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Spekman JA, Israëls J, de Vreede I, Los M, Geelhoed MJ, van Zwet EW, Haak MC, Roest AA, van Klink JM, Lopriore E, Groene SG. Reduced lung function during childhood in identical twins with discordant fetal growth: a cohort study. EClinicalMedicine 2024; 72:102600. [PMID: 38633574 PMCID: PMC11019090 DOI: 10.1016/j.eclinm.2024.102600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/19/2024] Open
Abstract
Background Fetal growth restriction (FGR) can negatively affect lung development, leading to increased respiratory morbidity and reduced lung function later in life. Studies regarding the impact of FGR on lung function in singletons are influenced by genetic, obstetric, and maternal factors. To overcome these confounding factors, we aim to investigate lung function in identical twins with selective FGR (sFGR). Methods Lung function assessments were performed in identical twins with sFGR born in our centre between March 1, 2002, and December 31, 2017, aged between 5 and 17 years. sFGR was defined as birthweight discordance ≥20%. Outcome measures consisted of forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and transfer factor for carbon monoxide (DLCO) and were compared between the smaller and larger twin. Findings Thirty-nine twin pairs performed spirometry of sufficient quality. Median gestational age at birth was 34.3 (interquartile range (IQR) 32.1-36.0) weeks with median birthweights of 1500 (IQR 1160-1880) grams and 2178 (IQR 1675-2720) grams for the smaller and larger twin, respectively. Smaller twins had significantly lower z-scores for FEV1 (-0.94 versus -0.41, p = 0.0015), FVC (-0.56 versus -0.06, p < 0.0001) and DLCO (-0.50 versus 0.00, p < 0.0001) compared to larger co-twins. Interpretation Although being genetically identical, sFGR in identical twins is associated with a reduction in static and dynamic lung volume and a reduction in lung diffusion, even when taking the reduced lung volume into account. This indicates that adverse growth conditions in utero negatively affect lung development and function, potentially contributing to an increase in respiratory morbidities later in life. Funding The Dutch Heart Foundation and The Bontius Foundation.
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Affiliation(s)
- Jip A. Spekman
- Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Joël Israëls
- Pediatric Pulmonology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Ilja de Vreede
- Pediatric Pulmonology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mady Los
- Department of Pulmonology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Miranda J.J. Geelhoed
- Department of Pulmonology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Erik W. van Zwet
- Medical Statistics, Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
| | - Monique C. Haak
- Fetal Therapy, Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Arno A.W. Roest
- Pediatric Cardiology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jeanine M.M. van Klink
- Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Enrico Lopriore
- Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Sophie G. Groene
- Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
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2
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Rasing I, Voigt S, Koemans EA, de Kort AM, van Harten TW, van Etten ES, van Zwet EW, Stoops E, Francois C, Kuiperij BH, Klijn CJM, Schreuder FHBM, van der Weerd L, van Osch MJP, van Walderveen MAA, Verbeek MM, Terwindt GM, Wermer MJH. Serum and cerebrospinal fluid neurofilament light chain and glial fibrillary acid protein levels in early and advanced stages of cerebral amyloid Angiopathy. Alzheimers Res Ther 2024; 16:86. [PMID: 38654326 PMCID: PMC11036675 DOI: 10.1186/s13195-024-01457-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/12/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Neurofilament light chain (NFL) is a biomarker for neuroaxonal damage and glial fibrillary acidic protein (GFAP) for reactive astrocytosis. Both processes occur in cerebral amyloid angiopathy (CAA), but studies investigating the potential of NFL and GFAP as markers for CAA are lacking. We aimed to investigate NFL and GFAP as biomarkers for neuroaxonal damage and astrocytosis in