Anesthesiology

Inhibins and activins: Their roles in the adrenal gland and the development of adrenocortical tumors (Article)

Hofland, J. — 2011-07-14T00:00:00Z

The adrenal gland is composed of two separate endocrine tissues that control a multitude of bodily functions in their adaptation to external and internal stressors through hormone secretion. The functions of the adrenal gland are regulated by circulating, neural and local factors that ensure proper cell growth and hormone production. Activins and inhibins are among the locally expressed growth factors affecting adrenal cell function. They have been found to influence several aspects of adrenal cell development, adrenocortical steroidogenesis, adrenocortical tumor formation and adrenomedullary cell differentiation. Especially the finding that inhibin α-subunit knockout mice develop adrenocortical carcinomas after gonadectomy has prompted research on the physiological and pathophysiological roles of activin and inhibin in the adrenal cortex. It is now clear that both peptides control adrenocortical physiology and are involved in adrenocortical tumorigenesis at multiple levels, both in murine models as well as in human patients.

Anesthesiologists' views on using immune modulating drugs in pain medicine (Article)

Goebel, A. — 2011-07-01T00:00:00Z

With few exceptions, anesthesiologists have not received training in the use of immune modulating drugs (IMDs); but recent evidence suggests that such drugs may be effective in reducing chronic pain. We therefore wished to learn how anesthesiologists working in pain medicine might envisage the treatment of their patients with IMDs in the future. We expected that anesthesiologists would want to refer patients for treatment with IMDs to medical colleagues, such as oncologists or rheumatologists, with prior experience in using these drugs, rather than treat these patients within their own practice. We conducted questionnaire surveys among anesthesiologists working in pain medicine in both the Netherlands and the U.K. to explore their views on using IMDs. Contrary to what we had expected, we found that a majority of the respondents would administer IMDs within their own practice, after appropriate training. The overall response rates were 30% and 23%, respectively; therefore, no firm conclusions can be drawn as to the views of the majority of practicing pain specialists. Our findings may have implications for the planning of both health service delivery and training in pain medicine. © 2010 The Authors. Pain Practice

21.Phantom pain (Article)

Wolff, A.C. — 2011-07-01T00:00:00Z

Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation. The reported incidence of phantom limb pain after trauma, injury or peripheral vascular diseases is 60% to 80%. Over half the patients with phantom pain have stump pain as well. Phantom pain can also occur in other parts of the body; it has been described after mastectomies and enucleation of the eye. Most patients with phantom pain have intermittent pain, with intervals that range from 1day to several weeks. Even intervals of over a year have been reported. The pain often presents itself in the form of attacks that vary in duration from a few seconds to minutes or hours. In most cases, the pain is experienced distally in the missing limb, in places with the most extensive innervation density and cortical representation. Although there are still many questions as to the underlying mechanisms, peripheral as well as central neuronal mechanisms seem to be involved. Conservative therapy consists of drug treatment with amitriptyline, tramadol, carbamazepine, ketamine, or morphine. Based on the available evidence some effect may be expected from drug treatment. When conservative treatment fails, pulsed radiofrequency treatment of the stump neuroma or of the spinal ganglion (DRG) or spinal cord stimulation could be considered (evidence score 0). These treatments should only be applied in a study design. © 2011 The Authors. Pain Practice

Perioperative care of the older patient (Article)

Blommers, E. — 2011-06-01T00:00:00Z

Nearly 60% of the Dutch population undergoing surgery is aged 65 years and over. Older patients are at increased risk of developing perioperative complications (e.g., myocardial infarction, pneumonia, or delirium), which may lead to a prolonged hospital stay or death. Preoperative risk stratification calculates a patient's risk by evaluating the presence and extent of frailty, pathophysiological risk factors, type of surgery, and the results of (additional) testing. Type of anesthesia, fluid management, and pain management affect outcome of surgery. Recent developments focus on multimodal perioperative care of the older patient, using minimally invasive surgery, postoperative anesthesiology rounds, and early geriatric consultation.

