sphincter tone leading to ischemia which inhibits fissure healing, generating a vicious circle of pain and constipation.Pelvic floor dysfunction e.g., dyssynergia and/or increased pelvic floor muscle tone may also be an underlying cause and part of the pathophysiology and a reason for unresponsiveness to treatment.A digital rectal examination including examination of the pelvic floor muscles and a comprehensive evaluation of the pelvis and surrounding structures is important to determine the underlying cause of pain and pelvic floor dysfunction.According to current guidelines, the initial conservative management is comprised of fibre intake and/or use of laxatives, toilet behaviour, lifestyle advice, sitz baths, and ointments.In the Pelvic floor Anal Fissure (PAF) study, we demonstrated that pelvic floor physical therapy yields a significant and clinical benefit in the time course and should be advocated as adjuvant conservative treatment in patients with CAF. Show less
BackgroundChronic nonbacterial osteomyelitis (CNO) is a rare, and impactful auto-inflammatory bone disease occurring in children and adults. Clinical care for CNO is challenging, as the condition... Show moreBackgroundChronic nonbacterial osteomyelitis (CNO) is a rare, and impactful auto-inflammatory bone disease occurring in children and adults. Clinical care for CNO is challenging, as the condition lacks validated classification criteria and evidence-based therapies. This study aimed to map the current diagnostic and therapeutic practices for CNO in adults, as a first step towards a standardized disease definition and future consensus treatment plans.MethodsA primary survey was spread among global rheumatological/bone networks and 57 experts as identified from literature (May 2022), covering terminology, diagnostic tools (clinical, radiological, biochemical) and treatment steps. A secondary survey (sent to primary survey responders in August 2022) further queried key diagnostic features, treatment motivations, disease activity and treatment response monitoring.Results36 and 23 physicians completed the primary and secondary survey respectively. Diagnosis was mainly based on individual physician assessment, in which the combination of chronic relapsing-remitting bone pain with radiologically-proven osteitis/osteomyelitis, sclerosis, hyperostosis and increased isotope uptake on bone scintigraphy were reported indicative of CNO. Physicians appeared more likely to refer to the condition as synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome in the presence of joint and skin pathology. MRI was most frequently performed, and the preferred diagnostic test for 47%. X-rays were second-most frequently used, although considered least informative of all available tools. Typical imaging features reported were hyperostosis, osteitis, osteosclerosis, bone marrow edema, while degeneration, soft tissue calcification, and ankylosis were not regarded characteristic. Inflammation markers and bone markers were generally regarded unhelpful for diagnostic and monitoring purposes and physicians infrequently performed bone biopsies. Management strategies diverged, including indications for treatment, response monitoring and declaration of remission. Step-1 treatment consisted of non-steroidal anti-inflammatory drugs/COX-2 inhibitors (83%). Common step 2-3 treatments were pamidronate, methotrexate, and TNF-a-inhibition (anti-TNF & alpha;), the latter two regarded especially convenient to co-target extra-skeletal inflammation in SAPHO syndrome. Overall pamidronate and anti-TNF & alpha; and were considered the most effective treatments.ConclusionsFollowing from our survey data, adult CNO is a broad and insufficiently characterized disease spectrum, including extra-osseous features. MRI is the favoured imaging diagnostic, and management strategies vary significantly. Overall, pamidronate and anti-TNF & alpha; are regarded most successful. The results lay out current practices for adult CNO, which may serve as backbone for a future consensus clinical guideline. Show less
Although intercountry adoption, according to systematic reviews as well as meta- analysis, is a successful intervention from a perspective of child protection, often a long road of therapy and... Show moreAlthough intercountry adoption, according to systematic reviews as well as meta- analysis, is a successful intervention from a perspective of child protection, often a long road of therapy and support is needed. Intercountry adoptees are overrepresented in mental health services worldwide, as they are in the Netherlands. The single focus on classifying the problems and using mainly CBT or videobased treatments, are not enough to help these children and their families. In this practice based article I propose to use Waters’ Star model (2016) for both assessment and treatment of mental health problems. In doing so, not only overt but also covert issues are addressed, e.g. dissociation. The latter is a common coping mechanism in intercountry adoptees but not often referred to in assessment or treatment. A tailor made treatment plan, involving the parents as co-therapists employing attachment based, developmental, trauma- and neurobiologically informed interventions will be discussed. The approach is illustrated by using case-examples. Show less
