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Huang L, Petersen RH, Kehlet H. Postoperative outcomes in patients with diabetes after enhanced recovery thoracoscopic lobectomy. Surg Endosc 2024; 38:4207-4214. [PMID: 38849653 PMCID: PMC11289224 DOI: 10.1007/s00464-024-10936-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/17/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Diabetes is considered a general surgical risk factor, but with few data from enhanced recovery (ERAS) otherwise known to improve outcome. Therefore, this study aimed to investigate postoperative outcomes of patients with diabetes who underwent video-assisted thoracoscopic surgery (VATS) lobectomy in an established ERAS setting. METHODS We retrospectively analysed outcome data (hospital stay (LOS), readmissions, and mortality) from a prospective database with consecutive unselected ERAS VATS lobectomies from 2012 to 2022. Complete follow-up was secured by the registration system in East Denmark. RESULTS We included 3164 patients of which 323 had diabetes, including 186 treated with insulin and antidiabetic medicine, 35 with insulin only and 102 with antidiabetic medicine only. The median LOS was 3 days, stable over the study period. There were no differences in terms of LOS, postoperative complications, readmissions or 30 days alive and out of hospital. Patients with diabetes had significantly higher 30- and 90-day mortality rates compared to those without diabetes (p < .001), but also had higher preoperative comorbidity. Preoperative HbA1c levels did not correlate with postoperative outcomes. CONCLUSION In an ERAS setting, diabetes may not increase the risk for prolonged LOS, complications, and readmissions after VATS lobectomy, however with higher 30- and 90-day mortality probably related to more preoperative comorbidities.
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Affiliation(s)
- Lin Huang
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - René Horsleben Petersen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
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Koike Y, Aokage K, Osame K, Wakabayashi M, Miyoshi T, Suzuki K, Tsuboi M. Risk Factors of Severe Postoperative Complication in Lung Cancer Patients with Diabetes Mellitus. Ann Thorac Cardiovasc Surg 2024; 30:24-00018. [PMID: 38897941 PMCID: PMC11196160 DOI: 10.5761/atcs.oa.24-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 05/15/2024] [Indexed: 06/21/2024] Open
Abstract
PURPOSE Clinically, postoperative complications are occasionally observed in lung cancer patients with diabetes mellitus (DM). The increased risk of postoperative complications in DM patients has been reported in other fields. This study aims to identify risk factors for severe postoperative complications in lung cancer patients with DM. METHODS Of 2756 consecutive patients who underwent complete resection for lung cancer between 2008 and 2018 in our hospital, 475 patients (20%) were complicated by DM. Clinical factors and diabetic factors (HbA1c, preoperative fasting blood glucose [FBG], postoperative mean FBG on 1, 3 postoperative days [PODs], and use of insulin) were evaluated by univariable and multivariable analyses to identify independent risk factors of severe complication. RESULTS The 349 (73%) patients were male. Their median age was 71 years. Severe perioperative complications occurred in 128 (27%) patients. In the multivariable analysis, male (p <0.01), age (≥75 years) (p = 0.04), preoperative FBG (≥140 mg/dL) (p = 0.03), and increased mean FBG on 1, 3 PODs (≥180 mg/dL) (p <0.01) were significantly associated with severe perioperative complications. CONCLUSION Increased FBG on 1, 3 PODs (≥180 mg/dL) was an independent risk factor for severe perioperative complications in lung cancer with DM. Postoperative hyperglycemia may be correlated to severe perioperative complications.
