http://repub.eur.nl/res/aut/21982/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/18497/ 2009-02-01T00:00:00Z Purpose: To compare clinical success, functional capacity, and quality of life during 12 months after revascularization or supervised exercise training in patients with intermittent claudication. Materials and Methods: This study had institutional review board approval, and all patients gave written informed consent. Between September 2002 and September 2005, 151 consecutive patients who presented with symptoms of intermittent claudication were randomly assigned to undergo either endovascular revascularization (angioplasty-first approach) (n = 76) or hospital-based supervised exercise (n = 75). The outcome measures were clinical success, functional capacity, and quality of life after 6 and 12 months. Clinical success was defined as improvement in at least one category in the Rutherford scale above the pretreatment level. Significance of differences between the groups was assessed with the unpaired τ test, x2 test, or Mann-Whitney U test. To adjust outcomes for imbalances of baseline values, multi-variable regression analysis was performed. Results: Immediately after the start of treatment, patients who underwent revascularization improved more than patients who performed exercise in terms of clinical success (adjusted odds ratio [OR], 39; 99% confidence interval [CI]: 11, 131; P <.001), but this advantage was lost after 6 (adjusted OR, 0.9; 99% CI: 0.3, 2.3; P = .70) and 12 (adjusted OR, 1.1; 99% CI: 0.5, 2.8; P = .73) months. After revascularization, fewer patients showed signs of ipsilateral symptoms at 6 months compared with patients in the exercise group (adjusted OR, 0.4; 99% CI: 0.2, 0.9; P <.001), but no significant differences were demonstrated at 12 months. After both treatments, functional capacity and quality of life scores increased after 6 and 12 months, but no significant differences between the groups were demonstrated. Conclusion: After 6 and 12 months, patients with intermittent claudication benefited equally from either endovascular revascularization or supervised exercise. Improvement was, however, more immediate after revascularization. http://repub.eur.nl/res/pub/29781/ 2008-12-01T00:00:00Z Background: The optimal first-line treatment for intermittent claudication is currently unclear. Objective: To compare the cost-effectiveness of endovascular revascularization vs supervised hospital-based exercise in patients with intermittent claudication during a 12-month follow-up period. Design: Randomized controlled trial with patient recruitment between September 2002-September 2006 and a 12-month follow-up per patient. Setting: A large community hospital. Participants: Patients with symptoms of intermittent claudication due to an iliac or femoro-popliteal arterial lesion (293) who fulfilled the inclusion criteria (151) were recruited. Excluded were, for example, patients with lesions unsuitable for revascularization (iliac or femoropopliteal TASC-type D and some TASC type-B/C. Intervention: Participants were randomly assigned to endovascular revascularization (76 patients) or supervised hospital-based exercise (75 patients). Measurements: Mean improvement of health-related quality-of-life and functional capacity over a 12-month period, cumulative 12-month costs, and incremental costs per quality-adjusted life year (QALY) were assessed from the societal perspective. Results: In the endovascular revascularization group, 73% (55 patients) had iliac disease vs 27% (20 patients) femoral disease. Stents were used in 46/71 iliac lesions (34 patients) and in 20/40 femoral lesions (16 patients). In the supervised hospital-based exercise group, 68% (51 patients) had iliac disease vs 32% (24 patients) with femoral disease. There was a non-significant difference in the adjusted 6- and 12-month EuroQol, rating scale, and SF36-physical functioning values between the treatment groups. The gain in total mean QALYs accumulated during 12 months, adjusted for baseline values, was not statistically different between the groups (mean difference revascularization versus exercise 0.01; 99% CI -0.05, 0.07; P = .73). The total mean cumulative costs per patient was significantly higher in the revascularization group (mean difference €2318; 99% CI €2130, € 2506; P < .001) and