Research on the prevalence, diagnostic and prognostic value for treatment of personality pathology – i.e., both personality disorders and problematic personality characteristics – was... Show more Research on the prevalence, diagnostic and prognostic value for treatment of personality pathology – i.e., both personality disorders and problematic personality characteristics – was carried out within a mainly Dutch forensic mental health setting. Issues such as (dis)simulation and unintentional self-deception limit the utility of self-report instruments within a pre-trial setting. Personality disorders and psychopathic traits in suspected offenders in the Netherlands often lead to court rulings of enforced psychiatric treatment – an internationally unique situation. A prospective study on the predictive value of personality disorder isolated factors that can affect enforced treatment length, such as crime type and comorbidity, that can be a focus for policy makers and forensic mental health experts. Caution is advised when using self-report instruments within the forensic context, especially in the absence of response bias scales and in the case of (legal) incentives for certain outcomes. There is urgent need for international standardization of instruments and terminology and a test battery that is specifically designed for and validated within forensic populations. An increase in (detail of) digital registration of patient, treatment and risk characteristics is necessary for meaningful scientific research, a better assessment of personality and risks, fewer incidents, lower recidivism and shorter treatment. Show less
Parents are increasingly viewed as key to successful child (semi-) residential treatment. Positive outcomes for both the parents as the child with a psychiatric disorder are more likely to occur... Show moreParents are increasingly viewed as key to successful child (semi-) residential treatment. Positive outcomes for both the parents as the child with a psychiatric disorder are more likely to occur when effective levels of therapeutic alliances exist between team members and parents. Unfortunately, it remains unclear from the literature, how the establishment of the parent-treatment team alliance best contributes to child residential treatment outcome. Therefore, a more systematic approach is needed to help practitioners.The aim of this thesis is threefold: 1. Development of assessment strategies (instruments) of the parent-team alliance, 2. Longitudinal investigation of the relation between parent-team therapeutic alliance and semi-residential treatment outcome factors and 3. Examining the effect of strengthening the parent-team alliance on (semi-) residential treatment outcomes. Routine Outcome Monitoring was implemented at five semi-residential treatment units of Curium-LUMC, a Centre for Child and Adolescent Psychiatry. All newly admitted children and their parents, 46 children (6-12 years old) in total, were included in the ROM assessment. Results showed: 1)Alliance instruments are capable of assessing the parent-team alliance; 2)Parent-team alliance, parental stress and child'symptoms are interconnected, and 3)A structured investment of team members in the parent-team alliance strenghtens this alliance and positively indfluences childs'symptoms. Show less
Kersten, L.; Präzlich, M.; Mannstadt, S.; Ackermann, K.; Kohls, G.; Oldenhof, H.; ... ; Stadler, C. 2016
Background: In Europe, the number of females exhibiting oppositional defiant disorder (ODD) and conduct disorder (CD) is growing. Many of these females live in youth welfare institutions.... Show moreBackground: In Europe, the number of females exhibiting oppositional defiant disorder (ODD) and conduct disorder (CD) is growing. Many of these females live in youth welfare institutions. Consequently, there is a great need for evidence-based interventions within youth welfare settings. A recently developed approach targeting the specific needs of girls with ODD and CD in residential care is START NOW. The aim of this group-based behavioural skills training programme is to specifically enhance emotional regulation capacities to enable females with CD or ODD to appropriately deal with daily-life demands. It is intended to enhance psychosocial adjustment and well-being as well as reduce oppositional and aggressive behaviour. We present the study protocol (version 4.1; 10 February 2016) of the FemNAT-CD intervention trial titled 'Group-Based Treatment of Adolescent Female Conduct Disorders: The Central Role of Emotion Regulation'. Methods/design: The study is a prospective, confirmatory, cluster-randomised, parallel-group, multi-centre, randomised controlled trial with 128 institutionalised female adolescents who fulfil the diagnostic criteria of ODD and/or CD. Institutions/wards will be randomised either to provide the 12-week skills training as an add-on intervention or to provide treatment as usual. Once the first cycle is completed, each institution will run a second cycle with the opposite condition. Primary endpoints are the pre-post change in number of CD/ODD symptoms as assessed by a standardised, semi-structured psychiatric interview (Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime, CD/ODD section) between baseline and the end of intervention, as well as between baseline and a 3-month follow-up point. Secondary objectives include pre-post change in CD/ODD-related outcome measures, most notably emotional regulation on a behavioural and neurobiological level after completion of START NOW compared with treatment as usual. Discussion: To our knowledge, this study is the first to date to systematically investigate the effectiveness of an adapted integrative psychosocial intervention designed for female adolescents with ODD and CD in youth welfare settings. Trial registration: German Clinical Trials Register (DRKS) identifier: DRKS00007524. Registered on 18 December 2015 and with the World Health Organisation International Clinical Trials Registry Platform. Show less