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Affiliation(s)
- Yutaro Koike
- Department of Thoracic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Keiju Aokage
- Department of Thoracic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Keiichiro Osame
- Department of Diabetes Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Masashi Wakabayashi
- Biostatistics Division, Center for Research Administration and Support, National Cancer Center Hospital, Tokyo, Japan
| | - Tomohiro Miyoshi
- Department of Thoracic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Kenji Suzuki
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Masahiro Tsuboi
- Department of Thoracic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
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He Q, Sun M, Zhao H, Sun N, Han Q, Feng Z, Li T, Wang Y, Li G, Ma Z, Liu X, Shen Y. Ultra-processed food consumption, mediating biomarkers, and risk of chronic obstructive pulmonary disease: a prospective cohort study in the UK Biobank. Food Funct 2023; 14:8785-8796. [PMID: 37674411 DOI: 10.1039/d3fo02069j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Background: Ultra-processed food (UPF) is a popular supplement in the UK and other developed countries. However, whether and how UPF intake is associated with chronic obstructive pulmonary disease (COPD) remains unclear. Objective: We aimed to examine the association between UPF consumption and COPD incidence and explore the potential mediating effects of COPD-related biomarkers. Methods: This prospective cohort study included 207 002 participants without COPD at recruitment and completed 24-hour dietary recalls. UPF was defined according to the NOVA classification system. Incident COPD was ascertained using electronic hospital and mortality records. Cox regression models were used to estimate UPF consumption and the subsequent risk of COPD. Substitution analysis was performed to assess the risk of COPD by substituting UPF with an equivalent proportion of unprocessed or minimally processed food (UNPF). Mediation analyses were performed to evaluate the contribution of biomarkers related to the lipid profile, glucose metabolism, and systemic inflammation to the observed associations. Results: During a median follow-up of 13.1 (interquartile range: 12.5-13.9) years, 4670 COPD events were recorded. The adjusted hazard ratio (HR) of COPD in the highest quintile versus the lowest quintile of the UPF consumption proportion (weight percentage of the UPF) was 1.22 (95% confidence interval [CI]: 1.11-1.34). There was a 10% elevated risk of COPD incidence per SD increase in UPF intake (HR: 1.10; 95% CI: 1.08-1.13). Replacing 20% of the UNPF weight with the UPF was associated with a 13% decrease in COPD risk (95% CI: 0.84-0.91). In mediation analyses, biomarkers explained 1.0-10.1% of the association between UPF intake and COPD. Results from stratified and sensitivity analyses further support the robustness of these findings. Conclusions: Elevated UPF consumption was associated with a higher risk of COPD, and this association was primarily mediated by glucose, inflammation, and lipids, whereas substituting UNPF for UPF was associated with a decreased risk of COPD.
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Affiliation(s)
- Qida He
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou City, Jiangsu Province, P. R. China.
| | - Mengtong Sun
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou City, Jiangsu Province, P. R. China.
| | - Hanqing Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou City, Jiangsu Province, P. R. China.
| | - Na Sun
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou City, Jiangsu Province, P. R. China.
| | - Qiang Han
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou City, Jiangsu Province, P. R. China.
| | - Zhaolong Feng
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou City, Jiangsu Province, P. R. China.
| | - Tongxing Li
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou City, Jiangsu Province, P. R. China.
| | - Yu Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou City, Jiangsu Province, P. R. China.
| | - Guoxian Li
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou City, Jiangsu Province, P. R. China.
| | - Ze Ma
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou City, Jiangsu Province, P. R. China.
| | - Xiaoqin Liu
- The National Centre for Register-based Research, Aarhus University, Denmark
| | - Yueping Shen
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou City, Jiangsu Province, P. R. China.
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Prus K, Akça B, Bilotta F. Preoperative glycated hemoglobin concentration and early postoperative infections in patients undergoing spinal surgery: A systematic review. Clin Neurol Neurosurg 2023; 233:107938. [PMID: 37597425 DOI: 10.1016/j.clineuro.2023.107938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/29/2023] [Accepted: 08/06/2023] [Indexed: 08/21/2023]
Abstract
Early postoperative infections can affect a significant number of spinal surgery patients. Many studies reported on the features that may associate with elevated risk of infectious complications in this group. Data on the impact of glucose metabolism disorders in this area are well known. At the same time information on the correlation of preoperative HbA1c level and postoperative infections in spinal surgery are still scarce. Furthermore there are no strict recommendations regarding routine HbA1c testing prior to elective surgery. In present SR we aimed to report available clinical evidence on association between preoperative HbA1c and early postoperative infections. We used PubMed and EMBASE database and a set of specific key words (spine surgery AND infections AND HbA1c) to identify eligible studies. The study was registered in PROSPERO database and reported according to PRISMA recommendations. 16 studies were selected for further assessment. Predominance of data indicated a significant correlation between preoperative HbA1c concentration and elevated risk of postoperative infections, as well as higher rate of non - infective complications and worse patients future outcome. Adequately designed future studies on purposely dimensioned sample size are needed to confirm the role of preoperative HbA1c testing in preoperative management of spinal surgery patients.
