__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
This thesis describes the outcomes of 2 year follow-up of the BeSt study (Behandel-Strategieen). This is a multicenter, randomized clinical trial comparing 4 different treatment strategies in... Show moreThis thesis describes the outcomes of 2 year follow-up of the BeSt study (Behandel-Strategieen). This is a multicenter, randomized clinical trial comparing 4 different treatment strategies in patients with recent-onset active rheumatoid arthritis: 1. sequential monotherapy, starting with methotrexate, switching to another antirheumatic drug in case of an insufficient response; 2. step-up combination therapy, also starting with methotrexate, adding other antirheumatic drugs in case of an insufficient response; 3. initial combination therapy with methotrexate, sulphasalazine and high-dose tapered prednisone; 4. initial combination therapy with methotrexate and infliximab. In all groups the goal was to achieve a disease activity score (DAS) __2.4 (low disease activity). The DAS was measured 3-monthly by a research nurse, blinded for the allocated group. The physician then adjusted therapy according to the protocol. During the 2 year follow-up, groups 3 and 4 had a more rapid clinical response, less joint damage and less treatment adjustments than groups 1 and 2. Interestingly, groups 1 and 2 did better than expected. This is probably the result of aimimg for low disease activity. Most patients prefer treatment with the newest drug. The higher costs of infliximab can largely be compensated by savings on productivity. Show less
Congenital Human Parvovirus B19 (B19V) infection can lead to life threatening fetal complications as hydrops, fetal demise or severe fetal anaemia and thrombocytopenia. Maternal symptoms frequently... Show moreCongenital Human Parvovirus B19 (B19V) infection can lead to life threatening fetal complications as hydrops, fetal demise or severe fetal anaemia and thrombocytopenia. Maternal symptoms frequently pass unnoticed at the time of maternal infection and there was little information on the mechanism and time course of vertical transmission of B19V during gestation. Treatment consists of intrauterine fetal red blood cell and/ or platelet transfusion (IUT). The indication for treatment with IUT is set by performing fetal ultrasound screening for fetal anaemia and signs of fetal hydrops. The fetal middle cerebral artery peak systolic flow correlates well with the severity of fetal anaemia. The first two chapters of this thesis give an overview of the existing literature concerning fetal hydrops and congenital B19V infection. In the ensuing chapters we describe the course of maternal and fetal B19V infection by the B19V viral load and maternal immune response. We did not find a correlation between the fetal or maternal B19V viral load and the severity of fetal anaemia or thrombocytopenia. Thrombocytopenia is frequently encountered in congenital B19V infection, but fetal bleeding complications are not. The use of fetal platelet transfusion is therefore a matter of debate. The long- term neurodevelopment of affected fetus can be significantly delayed at a later age despite a technically correct IUT procedure. The possibility of cerebral damage due to congenital B19V infection is discussed. Parents should be counselled of these risks before the IUT procedure and long term follow -up following congenital B19V infection is advised Show less