A new future of forensic Y-chromosome analysis: Rapidly mutating Y-STRs for differentiating male relatives and paternal lineages (Article)

Ballantyne, K. — 2011-05-24T00:00:00Z

The panels of 9-17 Y-chromosomal short tandem repeats (Y-STRs) currently used in forensic genetics have adequate resolution of different paternal lineages in many human populations, but have lower abilities to separate paternal lineages in populations expressing low Y-chromosome diversity. Moreover, current Y-STR sets usually fail to differentiate between related males who belong to the same paternal lineage and, as a consequence, conclusions cannot be drawn on the individual level as is desirable for forensic interpretations. Recently, we identified a new panel of rapidly mutating (RM) Y-STRs, composed of 13 markers with mutation rates above 1 × 10-2, whereas most Y-STRs, including all currently used in forensics, have mutation rates in the order of 1 × 10-3or lower. In the present study, we demonstrate in 604 unrelated males sampled from 51 worldwide populations (HGDP-CEPH) that the RM Y-STRs provide substantially higher haplotype diversity and haplotype discrimination capacity (with only 3 haplotypes shared between 8 of the 604 worldwide males), than obtained with the largest set of 17 currently used Y-STRs (Yfiler) in the same samples (33 haplotypes shared between 85 males). Hence, RM Y-STRs yield high-resolution paternal lineage differentiation and provide a considerable improvement compared to Yfiler. We also find in this worldwide dataset substantially less genetic population substructure within and between geographic regions with RM Y-STRs than with Yfiler Y-STRs. Furthermore, with the present study we provide enhanced data evidence that the RM Y-STR panel is extremely successful in differentiating between closely and distantly related males. Among 305 male relatives, paternally connected by 1-20 meiotic transfers in 127 independent pedigrees, we show that 66% were separated by mutation events with the RM Y-STR panel whereas only 15% were with Yfiler; hence, RM Y-STRs provide a statistically significant 4.4-fold increase of average male relative differentiation relative to Yfiler. The RM Y-STR panel is powerful enough to separate closely related males; nearly 50% of the father and sons, and 60% of brothers could be distinguished with RM Y-STRs, whereas only 7.7% and 8%, respectively, with Yfiler. Thus, by introducing RM Y-STRs to the forensic genetic community we provide important solutions to several of the current limitations of Y chromosome analysis in forensic genetics.

Nonsteroidal anti-inflammatory drugs do not interfere with imiquimod treatment for usual type vulvar intraepithelial neoplasia (Article)

Terlou, A. — 2011-05-01T00:00:00Z

Imiquimod has been shown to be an effective treatment for usual type vulvar intraepithelial neoplasia (uVIN). Since local inflammation and burning are common side effects, patients often use nonsteroidal anti-inflammatory drugs (NSAIDs). Our study investigated whether NSAID-use, which has been documented to inhibit the cell-mediated immune response, interferes with the outcome of imiquimod treatment. Monocyte-derived dendritic cells (moDCs) and Langerhans cells (moLCs) were cultured in the presence of NSAIDs. The expression of relevant surface markers (CD80, CD86, CD40, HLA-DR, CCR6 and CCR7), stimulatory function, and cytokine production were evaluated. Furthermore, we analyzed in uVIN patients whether frequent NSAID-use had an effect on the clinical response and on immunocompetent cell counts before and after imiquimod treatment. Although an effect was observed on the expression of moDC and moLC maturation markers, NSAIDs did not affect the ability of moDCs and moLCs to stimulate allogeneic T-cell proliferation, or the production of cytokines in an allogeneic T-cell stimulation assay. In agreement with this, in uVIN patients treated with imiquimod, no interference of frequent NSAID-use with clinical outcome was observed. However, we did notice that high CD1a+and CD207+cell counts in frequent NSAID-users before treatment seemed to predict a favourable response to imiquimod treatment. Our data indicate that NSAID-use does not seem to interfere with moDC and moLC function and does not interfere with immunomodulatory properties of imiquimod in uVIN patients. Therefore, NSAIDs can safely be used to reduce imiquimod side effects in uVIN patients during treatment. Copyright

Radial force measurements in carotid stents: Influence of stent design and length of the lesion (Article)