Buikhuisen, W.A.; Hiddingab, B.I.; Baas, P.; Meerbeeck, J.P. van 2015
After the implementation of standard first line chemotherapy with platinum and antifolates in pleural mesothelioma, patients are confronted with a need for second line treatment at relapse or... Show moreAfter the implementation of standard first line chemotherapy with platinum and antifolates in pleural mesothelioma, patients are confronted with a need for second line treatment at relapse or progression. We conducted a systematic review of the literature for the activity, effectiveness and toxicity of second line treatment. The results are presented according to the class of drugs: chemotherapy and targeted or biological agent. (C) 2015 Elsevier Ireland Ltd. All rights reserved. Show less
Clavicular fractures are among the most common fractures of the shoulder. Displacement or comminution of the fracture fragments may lead to shortening of the clavicle, but could also cause mal... Show moreClavicular fractures are among the most common fractures of the shoulder. Displacement or comminution of the fracture fragments may lead to shortening of the clavicle, but could also cause mal-union or non-union of the clavicle and might lead to poor functional outcome. These fracture characteristics are therefore important in clinical decision making. The diagnostic aspects of clavicular fractures are evaluated in the first part of this thesis, whereas the second part describes studies on treatment and clinical outcomes. The third part of these thesis focuses on the complex biomechanics of the shoulder after a displaced midshaft clavicular fracture. The findings on diagnostic aspects underline the importance of fracture characteristics for classification and of two-view radiography for treatment decisions for clavicular fractures. Clavicular shortening after a midshaft clavicular fracture is deemed the most important factor in deciding whether or not to operate, but no clinically relevant changes after clavicular shortening in the scapular kinematics and functional outcome were demonstrated. Clavicular shortening should therefore not be used as the only reason to justify operative treatment. Show less
Willeumier, J.; Fiocco, M.; Nout, R.; Dijkstra, S.; Aston, W.; Pollock, R.; ... ; Sande, M. van de 2015
Clostridium difficile is a spore-forming bacterium, the toxin-producing strains of which cause colitis. Risk factors are antibiotics, advanced age and severe comorbidity. C. difficile infection ... Show moreClostridium difficile is a spore-forming bacterium, the toxin-producing strains of which cause colitis. Risk factors are antibiotics, advanced age and severe comorbidity. C. difficile infection (CDI) has been regarded as mostly a hospital-acquired infection. Preventing relapses is considered the biggest challenge in CDI management. In this thesis, we show that CDI occurs in Dutch general practices, often in patients without contact with hospitals. Also, we show that the emerging virulent strain PCR ribotype 027 has not become dominant in European hospitals, but community-associated type 078 has become highly prevalent. Furthermore, we found that cystic fibrosis outpatients are frequently colonized with C. difficile, though mostly with nonpathogenic strains. Thus, acquisition of C. difficile in the community appears more important than previously thought. Next, we show that renal failure at the time of diagnosis predicts relapses. In addition, patients who fail to develop antibodies against C. difficile toxins have a higher chance of relapse. We describe an experimental product derived from the milk of cows vaccinated against C. difficile and its toxins, which might prevent relapses. The last part of the thesis consists of the European guideline for CDI treatment and its recent update Show less
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
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
__The non-displaced scaphoid fracture: evaluation of diagnostic modalities & conservative treatment__ Over de diagnostiek en de behandeling van scafo_dfracturen bestaat nog veel verschil van... Show more__The non-displaced scaphoid fracture: evaluation of diagnostic modalities & conservative treatment__ Over de diagnostiek en de behandeling van scafo_dfracturen bestaat nog veel verschil van mening. Een onjuiste of vertraagd ingestelde behandeling kan leiden tot ernstige complicaties. R_ntgenfoto mist een groot deel van de scafo_dfracturen. De botscintigrafie kan gebruikt worden om deze fracturen zichtbaar te maken. Een botscintigrafie is echter invasief en maakt gebruik van radioactief materiaal. Een MRI of CT zou wellicht de botscintigrafie kunnen vervangen. Dit proefschrift beschrijft twee prospectieve studies, waarbij in de eerste studie de botscintigrafie werd vergeleken met de MRI. In de tweede studie werd de botscintigrafie vergeleken met de CT. Beide onderzoeken konden niet aantonen dat de MRI en CT de botscintigrafie kan vervangen. Het probleem is dat beide onderzoeken scafo_dfracturen missen. Ook is onderzocht of een zogenaamde 'clinical prediction rule' te ontwikkelen was, om de a priori kans op een ware fractuur bij een pati_nt met de verdenking op een scafo_dfractuur te verhogen. Analyse liet zien dat er drie voorspellers significant waren: extensie < 50%, supinatiekracht < 10% en het hebben van een fractuur in de voorgeschiedenis. Tenslotte is de