CAA. METHODS For this cross-sectional study serum and cerebrospinal fluid (CSF) samples were collected between 2010 and 2020 from controls, (pre)symptomatic Dutch-type hereditary (D-CAA) mutation-carriers and participants with sporadic CAA (sCAA) from two prospective CAA studies at two University hospitals in the Netherlands. NFL and GFAP levels were measured with Simoa-assays. The association between NFL and GFAP levels and age, cognitive performance (MoCA), CAA-related MRI markers (CAA-CSVD-burden) and Aβ40 and Aβ42 levels in CSF were assessed with linear regression adjusted for confounders. The control group was divided in age < 55 and ≥55 years to match the specific groups. RESULTS We included 187 participants: 28 presymptomatic D-CAA mutation-carriers (mean age 40 years), 29 symptomatic D-CAA participants (mean age 58 years), 59 sCAA participants (mean age 72 years), 33 controls < 55 years (mean age 42 years) and 38 controls ≥ 55 years (mean age 65 years). In presymptomatic D-CAA, only GFAP in CSF (7.7*103pg/mL vs. 4.4*103pg/mL in controls; P<.001) was increased compared to controls. In symptomatic D-CAA, both serum (NFL:26.2pg/mL vs. 12.5pg/mL; P=0.008, GFAP:130.8pg/mL vs. 123.4pg/mL; P=0.027) and CSF (NFL:16.8*102pg/mL vs. 7.8*102pg/mL; P=0.01 and GFAP:11.4*103pg/mL vs. 7.5*103pg/mL; P<.001) levels were higher than in controls and serum levels (NFL:26.2pg/mL vs. 6.7pg/mL; P=0.05 and GFAP:130.8pg/mL vs. 66.0pg/mL; P=0.004) were higher than in pre-symptomatic D-CAA. In sCAA, only NFL levels were increased compared to controls in both serum (25.6pg/mL vs. 12.5pg/mL; P=0.005) and CSF (20.0*102pg/mL vs 7.8*102pg/mL; P=0.008). All levels correlated with age. Serum NFL correlated with MoCA (P=0.008) and CAA-CSVD score (P<.001). NFL and GFAP in CSF correlated with Aβ42 levels (P=0.01/0.02). CONCLUSIONS GFAP level in CSF is an early biomarker for CAA and is increased years before symptom onset. NFL and GFAP levels in serum and CSF are biomarkers for advanced CAA.
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Affiliation(s)
- Ingeborg Rasing
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Sabine Voigt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Emma A Koemans
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Anna M de Kort
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Thijs W van Harten
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ellis S van Etten
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Bea H Kuiperij
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Louise van der Weerd
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Marcel M Verbeek
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
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3
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Reilly NA, Sonnet F, Dekkers KF, Kwekkeboom JC, Sinke L, Hilt S, Suleiman HM, Hoeksema MA, Mei H, van Zwet EW, Everts B, Ioan-Facsinay A, Jukema JW, Heijmans BT. Oleic acid triggers metabolic rewiring of T cells poising them for T helper 9 differentiation. iScience 2024; 27:109496. [PMID: 38558932 PMCID: PMC10981094 DOI: 10.1016/j.isci.2024.109496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/29/2023] [Accepted: 03/09/2024] [Indexed: 04/04/2024] Open
Abstract
T cells are the most common immune cells in atherosclerotic plaques, and the function of T cells can be altered by fatty acids. Here, we show that pre-exposure of CD4+ T cells to oleic acid, an abundant fatty acid linked to cardiovascular events, upregulates core metabolic pathways and promotes differentiation into interleukin-9 (IL-9)-producing cells upon activation. RNA sequencing of non-activated T cells reveals that oleic acid upregulates genes encoding key enzymes responsible for cholesterol and fatty acid biosynthesis. Transcription footprint analysis links these expression changes to the differentiation toward TH9 cells, a pro-atherogenic subset. Spectral flow cytometry shows that pre-exposure to oleic acid results in a skew toward IL-9+-producing T cells upon activation. Importantly, pharmacological inhibition of either cholesterol or fatty acid biosynthesis abolishes this effect, suggesting a beneficial role for statins beyond cholesterol lowering. Taken together, oleic acid may affect inflammatory diseases like atherosclerosis by rewiring T cell metabolism.