Vote, M.T. — 2011-05-01T00:00:00Z

Purpose: To assess the differences in radial force of carotid stents and whether the length of the lesion influences the measurements. Materials and Methods: Different models of tapered stents of similar size (length, 30 mm) were used. The tapered nitinol Acculink, Protg, and Cristallo Ideale carotid artery stents and the straight, braided Elgiloy carotid Wallstent were compared. A measurement device consisting of three film loops along the stent body connected to aluminium rods with copper strain gauges was developed. Five stents of each type were deployed within 3-mm stenoses in simulated long (26 mm) and short (8 mm) stenoses. Results: In the short stenosis simulation, the greatest radial force was seen in the Protg stent, at 3.14 N ± 0.45, followed by the Cristallo Ideale stent (1.73 N ± 0.51), Acculink (1.16 N ± 0.21), and Wallstent (0.84 N ± 0.10; P < .001). In the long stenosis simulation, peak radial force again was highest in the Protg stent (1.67 N ± 0.37), but the Acculink stent was second (0.95 N ± 0.12) and the Wallstent third (0.80 N ± 0.06). The Cristallo Ideale stent, in contrast to the short stenosis simulation, produced the least radial force (0.44 N ± 0.13) in the long stenosis simulation (P = .001). Conclusions: Radial forces exerted by carotid stents vary significantly among stent designs. Differences between stent types are dependent on the length of the stenosis. An understanding of radial force is necessary for a well-considered choice of stent type in each individual patient.

19. Carpal Tunnel Syndrome (Article)

Patijn, J. — 2011-04-06T00:00:00Z

Carpal tunnel syndrome (CTS) is a common disorder. In the majority of cases, patients with CTS can be diagnosed by means of appropriate history taking. Nerve conduction examination of the nervus medianus is the most important additional diagnostic test and is the best predictor of symptom severity and functional status in idiopathic CTS. Treatment option depends on the severity of the symptoms and the degree of functional daily limitations. If few limitations are present, splinting or corticosteroid injections are preferred. Surgical interventions are reserved for the more severe conditions resulting in significant disability. Interventional pain treatment such as pulsed radiofrequency could be an addition to the future treatment options for CTS.Pain Practice

The association between psychological factors and the development of complex regional pain syndrome type 1 (CRPS1) - A prospective multicenter study (Article)

Beerthuizen, A. — 2011-04-04T00:00:00Z

The objective of this study was to investigate the association between psychological factors and complex regional pain syndrome type 1 (CRPS1). A prospective multicenter cohort study was performed involving the emergency room of three hospitals, and patients age 18 years or older, with a single fracture, were included in the study. At baseline (T0), participants completed a questionnaire covering demographic, psychological (Symptom Checklist-90), and medical variables. At plaster removal (T1) and at T2, the participants completed a questionnaire addressing symptoms of CRPS1. Psychological factors that were analysed were agoraphobia, depression, somatization, insufficiency, (interpersonal) sensitivity, insomnia, and life events. In total, 596 consecutive patients were included in the study, and 7.0% were diagnosed with CRPS1. None of the psychological factors predicted the development of CRPS1. The scores on the Symptom Checklist-90 subscales fell into the range of the general population and were, in most cases, average or below average when compared with those of pain patients or psychiatric patients. No empirical evidence supports a diagnosis of CRPS1 patients as psychologically different, and the current results indicate that there is no association between psychological factors and CRPS1.

Treatment of vulvar intraepithelial neoplasia with topical imiquimod: Seven years median follow-up of a randomized clinical trial (Article)

