Sebek LLG, de Winter BCM, Bethlehem C
… +3 more, Prins G, Huisman R, Alsma J
Neth J Med
· 2020 Dec · PMID 33380548
Approximately 500 patients per year are admitted to the emergency department (ED) of the Erasmus University Medical Center presenting with intoxications with medication. For adequate treatment, it is sometimes important...Approximately 500 patients per year are admitted to the emergency department (ED) of the Erasmus University Medical Center presenting with intoxications with medication. For adequate treatment, it is sometimes important to know which drugs in which quantities were ingested. This can require laboratory analysis of blood or urine samples; however, these samples do not provide information about the possible effects that can still be expected. We performed toxicological screening on the gastric content of three patients admitted to our ED in January and February 2018. These patients underwent gastric lavage or received a gastric tube as part of routine care. The gastric fluid was analysed via UPLC-MS/MS using the Waters method for toxicological screening. In all three patients, we successfully determined drugs in the gastric content. In two patients, we identified more different drugs in the gastric content than in blood plasma. In the other patient, admitted approximately six hours after a severe autointoxication with the betablocker metoprolol, we found significant amounts of metoprolol in the gastric content acquired by gastric lavage. We therefore believe that analysis of gastric content after an intoxication can have multiple applications; for example, it may provide information about symptoms of intoxication that can be expected, it may aid patient care and may provide insight in the toxicokinetics of different drugs. In conclusion, we demonstrate that toxicological screening and quantification of drug levels in gastric content is possible and has potential as an adjunct in patient care, but limitations need to be addressed before implementation in clinical practice.
We report on a 75-year-old man with a history of metastatic prostate cancer who presented with haematuria, peripheral oedema, metabolic alkalosis, hypokalaemia, and hypertension. Laboratory evaluation was compatible with...We report on a 75-year-old man with a history of metastatic prostate cancer who presented with haematuria, peripheral oedema, metabolic alkalosis, hypokalaemia, and hypertension. Laboratory evaluation was compatible with the diagnosis of adrenocorticotropic hormone (ACTH)-dependent cushing's syndrome and suggestive of ectopic ACTH production. Pathology of a prostate biopsy specimen showed a large cell neuroendocrine carcinoma (LCNEC) of the prostate. This report describes a case of Cushing's syndrome that was probably caused by ectopic ACTH secretion by a LCNEC of the prostate.
Thionamides (such as thiamazole/methimazole) are a common first line treatment for Graves' disease. Common side effects include rash, urticaria, and arthralgia. However, thionamide treatment has also been associated with...Thionamides (such as thiamazole/methimazole) are a common first line treatment for Graves' disease. Common side effects include rash, urticaria, and arthralgia. However, thionamide treatment has also been associated with a variety of auto-immune syndromes. Here, we describe a patient presenting with mild arthritis after starting thiamazole. Although severe presentation warrants acute withdrawal of the causative agent, our case suggests that milder forms can be successfully treated with anti-inflammatory drugs alone. Recognition of the syndrome is key to warrant timely and effective treatment.
de Wolff L, Vogels S, Andriesse GI
… +1 more, Vlasveld IN
Neth J Med
· 2020 Dec · PMID 33380537
We describe a patient with an orthohantavirus infection in the north of the Netherlands. Orthohantavirus cases in the Netherlands are rare and most cases occur in the east of the Netherlands. Orthohantavirus infections s...We describe a patient with an orthohantavirus infection in the north of the Netherlands. Orthohantavirus cases in the Netherlands are rare and most cases occur in the east of the Netherlands. Orthohantavirus infections should be included in the differential diagnosis in travellers and non-travellers, and patients from areas other than the east of the Netherlands if flu-like symptoms and acute renal insufficiency are present.