the incremental cost per QALY was 231 800 €/QALY adjusted for the baseline variables. One-way sensitivity analysis demonstrated improved effectiveness after revascularization (mean difference 0.03; CI 0.02, 0.05; P < .001), making the incremental costs 75 208 €/QALY. Conclusion: In conclusion, there was no significant difference in effectiveness between endovascular revascularization compared to supervised hospital-based exercise during 12-months follow-up, any gains with endovascular revascularization found were non-significant, and endovascular revascularization costs more than the generally accepted threshold willingness-to-pay value, which favors exercise. http://repub.eur.nl/res/pub/13797/ 2005-06-01T00:00:00Z PURPOSE: To systematically review published data about the short- and long-term effects of exercise training and angioplasty on functional capacity and quality of life of patients with intermittent claudication. MATERIALS AND METHODS: Articles published between January 1980 and February 2003 were included if patients had intermittent claudication treated with exercise training or angioplasty and if both functional capacity and quality-of-life scores from Medical Outcomes Study 36-Item Short Form health survey were reported for at least 3 months of follow-up. Data were pooled by using a random effects model and weighted means. Pooled results were compared between the treatment groups by using the chi2 test and the Student t test (alpha = .05, two sided). RESULTS: In the analyses, five studies (202 patients) were included in the exercise group, and three studies (470 patients), in the angioplasty group. At 3 months of follow-up, the ankle-brachial index was significantly improved in the angioplasty group (mean change, 0.18; P < .01) but not in the exercise group (mean change, 0.01; P = .29). At 3 months, quality of life was significantly improved with regard to ratings of physical functioning and bodily pain in the exercise group (mean change, 18 and 10, respectively; P < .01) and physical role functioning in the angioplasty group (mean change, 30; P = .03). Mean change in ankle-brachial index significantly differed between the two treatment groups at 3 and 6 months (P < .01); mean change in quality-of-life scores did not. CONCLUSION: Improvement in quality of life was demonstrated after both exercise training and angioplasty, whereas functional capacity showed significant improvement after angioplasty. The ankle-brachial index significantly differed between the two treatment groups at 3 and 6 months, whereas the quality-of-life scores did not. http://repub.eur.nl/res/pub/31520/ 1980-10-15T00:00:00Z Over de behandeling van schildklierziekten is het laatste woord nog niet gesproken. Eén van de voornaamste redenen hiervoor is, dat er nog niet voldoende bekend is over de pathofysiologie van schildklierziekten. In dit onderzoek is de chirurgische behandeling van drie schildklieraandoeningen, te weten: de ziekte van Graves, het toxisch multinodulaire struma en het euthyreotisch multinodulaire struma, bestudeerd. Aan de hand van een aantal vragen wordt in dit onderzoek hier uitvoerig op ingegaan. De concentratie van vrije schildklierhormonen in het bloed wordt éénsdeels bepaald door de schildklierfunctie en anderdeels door het perifere metabolisme van de schildklierhormonen. Factoren, zoals onder andere leeftijd, ziekte, stress, kunnen mogelijk de schildklierfunctie, maar vooral het metabolisme van de schildklierhormonen beïnvloeden. Het T4 (thyroxine of 3, 3", 5, 5', tetra-jodothyronine) wordt in de schildklier geproduceerd en dient onder meer als pro-hormoon voor T3 (3, 3', 5 tri-jodothyronine), wat biologisch het meest actieve schildklierhormoon is (hoofdstuk 2.1.1.). Van de dagelijkse hoeveelheid T3, die in het lichaam wordt geproduceerd, komt het grootste gedeelte uit de perifere omzetting (in de lichaamsweefsels buiten de schildklier) van T 4 in T3 en slechts een klein gedeelte uit de schildklier zelf (hoofdstuk 2.1.3.). Onder bepaalde omstandigheden, zoals bijvoorbeeld bij acute en chronische ziekten en bij vermagering (Schimmel en Utiger 1977), wordt minder T4 in de perifere weefsels omgezet in T3• Hierbij stijgt echter de concentratie van het biologisch inactieve 3, 3', 5", tri-jodothyronine (reverse T3, rT3) sterk. (Chopra e.a. 1975, Ka plan e.a. 1977, Visser 1978)