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Affiliation(s)
- Nathalie A. Reilly
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Friederike Sonnet
- Leiden University Center for Infectious Diseases (LUCID), Leiden, the Netherlands
| | - Koen F. Dekkers
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden, the Netherlands
| | | | - Lucy Sinke
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden, the Netherlands
| | - Stan Hilt
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden, the Netherlands
| | - Hayat M. Suleiman
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden, the Netherlands
| | - Marten A. Hoeksema
- Department of Medical Biochemistry, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Hailiang Mei
- Sequencing Analysis Support Core, Department of Biomedical Data Sciences, Leiden, the Netherlands
| | - Erik W. van Zwet
- Medical Statistics, Department of Biomedical Data Sciences, Leiden, the Netherlands
| | - Bart Everts
- Leiden University Center for Infectious Diseases (LUCID), Leiden, the Netherlands
| | - Andreea Ioan-Facsinay
- Department of Rheumatology Leiden University Medical Center, Leiden, the Netherlands
| | - J. Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
| | - Bastiaan T. Heijmans
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden, the Netherlands
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4
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Kaushik K, de Kort AM, van Dort R, van der Zwet RGJ, Siegerink B, Voigt S, van Zwet EW, van der Plas MC, Koemans EA, Rasing I, Kessels RPC, Middelkoop HAM, Schreuder FHBM, Klijn CJM, Verbeek MM, Terwindt GM, van Etten ES, Wermer MJH. Neuropsychiatric symptoms with focus on apathy and irritability in sporadic and hereditary cerebral amyloid angiopathy. Alzheimers Res Ther 2024; 16:74. [PMID: 38582898 PMCID: PMC10998371 DOI: 10.1186/s13195-024-01445-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/31/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Neuropsychiatric symptoms (NPS) may affect cognition, but their burden in cerebral amyloid angiopathy (CAA), one of the main causes of intracerebral hemorrhage (ICH) and dementia in the elderly, remains unclear. We investigated NPS, with emphasis on apathy and irritability in sporadic (sCAA) and Dutch-type hereditary (D-)CAA. METHODS We included patients with sCAA and (pre)symptomatic D-CAA, and controls from four prospective cohort studies. We assessed NPS per group, stratified for history of ICH, using the informant-based Neuropsychiatric Inventory (NPI-Q), Starkstein Apathy scale (SAS), and Irritability Scale. We modeled the association of NPS with disease status, executive function, processing speed, and CAA-burden score on MRI and investigated sex-differences. RESULTS We included 181 participants: 82 with sCAA (mean[SD] age 72[6] years, 44% women, 28% previous ICH), 56 with D-CAA (52[11] years, 54% women, n = 31[55%] presymptomatic), and 43 controls (69[9] years, 44% women). The NPI-Q NPS-count differed between patients and controls (sCAA-ICH+:adj.β = 1.4[95%CI:0.6-2.3]; sCAA-ICH-:1.3[0.6-2.0]; symptomatic D-CAA:2.0[1.1-2.9]; presymptomatic D-CAA:1.2[0.1-2.2], control median:0[IQR:0-3]), but not between the different CAA-subgroups. Apathy and irritability were reported most frequently: n = 12[31%] sCAA, 19[37%] D-CAA had a high SAS-score; n = 12[29%] sCAA, 14[27%] D-CAA had a high Irritability Scale score. NPS-count was associated with decreased processing speed (adj.β=-0.6[95%CI:-0.8;-0.4]) and executive function (adj.β=-0.4[95%CI:-0.6;-0.1]), but not with radiological CAA-burden. Men had NPS more often than women. DISCUSSION According to informants, one third to half of patients with CAA have NPS, mostly apathy, even in presymptomatic D-CAA and possibly with increased susceptibility in men. Neurologists should inform patients and caregivers of these disease consequences and treat or refer patients with NPS appropriately.
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Affiliation(s)
- Kanishk Kaushik
- Neurology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2300RC, Leiden, NL, the Netherlands.