Cerebral toxoplasmosis is a potentially fatal infection most commonly seen in immunocompromised patients. We present a patient on long-term immunosuppressive therapy after kidney transplantation and a recent history of o...Cerebral toxoplasmosis is a potentially fatal infection most commonly seen in immunocompromised patients. We present a patient on long-term immunosuppressive therapy after kidney transplantation and a recent history of oligometastatic rectal cancer, with cerebral lesions as a result of toxoplasmosis. Heightened awareness of the occurrence of opportunistic infections in patients with cancer who are taking immunosuppressive drugs is needed among clinicians.
de Vries-Sluijs TEMS, Andrinopoulou ER, de Man RA
… +1 more, van der Ende ME
Neth J Med
· 2020 Dec · PMID 33380535
BACKGROUND: In HIV-infected patients, the immunogenicity of hepatitis B vaccines is impaired. In this randomised controlled study (RCT), we investigated the effect of Fendrix® versus double-dose Engerix® vaccination in p...BACKGROUND: In HIV-infected patients, the immunogenicity of hepatitis B vaccines is impaired. In this randomised controlled study (RCT), we investigated the effect of Fendrix® versus double-dose Engerix® vaccination in previously non-responsive HIV-infected subjects. METHODS: Patients included those who were HIV-infected and non-responders to a primary (single-dose hepatitis B (HBV) vaccination) and a subsequent double-dose HBV revaccination schedule. Subjects were randomised 1:1 to receive Fendrix® (t = 0, 4, 8, 24 weeks) or double-dose Engerix® (t = 0, 4, 24 weeks) vaccinations. Primary efficacy, defined as anti-HBs response ≥ 10 IU/l, was evaluated at week 28 in both study arms. RESULTS: A subset of 48 patients non-responsive to HBV vaccination was selected, from a cohort of patients at our institution, who underwent HBV vaccination unsuccessfully either in a previous RCT or through standard care. The anti-HBs ≥ 10 IU/l response rate at week 28 in the Fendrix® arm and the Engerix® arm were 85.7% and 65.0%, respectively (p = 0.09). There was no significant difference between the two used vaccine types in the anti-HBs levels reached. In our institution, the overall response rate after initial standard-dose vaccination schedule and double-dose revaccination in our cohort was 75%. In this study, combining the effects of Fendrix and Engerix resulted in a 75% response rate in the 25% remaining non-responders on initial and double-dose revaccination series. This yielded an absolute 19% increase and an overall response to HBV vaccination in HIV-infected patients of around 94% in our cohort. CONCLUSION: These results together, suggest that continuing HBV vaccination in non-responders to a first course of single-dose vaccine and a double-dose revaccination scheme is worth the effort. No superiority of one of the investigated hepatitis B vaccines was shown in this cohort but an appropriate number of patients needed to achieve reliable answers was not achieved.
Brakenhoff SM, Verburgh ML, Willemse SB
… +3 more, Baak LC, Brinkman K, van der Valk M
Neth J Med
· 2020 Dec · PMID 33380534
BACKGROUND: Successful treatment of chronic hepatitis C with direct-acting antiviral agents (DAAs) is expected to lead to improvement in liver fibrosis in most of the patients. However, limited data are available on the...BACKGROUND: Successful treatment of chronic hepatitis C with direct-acting antiviral agents (DAAs) is expected to lead to improvement in liver fibrosis in most of the patients. However, limited data are available on the improvement of advanced liver fibrosis and cirrhosis, measured by transient elastography after treatment. This study assessed the change in liver stiffness measurements after successful treatment with DAAs in patients with pre-treatment advanced fibrosis or cirrhosis. METHODS: This observational retrospective cohort study included 514 mono-infected chronic hepatitis C patients, treated with all possible DAA-regimes in the Amsterdam region, the Netherlands. Liver stiffness was measured using FibroScan® at baseline and during follow-up. Cut-off values for staging liver fibrosis were ≥ 9.5 kPa for advanced fibrosis (F3) and ≥ 14.6 kPa for cirrhosis (F4). RESULTS: Liver stiffness decreased significantly from a median of 15.6 kPa (IQR 11.4-25.4) to 9.4 kPa (IQR 6.2-17.0) in 197 patients with pre-treated advanced fibrosis or cirrhosis. In 50.3% of these patients, liver stiffness improved to a value fitting with mild to moderate fibrosis (< 9.5 kPa, F0-F2) after successful treatment. Multivariate analysis demonstrated that a pre-treatment FibroScan® value of ≥ 20.0 kPa was associated with persisting advanced fibrosis or cirrhosis after treatment (OR 29.07, p < 0.001). CONCLUSION: Liver stiffness improves significantly after successful direct-acting antiviral agent treatment in chronic hepatitis C patients with advanced fibrosis or cirrhosis prior to DAA treatment. Long-term outcomes regarding occurrence of hepatocellular carcinoma (HCC) in these patients are required to determine whether they can be safely discharged from HCC surveillance.