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Affiliation(s)
- Katarzyna Prus
- Department of Neurology, Medical University of Lublin, Poland.
| | - Başak Akça
- Department of Anesthesiology and Reanimation, Hacettepe University, Ankara, Turkey
| | - Federico Bilotta
- Department of Anesthesiology, Intensive care and pain management, "Sapienza" University of Rome, Rome, Italy
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Kulikov A, Krovko Y, Zagidullin T, Ershova O, Bilotta F. Association of Preoperative Glycated Hemoglobin and Early Postoperative Infections After Elective Craniotomy: A Retrospective Cohort Study. World Neurosurg 2023; 175:e505-e510. [PMID: 37028477 DOI: 10.1016/j.wneu.2023.03.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND The prognostic value of preoperative glycated hemoglobin (HbA1c) testing is controversial. The available evidence on the role of preoperative HbA1c in predicting postoperative complications after different surgical procedures has been conflicting. The primary aim of our retrospective observational cohort study was to assess the association between preoperative HbA1c and postoperative infections after elective craniotomy. METHODS We extracted and analyzed data from an internal hospital database on 4564 patients who underwent neurosurgical intervention from January 2017 to May 2022. The primary outcome measure of the present study was infections established in the first week after surgery using the Centers for Disease Control and Prevention criteria. The records were stratified by the HbA1c values and intervention types. RESULTS For patients who had undergone brain tumor removal with a preoperative HbA1c ≥6.5%, the odds of early postoperative infections were increased (odds ratio, 2.08; 95% confidence interval, 1.16-3.72; P = 0.01). We found no association between HbA1c and early postoperative infections for patients who had undergone elective cerebrovascular intervention, cranioplasty, or a minimally invasive procedure. After adjusting for age and gender, the threshold for significant infection risk for neuro-oncological patients increased with an HbA1c ≥7.5% (adjusted odds ratio, 2.97; 95% confidence interval, 1.37-6.45; P = 0.0058). CONCLUSIONS For patients undergoing elective intracranial surgery for brain tumor removal, a preoperative HbA1c ≥7.5% is associated with a higher infection rate within the first postoperative week. Future prospective studies are required to assess the prognostic value of this association for clinical decision-making.
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Affiliation(s)
- Alexander Kulikov
- Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia.
| | - Yulia Krovko
- Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Timur Zagidullin
- Laboratory of Biomedical Informatics and Artificial Intelligence, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Olga Ershova
- Department of Epidemiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Italy
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Watson ML, Hickman SHM, Dreesbeimdiek KM, Kohler K, Stubbs DJ. Directed acyclic graphs in perioperative observational research-A systematic review and critique against best practice recommendations. PLoS One 2023; 18:e0281259. [PMID: 36758007 PMCID: PMC9910726 DOI: 10.1371/journal.pone.0281259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/18/2023] [Indexed: 02/10/2023] Open
Abstract
The Directed Acyclic Graph (DAG) is a graph representing causal pathways for informing the conduct of an observational study. The use of DAGs allows transparent communication of a causal model between researchers and can prevent over-adjustment biases when conducting causal inference, permitting greater confidence and transparency in reported causal estimates. In the era of 'big data' and increasing number of observational studies, the role of the DAG is becoming more important. Recent best-practice guidance for constructing a DAG with reference to the literature has been published in the 'Evidence synthesis for constructing DAGs' (ESC-DAG) protocol. We aimed to assess adherence to these principles for DAGs constructed within perioperative literature. Following registration on the International Prospective Register of Systematic Reviews (PROSPERO) and with adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting framework for systematic reviews, we searched the Excerpta Medica dataBASE (Embase), the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cochrane databases for perioperative observational research incorporating a DAG. Nineteen studies were included in the final synthesis. No studies demonstrated any evidence of following the mapping stage of the protocol. Fifteen (79%) fulfilled over half of the translation and integration one stages of the protocol. Adherence with one stage did not guarantee fulfilment of the other. Two studies (11%) undertook the integration two stage. Unmeasured variables were handled inconsistently between studies. Only three (16%) studies included unmeasured variables within their DAG and acknowledged their implication within the main text. Overall, DAGs that were constructed for use in perioperative observational literature did not consistently adhere to best practice, potentially limiting the benefits of subsequent causal inference. Further work should focus on exploring reasons for this deviation and increasing methodological transparency around DAG construction.