behandeling van scafo_dfracturen geanalyseerd. Gekeken is of een kortere behandeling mogelijk was. Normaal wordt een scafo_dfractuur 12 weken ge_mmobiliseerd met een gips. Lange immobilisatie kan klachten veroorzaken. Wij hebben onderzocht of de scafo_dfractuur ook te behandelen is middels een gipsimmobilisatie van 6 weken. Hiervoor werden 98 pati_nten geanalyseerd en na 6 weken bleek 80% te zijn genezen. Wat ook bleek is dat de localisatie met name invloed had op de functionele uitkomst van de behandeling. Om deze functionele uitkomst in beeld te brengen gebruikten we een DASH-score (Disabilities of the Arm, Shoulder and Hand score). De gemiddelde DASH-score was 6 voor 13 distale pool en 5 voor 44 middenpool fracturen. Concluderend kunnen wij stellen dat voor het opsporen van scafo_dfracturen bij pati_nten met een klinische verdenking hierop, de botscintigrafie nog steeds de gouden standaard is. Niet gedisloceerde scafo_dfracturen van de distale middenpool dienen conservatief behandeld te worden middels gipsimmobilisatie gedurende 6 weken. Show less
Major advances have been made in the treatment of rheumatoid arthritis, a potentially chronic disabling disease which poses a large burden on both patients and society. By early start of disease... Show moreMajor advances have been made in the treatment of rheumatoid arthritis, a potentially chronic disabling disease which poses a large burden on both patients and society. By early start of disease-modifying antirheumatic drugs, including methotrexate as a prominent drug, the use of combination therapies including prednisone or biologicals, and tight control of disease activity, many patients are able to reach a state of clinical remission and some can even taper and stop antirheumatic therapy. Challenges lie in correctly identifying the earliest manifestations of the disease, starting the right treatment sufficiently early, tailored to the individual patient, and setting the optimal treatment goal at which to steer therapy adjustments. This thesis has made a start towards tackling several of these challenges and discusses further necessary steps that may lead to a fundamental change in the outlook of patients with rheumatoid arthritis. Show less
Large variation between hospitals and pathology laboratories was demonstrated in adherence to the guidelines. This is associated with type and volume of hospitals and pathology laboratories.... Show moreLarge variation between hospitals and pathology laboratories was demonstrated in adherence to the guidelines. This is associated with type and volume of hospitals and pathology laboratories. However, not all variation could be explained by these characteristics. The aim of this thesis was to identify factors influencing quality of care by investigating the variation in guidelines adherence of patients with colon and rectal cancer in the Netherlands. Considerable variation in lymph node evaluation between hospitals and pathology laboratories was revealed leading to suboptimal staging and potentially inaccurate treatment plans. Furthermore, large differences between hospitals were found in treatment according tot the guidelines. Based on the results of this thesis, it can be conclude that a part of the variation is associated with type and volume of hospitals and pathology laboratories. However, the large differences between individual hospitals suggests that these characteristics do not account for all variation. Therefore, further research is necessary to identify best practices and analyse factors which influence quality of care and outcome. Show less
The first chapters of this thesis describe the treatment of radioiodine non-avid thyroid carcinoma with the tyrosine kinase inhibitor sorafenib. The remainder of the thesis describes the clinical... Show moreThe first chapters of this thesis describe the treatment of radioiodine non-avid thyroid carcinoma with the tyrosine kinase inhibitor sorafenib. The remainder of the thesis describes the clinical consequences of the treatment of thyroid carcinoma. Show less
This thesis focuses on patients with Binge Eating Disorder. The thesis consists of three parts. In the first part the validity of the diagnosis of BED will be discussed. The results of two... Show moreThis thesis focuses on patients with Binge Eating Disorder. The thesis consists of three parts. In the first part the validity of the diagnosis of BED will be discussed. The results of two literature reviews and an empirical cross-sectional study suggested that BED is a distinct eating disorder and should be added to a next version of the DSM. In the second part results of a randomized controlled trial were described. The effectiveness of cognitive behavioural therapy was compared to a waiting list control group. As expected, objective binge eating frequency, eating disordered psychopathology, and comorbid psychopathology decreased significantly in the CBT group whereas no reduction was found in the control (WLC) group. Mediator analyses indicated that abstinence from binge eating at post treatment was fully mediated by changes in weight concerns and marginally by changes in concerns about shape and eating, depressive symptoms, and more general psychopathological symptoms. In the third and last part the results of two experimental studies were presented. The purpose of the studies was to investigate the causal relationship between negative mood and binge eating. Both experimental studies found evidence for the fact that in individuals with BED depressive symptoms and caloric intake are positively related. Show less