BACKGROUND: Length of stay (LOS) in the Emergency Department (ED) is correlated with an extended in-hospital LOS and may even increase 30-day mortality. Older patients represent a growing population in the ED and they ar...BACKGROUND: Length of stay (LOS) in the Emergency Department (ED) is correlated with an extended in-hospital LOS and may even increase 30-day mortality. Older patients represent a growing population in the ED and they are especially at risk of adverse outcomes. Screening tools that adequately predict admission could help reduce waiting times in the ED and reduce time to treatment. We aimed to develop and validate a clinical prediction tool for admission, applicable to the aged patient population in the ED. METHODS: Data from 7,606 ED visits of patients aged 70 years and older between 2012 and 2014 were used to develop the CLEARED tool. Model performance was assessed with discrimination using logistic regression and calibration. The model was internally validated by bootstrap resampling in Erasmus Medical Center and externally validated at two other hospitals, Medisch Spectrum Twente (MST) and Leiden University Medical Centre (LUMC). RESULTS: CLEARED contains 10 predictors: body temperature, heart rate, diastolic blood pressure, systolic blood pressure, oxygen saturation, respiratory rate, referral status, the Manchester Triage System category, and the need for laboratory or radiology testing. The internally validated area under the curve (AUC) was 0.766 (95% CI [0.759;0.781]). External validation in MST showed an AUC of 0.797 and in LUMC, an AUC of 0.725. CONCLUSIONS: The developed CLEARED tool reliably predicts admission in elderly patients visiting the ED. It is a promising prompt, although further research is needed to implement the tool and to investigate the benefits in terms of reduction of crowding and LOS in the ED.
Rietveld MJA, van der Velden J, Westermann AM
… +6 more, van Driel WJ, Sonke GS, Witteveen PO, Ploos van Amstel FK, Massuger LFAG, Ottevanger PB
Neth J Med
· 2020 Dec · PMID 33380532
BACKGROUND: Combined administration of intravenous (iv) and intraperitoneal (ip) (iv/ip) chemotherapy is an effective adjuvant treatment option after primary debulking surgery (PDS) for advanced ovarian cancer (OC). Incr...BACKGROUND: Combined administration of intravenous (iv) and intraperitoneal (ip) (iv/ip) chemotherapy is an effective adjuvant treatment option after primary debulking surgery (PDS) for advanced ovarian cancer (OC). Increased toxicityand patient burden limit its use in daily practice. OBJECTIVE: To assess toxicity and survival outcomes of iv/ip chemotherapy in daily practice in the Netherlands. METHODS: This retrospective cohort study included 81 women who underwent at least an optimal PDS for FIGO stage III OC followed by iv/ip chemotherapy according to the Armstrong regimen, in four hospitals in the Netherlands between January 2007 and May 2016. We collected information on surgical procedure, abdominal port implantation, toxicity, and recurrence-free and overall survival. RESULTS: All participants underwent PDS, of whom 60 (74%) had their ip catheter implanted during PDS. Most frequently reported all grade toxicity was haematological n = 44 (54%). Forty-four patients (54%) completed all six cycles of iv/ip chemotherapy. The most frequent causes of discontinuation of iv/ip administration were renal dysfunction (12/37 = 32%) and catheter problems (7/37 = 19%). Median recurrence-free survival and overall survival were 24 months (range 0 - 108) and 80 months (range 4-115), respectively. Surgical outcome, completion of more than three courses of treatment and intra-abdominal localisation of recurrent disease were associated with better survival outcomes. CONCLUSION: In daily practice, 54% of patients with advanced OC could complete all scheduled cycles of iv/ ip chemotherapy with acceptable morbidity and toxicity, leading to outcomes comparable with the results of published trials on iv/ip chemotherapy.