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Affiliation(s)
- Matthew Lamont Watson
- Clinical School of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Sebastian H. M. Hickman
- Yusuf Hamied Department of Chemistry, University of Cambridge, Cambridge, United Kingdom
- The Alan Turing Institute, London, United Kingdom
| | - Kaya Marlen Dreesbeimdiek
- Department of Engineering, Health Systems Design Group, University of Cambridge, Cambridge, United Kingdom
| | - Katharina Kohler
- University Division of Anaesthesia, University of Cambridge, Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Daniel J. Stubbs
- Department of Engineering, Health Systems Design Group, University of Cambridge, Cambridge, United Kingdom
- Wellcome Trust Research Fellow, University Division of Anaesthesia, Addenbrooke’s Hospital, Cambridge, United Kingdom
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Charlesworth M, Carlisle J. How to design and interpret a randomised controlled trial using Bayesian statistics. Anaesthesia 2023; 78:119-124. [PMID: 35793093 DOI: 10.1111/anae.15800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 12/13/2022]
Affiliation(s)
- M Charlesworth
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester, UK
| | - J Carlisle
- Department of Anaesthesia, Peri-operative Medicine and Intensive Care, Torbay Hospital, Devon, UK
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Lam S, Kumar B, Dhatariya K. Screening for diabetes peri-operatively: a reply. Anaesthesia 2022; 77:1180. [PMID: 35864723 DOI: 10.1111/anae.15805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2022] [Indexed: 11/01/2022]
Affiliation(s)
- S Lam
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - B Kumar
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - K Dhatariya
- Norwich Medical School, University of East Anglia, Norwich, UK
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White SM, Regan K. Screening for diabetes peri-operatively: should we be measuring glucose, HbA 1c … and insulin? Anaesthesia 2022; 77:1179. [PMID: 35776135 DOI: 10.1111/anae.15799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2022] [Indexed: 12/15/2022]
Affiliation(s)
- S M White
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - K Regan
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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Zhao BC, Liu KX. Comorbidities as mediator or confounder for the association between glycated haemoglobin and postoperative complications. Anaesthesia 2022; 77:1177-1178. [PMID: 35737462 DOI: 10.1111/anae.15792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 12/20/2022]
Affiliation(s)
- B-C Zhao
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - K-X Liu
- Nanfang Hospital, Southern Medical University, Guangzhou, China
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Lam S. Comorbidities as mediator or confounder for the association between glycated haemoglobin and postoperative complications: a reply. Anaesthesia 2022; 77:1178. [PMID: 35737467 DOI: 10.1111/anae.15791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/29/2022]
Affiliation(s)
- S Lam
- University of East Anglia Norwich Medical School, Norwich, UK
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Boroojeny AB, Nunney I, Dhatariya KK. The Association Between Glycaemic Control, Renal Function and Post-operative Ophthalmic Complications in People With Diabetes Undergoing Cataract Surgery-A Single-Centre Retrospective Analysis. Diabetes Ther 2022; 13:723-732. [PMID: 35278194 PMCID: PMC8991233 DOI: 10.1007/s13300-022-01241-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/23/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION In general surgery, it has been shown that poor peri-operative diabetes control, as measured by glycated haemoglobin (HbA1c), is associated with adverse post-operative outcomes. National data for the UK suggest that the post-operative complication rate for cataract surgery is 2.8%. It is unknown whether people with diabetes who undergo cataract surgery are also at increased risk. METHODS This single-centre retrospective study looked at the association of peri-operative HbA1c and estimated glomerular filtration rate (eGFR) with the risk of post-operative complications in people undergoing phacoemulsification and intraocular lens implantation under local anaesthesia during 2016. RESULTS 4401 individuals had cataract surgery. Of these, 34.6% (1525) had diabetes. Of those with diabetes, 114 (7.5%) developed a post-operative ophthalmological complication (as defined by the Royal College of Ophthalmologists) necessitating at least one eye clinic appointment. Mean HbA1c did not differ between those who did and those who did not develop complications (52 vs 50 mmol/mol, p = 0.12). After adjustment, HbA1c was not a significant risk (OR 1.00; 95% CI: 0.99-1.05; p = 0.85). However, eGFR had a small but statistically significant effect on outcome (OR 0.99; 95% CI: 0.98-1.00; p = 0.02). CONCLUSIONS This study has shown that more people who undergo cataract surgery have diabetes than previously reported. Also, people with diabetes are at higher risk of developing complications than previously reported. HbA1c concentration was not a factor in these adverse post-operative outcomes. However, eGFR was a predictor of risk. More focus should be placed on pre-operatively optimising co-morbidities than diabetes control in those undergoing cataract surgery.
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Affiliation(s)
| | - Ian Nunney
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Ketan K Dhatariya
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK.
- Department of Medicine, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK.
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK.
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Polderman JAW, Siegelaar SE. Finding the undiagnosed: should we screen for diabetes pre-operatively? Anaesthesia 2022; 77:631-634. [PMID: 35195893 DOI: 10.1111/anae.15688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 12/15/2022]
Affiliation(s)
- J A W Polderman
- Department of Anaesthesiology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - S E Siegelaar
- Department of Endocrinology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
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