Terlou, A. — 2011-04-01T00:00:00Z

Objective: Recently we reported on the efficacy of imiquimod for treating vulvar intraepithelial neoplasia (VIN) in a placebo-controlled, double-blinded randomized clinical trial (RCT). Four weeks after treatment, a complete response was observed in 35% of patients and a partial response in 46%. All complete responders remained disease-free at 12 months follow-up. In the current investigations, we assessed long-term follow-up at least 5 years after the initial RCT. Methods: Twenty-four of 26 imiquimod-treated patients who had participated in the initial RCT were seen for follow-up. Primary endpoint was durability of clinical response to imiquimod assessed by naked eye vulvar examination and histology. Long-term clinical response was correlated to lesion size before start of the initial RCT. Secondary endpoints were mental health, global quality of life, body image and sexual function in relation with long-term clinical response. Results: Median follow-up period was 7.2 years (range 5.6-8.3 years). VIN recurred in one of nine complete responders. Of the initial partial responders, two became disease-free after additional imiquimod treatment. In the other partial responders, VIN recurred at least once after the initial RCT. In long-term complete responders, lesion size at study entry was smaller and these patients had a significantly better global quality of life at follow-up than patients with residual disease and/or recurrence after imiquimod treatment. Conclusions: In case of a complete response, imiquimod is effective in the long-term. Furthermore, patients with a long-term complete response had a significantly better global quality of life than patients who recurred after imiquimod treatment.

Discrepant perceptions of communication, teamwork and situation awareness among surgical team members (Article)

Wauben, L.S.G.L. — 2011-04-01T00:00:00Z

Objective: To assess surgical team members' differences in perception of non-technical skills. Design: Questionnaire design. Setting: Operating theatres (OTs) at one university hospital, three teaching hospitals and one general hospital in the Netherlands. Participants: Sixty-six surgeons, 97 OT nurses, 18 anaesthetists and 40 nurse anaesthetists. Methods: All surgical team members, of five hospitals, were asked to complete a questionnaire and state their opinion on the current state of communication, teamwork and situation awareness at the OT. Results: Ratings for 'communication' were significantly different, particularly between surgeons and all other team members (P ≤ 0.001). The ratings for 'teamwork' differed significantly between all team members (P ≤ 0.005). Within 'situation awareness' significant differences were mainly observed for 'gathering information' between surgeons and other team members (P<0.001). Finally, 72-90% of anaesthetists, OT nurses and nurse anaesthetists rated routine team briefings and debriefings as inadequate. Conclusions: This study shows discrepancies on many aspects in perception between surgeons and other surgical team members concerning communication, teamwork and situation awareness. Future research needs to ascertain whether these discrepancies are linked to greater risk of adverse events or to process as well as systems failures. Establishing this link would support implementation and use of complex team interventions that intervene at multiple levels of the healthcare system.

Journal metrics for the Netherlands heart journal (Article)

Wall, E.E. van der — 2011-04-01T00:00:00Z

Aortic surgery complications evaluated by an implanted continuous electrocardiography device: A case report (Article)

Winkel, T.A. — 2011-03-01T00:00:00Z

Introduction: Cardiac arrhythmias are a major cause for morbidity and mortality in patients undergoing non-cardiac vascular surgery. Report: An implantable loop recorder (Reveal® XT) was used for continuous heart rhythm monitoring to detect perioperative arrhythmias in a 69-year-old man undergoing major vascular surgery for an infected aortobifemoral prosthesis. The Reveal® detected several episodes of asymptomatic new-onset atrial fibrillation postoperatively, associated with elevated serum levels of troponin-T and N-terminal pro-B-type natriuretic peptide NT-proBNP). Discussion: Continuous heart rhythm monitoring with assessment of serum cardiac biomarkers may allow early identification and treatment of patients at high risk of perioperative cardiovascular complications, in particular, cardiac arrhythmias.

A nationwide study of three invasive treatments for trigeminal neuralgia (Article)