van Daalen FV, Smeulers M, Bartels EJH
… +3 more, Holleman F, Visser CE, Geerlings SE
Neth J Med
· 2020 Dec · PMID 33380531
BACKGROUND: Blood cultures are essential diagnostic tools to identify pathogens in systemic infections. However, logistics of blood culture performance is often suboptimal. This study analyses the pre-analytic phase of b...BACKGROUND: Blood cultures are essential diagnostic tools to identify pathogens in systemic infections. However, logistics of blood culture performance is often suboptimal. This study analyses the pre-analytic phase of blood culture processing through different types of risk assessments. METHODS: We performed direct observations to gain in-depth knowledge of the root causes of suboptimal blood culture performance. These findings were summarised in a Bow-Tie chart. We then utilised a healthcare failure mode and effect analysis to prioritise failures per step in the process and to organise improvement activities. Finally, improvement actions were planned. RESULTS: Not obtaining a second set of blood cultures in the logistics of blood culture performance had the highest priority for action. Several failure modes, including human and system factors, were identified. Improvement actions included training and clinical lessons for nurses in the emergency department, updating hospital search engines to ease identification of relevant protocols, and an evaluation of the workload at the emergency department. Failure modes caused by human factors appear easy to address, however changing human behaviour is challenging. CONCLUSIONS: The analysis provided useful insight into the different steps in the logistics of blood culture performance and facilitated the organisation of actions focused on addressing the most urgent root causes.
de Wit K, van Delden OM, Beuers U
… +1 more, Takkenberg RB
Neth J Med
· 2020 Dec · PMID 33380530
BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention to treat complications of portal hypertension. Since the introduction of polytetrafluoroethylene (PTFE)-covered stent...BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention to treat complications of portal hypertension. Since the introduction of polytetrafluoroethylene (PTFE)-covered stents, TIPS patency rates have improved, and the need for routine TIPS surveillance has become questionable. Aims of this study were to assess the indications, clinical outcome and survival, and yield of Doppler ultrasound follow-up in patients who received a TIPS in an academic centre. METHODS: A retrospective cohort study of all adult consecutive patients who underwent PTFE-covered TIPS placement between 2001 and 2016. Clinical, biochemical, and imaging findings were reviewed and analysed. RESULTS: A total of 103 patients were included for analysis. At one-year follow-up, control of bleeding was successful in 91% (41/45), and control of refractory ascites in 80% (8/10). In patients with variceal bleeding, a higher MELD score was a risk factor for 90-day mortality (HR 1.28 per point, p < 0.001) and one-year mortality (HR 1.24 per point, p < 0.001). In patients with refractory ascites, a higher MELD score was only a risk factor for 90-day mortality (HR 1.13 per point, p = 0.03). Doppler ultrasound investigations during follow-up revealed abnormalities in 4% (6/166), all of which were associated with clinical deterioration, while abnormalities were detected in 11.4% (19/166) of patients who presented with clinical symptoms of TIPS dysfunction. CONCLUSION: The use of routine Doppler ultrasound follow-up after PTFE-covered TIPS placement seems unnecessary as it had a very low yield and abnormal Doppler findings were almost always associated with clinical symptoms of TIPS dysfunction.
Laan BJ, van de Woestijne AA, Kaasjager HAH
… +1 more, Geerlings SE
Neth J Med
· 2020 Dec · PMID 33380529
BACKGROUND: The Choosing Wisely campaign aims to reduce low-value care to improve quality and lower healthcare costs. Our objective was to determine the current implementation of the Choosing Wisely Netherlands campaign...BACKGROUND: The Choosing Wisely campaign aims to reduce low-value care to improve quality and lower healthcare costs. Our objective was to determine the current implementation of the Choosing Wisely Netherlands campaign and the 10 recommendations (released in 2014) for internal medicine. METHODS: We actively surveyed physicians and residents in the departments of internal medicine in 13 hospitals in the Netherlands. The survey was performed during a presentation about Choosing Wisely and we asked whether they thought that the recommendations were implemented. RESULTS: Between May and November 2018, we surveyed 281 physicians and residents, of which we received 2625 answers (response rate 85%). We found that 178 (68.5%) of 260 physicians were unaware of the Choosing Wisely campaign. For the implementation of recommendations, 1506 (75.2%) of 2003 answers stated that physicians applied the recommendations in clinical practice. We found no differences in implementation of physicians who were aware or unaware of the campaign, respectively 529 (76.1%) of 695 versus 854 (74.2%) of 1151 of the recommendations were implemented; p = 0.357. The recommendation that was implemented least was 'Do not routinely order coagulation tests before invasive procedures', in which 28% stated that they applied this in clinical practice. CONCLUSION: Four years after the introduction, only one-third of physicians and residents of internal medicine were aware of the Choosing Wisely Netherlands campaign. Nevertheless, most Choosing Wisely recommendations were implemented sufficiently in clinical practice. There is room for improvement, mainly in recommendations that need a multidisciplinary approach.