| | - Anna M de Kort
- Neurology, Radboud University Medical Center (RUMC), Nijmegen, the Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, the Netherlands
| | - Rosemarie van Dort
- Neurology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2300RC, Leiden, NL, the Netherlands
| | - Reinier G J van der Zwet
- Neurology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2300RC, Leiden, NL, the Netherlands
| | - Bob Siegerink
- Clinical Epidemiology, LUMC, Leiden, the Netherlands
| | - Sabine Voigt
- Neurology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2300RC, Leiden, NL, the Netherlands
- Radiology, LUMC, Leiden, the Netherlands
| | | | - Maaike C van der Plas
- Neurology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2300RC, Leiden, NL, the Netherlands
| | - Emma A Koemans
- Neurology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2300RC, Leiden, NL, the Netherlands
| | - Ingeborg Rasing
- Neurology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2300RC, Leiden, NL, the Netherlands
| | - Roy P C Kessels
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, the Netherlands
- Medical Psychology and RUMC Alzheimer Center, Nijmegen, the Netherlands
- Vincent van Gogh Institute for Psychiatry, Venray, the Netherlands
| | - Huub A M Middelkoop
- Neurology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2300RC, Leiden, NL, the Netherlands
- Institute of Psychology, Health and Neuropsychology, Leiden University, Leiden, the Netherlands
| | - Floris H B M Schreuder
- Neurology, Radboud University Medical Center (RUMC), Nijmegen, the Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, the Netherlands
| | - Catharina J M Klijn
- Neurology, Radboud University Medical Center (RUMC), Nijmegen, the Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, the Netherlands
| | - Marcel M Verbeek
- Neurology, Radboud University Medical Center (RUMC), Nijmegen, the Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, the Netherlands
- Laboratory Medicine, RUMC, Nijmegen, the Netherlands
| | - Gisela M Terwindt
- Neurology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2300RC, Leiden, NL, the Netherlands
| | - Ellis S van Etten
- Neurology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2300RC, Leiden, NL, the Netherlands
| | - Marieke J H Wermer
- Neurology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2300RC, Leiden, NL, the Netherlands
- Neurology, University Medical Center Groningen, Groningen, the Netherlands
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5
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Koemans EA, Rasing I, Voigt S, van Harten TW, van der Zwet RG, Kaushik K, Schipper MR, van der Weerd N, van Zwet EW, van Etten ES, van Osch MJ, Kuiperij B, Verbeek MM, Terwindt GM, Greenberg SM, van Walderveen MA, Wermer MJ. Temporal Ordering of Biomarkers in Dutch-Type Hereditary Cerebral Amyloid Angiopathy. Stroke 2024; 55:954-962. [PMID: 38445479 PMCID: PMC10962436 DOI: 10.1161/strokeaha.123.044688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/24/2023] [Accepted: 12/05/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND The temporal ordering of biomarkers for cerebral amyloid angiopathy (CAA) is important for their use in trials and for the understanding of the pathological cascade of CAA. We investigated the presence and abnormality of the most common biomarkers in the largest (pre)symptomatic Dutch-type hereditary CAA (D-CAA) cohort to date. METHODS We included cross-sectional data from participants with (pre)symptomatic D-CAA and controls without CAA. We investigated CAA-related cerebral small vessel disease markers on 3T-MRI, cerebrovascular reactivity with functional 7T-MRI (fMRI) and amyloid-β40 and amyloid-β42 levels in cerebrospinal fluid. We calculated frequencies and plotted biomarker abnormality according to age to form scatterplots. RESULTS We included 68 participants with D-CAA (59% presymptomatic, mean age, 50 [range, 26-75] years; 53% women), 53 controls (mean age, 51 years; 42% women) for cerebrospinal fluid analysis and 36 controls (mean age, 53 years; 100% women) for fMRI analysis. Decreased cerebrospinal fluid amyloid-β40 and amyloid-β42 levels were the earliest biomarkers present: all D-CAA participants had lower levels of amyloid-β40 and amyloid-β42 compared with controls (youngest participant 30 years). Markers of nonhemorrhagic injury (>20 enlarged perivascular spaces in the centrum semiovale and white matter hyperintensities Fazekas score, ≥2, present in 83% [n=54]) and markers of impaired cerebrovascular reactivity (abnormal BOLD amplitude, time to peak and time to baseline, present in 56% [n=38]) were present from the age of 30 years. Finally, markers of hemorrhagic injury were present in 64% (n=41) and only appeared after the age of 41 years (first microbleeds and macrobleeds followed by cortical superficial siderosis). CONCLUSIONS Our results suggest that amyloid biomarkers in cerebrospinal fluid are the first to become abnormal in CAA, followed by MRI biomarkers for cerebrovascular reactivity and nonhemorrhagic injury and lastly hemorrhagic injury. This temporal ordering probably reflects the pathological stages of CAA and should be taken into account when future therapeutic trials targeting specific stages are designed.