Koopman, J.S.H.A. — 2011-03-01T00:00:00Z

Invasive procedures for treatment of trigeminal neuralgia (TGN) include percutaneous radiofrequency thermocoagulation (PRT), partial sensory rhizotomy (PSR), and microvascular decompression (MVD). Using a nationwide discharge registry from The Netherlands, we assessed the frequency of use and patient characteristics, and evaluated treatment failure for each patient undergoing PRT, PSR, or MVD from January 2002 through December 2004. Only patients without a procedure in the year prior were included. Primary outcome was readmission for repeat procedures for TGN or known complications within 1 year. Comparability of patient populations was assessed through propensity scores based on hospital, age, sex, and comorbidity. Conditional logistic regression matched on propensity score was used to calculate relative risks (RR) with 95% confidence intervals (CIs) for repeat procedures or complications. During the study period, 672 patients with TGN underwent PRT, 39 underwent PSR, and 87 underwent MVD. Hospital type was the predominant determinant of procedure type; age, sex, and comorbidity were weak predictors. The RR for repeat procedures for PSR was 0.21 (95% CI: 0.07 to 0.65) and for MVD was 0.13 (95% CI: 0.05 to 0.35) compared with PRT (RR 1). For complications, the RR of PSR was 5.36 (95% CI: 1.46 to 19.64) and of MVD was 4.40 (95% CI: 1.44 to 13.42). Sex, urbanization, and comorbidity did not influence prognosis, but hospital and surgical volume did. In conclusion, although PSR and MVD are associated with a lower risk of repeat procedure than PRT, they seem to be more prone to complications requiring hospital readmission. Microvascular decompression and partial sensory rhizotomy are associated with a lower risk of undergoing a repeat procedure compared with percutaneous radiofrequency thermocoagulation but are more prone to complications requiring readmission to hospital.

Multiplex genotyping system for efficient inference of matrilineal genetic ancestry with continental resolution (Article)

Oven, M. van — 2011-03-01T00:00:00Z

Abstract Background: In recent years, phylogeographic studies have produced detailed knowledge on the worldwide distribution of mitochondrial DNA (mtDNA) variants, linking specific clades of the mtDNA phylogeny with certain geographic areas. However, a multiplex genotyping system for the detection of the mtDNA haplogroups of major continental distribution that would be desirable for efficient DNA-based bio-geographic ancestry testing in various applications is still missing. Results: Three multiplex genotyping assays, based on single-base primer extension technology, were developed targeting a total of 36 coding-region mtDNA variants that together differentiate 43 matrilineal haplo-/paragroups. These include the major diagnostic haplogroups for Africa, Western Eurasia, Eastern Eurasia and Native America. The assays show high sensitivity with respect to the amount of template DNA: successful amplification could still be obtained when using as little as 4 pg of genomic DNA and the technology is suitable for medium-throughput analyses. Conclusions: We introduce an efficient and sensitive multiplex genotyping system for bio-geographic ancestry inference from mtDNA that provides resolution on the continental level. The method can be applied in forensics, to aid tracing unknown suspects, as well as in population studies, genealogy and personal ancestry testing. For more complete inferences of overall bio-geographic ancestry from DNA, the mtDNA system provided here can be combined with multiplex systems for suitable autosomal and, in the case of males, Y-chromosomal ancestrysensitive DNA markers.

High thrombin activatable fibrinolysis inhibitor levels are associated with an increased risk of premature peripheral arterial disease (Article)

Bruijne, E.L.E. de — 2011-03-01T00:00:00Z

Background: Previous studies suggested that hypofibrinolysis is associated with increased risk of peripheral arterial disease. Thrombin activatable fibrinolysis inhibitor (TAFI) has been identified as an important inhibitor of fibrinolysis. The aim of our study was to assess the role of TAFI in young patients with peripheral arterial disease. Methods: In a single-center case-control study we measured plasma TAFI antigen levels and functional TAFI in consecutive young patients (men 18-45 years and women 18-55 years) with a first manifestation of peripheral arterial disease and compared these with a population-based control group. Results: A total of 47 peripheral arterial disease patients and 141 controls (mean age 43) were included. Intact TAFI antigen levels were significantly higher in patients with peripheral arterial disease (112.4 ± 21.1%) than in controls (104.9 ± 19.9%, p = 0.03). The risk of peripheral arterial disease increased with 18% (OR 1.18; CI 1.01-1.34) per 10% increase of TAFI antigen. Functional TAFI levels were slightly higher in patients compared to controls, however this difference was not significant. For individuals with the highest functional TAFI levels, above the 90th percentile, the increased risk for peripheral arterial disease was most pronounced (OR 3.1; CI 1.02-9.41). Conclusion: High TAFI levels are associated with increased risk of premature peripheral arterial disease.

Distribution of signs and symptoms of Complex Regional Pain Syndrome type I in patients meeting the diagnostic criteria of the International Association for the Study of Pain (Article)

Boer, R.D.H. de — 2011-02-21T00:00:00Z

The aim of the present study was to describe the occurrence of signs and symptoms in CRPS I patients meeting the IASP (Orlando) criteria, assess the occurrence of signs and symptoms in relation to disease duration and compare these to historical data based on a different diagnostic criteria set. Six hundred and ninety-two ambulatory patients meeting the IASP criteria for CRPS I referred to the outpatient clinics of five participating centers were included in this cross-sectional study. Characteristics were recorded in a standardized fashion and categorized according to the factor structure proposed by Bruehl/Harden. Subgroups were classified according to the duration of complaints and compared to historical data as described by Veldman et al. The Chi-square test corrected for multiple comparisons was used for statistical analysis. The prevalence of sensory signs was higher in patients with longer disease duration, especially for the allodynia's and hyperalgesia (all p < 0.001). Signs in vasomotor (color difference; p = 0.0007) and sudomotor (edema; p < 0.0001) subgroups were less frequently present in patients with longer disease duration (i.e. >6 months). Prevalences of signs in the motor subgroup were all higher (p < 0.0001) in patients with longer disease duration, except for limited range of motion. Occurrence of signs was significantly lower (<0.001) than those reported by Veldman et al., except for hyperesthesia and dystonia. Occurrence rates may vary at different time points after onset of CRPS, which may be of influence for diagnosing patients with novel derived diagnostic criteria. We argue for a mechanism based description of CRPS I based on one set of uniform generally accepted diagnostic criteria in future studies.

Pijn is van iedereen en van niemand (Inaugural Lecture)

Huygen, F.J.P.M. — 2011-02-18T00:00:00Z

In deze rede zal ik laten zien waarom pijn van iedereen is: patiënten, artsen, zorgverzekeraars en beleidsmakers. Want ik constateer dat er nog steeds veel pijn wordt geleden en dat er te weinig wordt gedaan om dit op te lossen. Blijkbaar is pijn dus van niemand. Ik zal u uitleggen wat pijn is en wat we weten over het lijden van pijn. Ik bepleit dat pijn van iedereen moet worden en kom met voorstellen hoe dit te bereiken. Pijn is van iedereen en van niemand. Rede, uitgesproken ter gelegenheid van het aanvaarden van het ambt van bijzonder hoogleraar met als leeropdracht Anesthesiologie in het bijzonder pijngeneeskunde, aan het Erasmus MC, faculteit van de Erasmus Universiteit Rotterdam op 18 februari 2011

Make a CHANGE: Optimising communication and pain management decisions (Article)

Müller-Schwefe, G. — 2011-02-01T00:00:00Z

The major objectives of the CHANGE PAIN International Advisory Board are to enhance understanding of chronic pain and to develop strategies for improving pain management. At its second meeting, in November 2009, evidence was presented that around one person in five in Europe and the USA experiences chronic pain, and the delay before referral to a pain specialist is often several years. Moreover, physicians' pharmacological approach to chronic pain is inconsistent, as evidenced by the huge variation in treatment between different European countries. It was agreed that efficient communication between physician and patient is essential for effective pain management, and that efficacy/side-effect balance is a key factor in choosing an analgesic agent. The multifactorial nature of chronic pain produces various physical and psychological symptoms, so the management of chronic pain should be tailored to the individual. Pharmacological therapy must be matched to the causative mechanisms responsible, or it is likely to prove ineffective and risk the development of a 'vicious circle'; doses are increased because of inadequate pain relief, but this increases side-effects so doses are reduced, pain relief is then inadequate, so doses are increased, and so on. Pain management decisions should not therefore be based solely on the severity of pain. Based on the concept of individual treatment targets (ITT), the CHANGE PAIN Scale was adopted a simple, user-friendly assessment tool to improve communication between physician and patient. The 11-point NRS enables the patient to rate the current pain intensity and to set a realistic individual target level. On the reverse are six key parameters affecting the patient's quality of life; clinicians simply need to agree with patients whether improvement is needed in each one. Regular use can establish the efficacy and tolerability of pain management, and the rate of progress towards individual treatment targets.

A nationwide study of three invasive treatments for trigeminal neuralgia (Article)

Koopman, J.S.H.A. — 2011-01-01T00:00:00Z