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Affiliation(s)
- Emma A. Koemans
- Departments of Neurology (E.A.K., I.R., S.V., R.G.J.v.d.Z., K.K., N.v.d.W., E.S.v.E., G.M.T., M.J.H.W.), Leiden University Medical Center, the Netherlands
| | - Ingeborg Rasing
- Departments of Neurology (E.A.K., I.R., S.V., R.G.J.v.d.Z., K.K., N.v.d.W., E.S.v.E., G.M.T., M.J.H.W.), Leiden University Medical Center, the Netherlands
| | - Sabine Voigt
- Departments of Neurology (E.A.K., I.R., S.V., R.G.J.v.d.Z., K.K., N.v.d.W., E.S.v.E., G.M.T., M.J.H.W.), Leiden University Medical Center, the Netherlands
- Radiology (S.V., T.W.v.H., M.R.S., M.J.v.P.O., M.A.A.v.W.), Leiden University Medical Center, the Netherlands
| | - Thijs W. van Harten
- Radiology (S.V., T.W.v.H., M.R.S., M.J.v.P.O., M.A.A.v.W.), Leiden University Medical Center, the Netherlands
| | - Reinier G.J. van der Zwet
- Departments of Neurology (E.A.K., I.R., S.V., R.G.J.v.d.Z., K.K., N.v.d.W., E.S.v.E., G.M.T., M.J.H.W.), Leiden University Medical Center, the Netherlands
| | - Kanishk Kaushik
- Departments of Neurology (E.A.K., I.R., S.V., R.G.J.v.d.Z., K.K., N.v.d.W., E.S.v.E., G.M.T., M.J.H.W.), Leiden University Medical Center, the Netherlands
| | - Manon R. Schipper
- Radiology (S.V., T.W.v.H., M.R.S., M.J.v.P.O., M.A.A.v.W.), Leiden University Medical Center, the Netherlands
| | - Nelleke van der Weerd
- Departments of Neurology (E.A.K., I.R., S.V., R.G.J.v.d.Z., K.K., N.v.d.W., E.S.v.E., G.M.T., M.J.H.W.), Leiden University Medical Center, the Netherlands
| | - Erik W. van Zwet
- Biostatistics (E.W.v.Z.), Leiden University Medical Center, the Netherlands
| | - Ellis S. van Etten
- Departments of Neurology (E.A.K., I.R., S.V., R.G.J.v.d.Z., K.K., N.v.d.W., E.S.v.E., G.M.T., M.J.H.W.), Leiden University Medical Center, the Netherlands
| | - Matthias J.P. van Osch
- Radiology (S.V., T.W.v.H., M.R.S., M.J.v.P.O., M.A.A.v.W.), Leiden University Medical Center, the Netherlands
| | - Bea Kuiperij
- Department Neurology and Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen (B.K., M.M.V.)
| | - Marcel M. Verbeek
- Department Neurology and Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen (B.K., M.M.V.)
| | - Gisela M. Terwindt
- Departments of Neurology (E.A.K., I.R., S.V., R.G.J.v.d.Z., K.K., N.v.d.W., E.S.v.E., G.M.T., M.J.H.W.), Leiden University Medical Center, the Netherlands
| | - Steven M. Greenberg
- J Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (S.M.G.)
| | | | - Marieke J.H. Wermer
- Departments of Neurology (E.A.K., I.R., S.V., R.G.J.v.d.Z., K.K., N.v.d.W., E.S.v.E., G.M.T., M.J.H.W.), Leiden University Medical Center, the Netherlands
- Department of Neurology, University Medical Center Groningen, the Netherlands (M.J.H.W.)
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6
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Ali M, Dekker L, Daems JD, Ali M, van Zwet EW, Steyerberg EW, Duvekot MHC, Nguyen TTM, Moudrous W, van de Wijdeven RM, Visser MC, de Laat KF, Kerkhoff H, van den Wijngaard IR, Dippel DWJ, Roozenbeek B, Kruyt ND, Wermer MJH. Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients With Suspected Stroke. Stroke 2024; 55:548-554. [PMID: 38299328 PMCID: PMC10896195 DOI: 10.1161/strokeaha.123.044898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/03/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Differences in clinical presentation of acute ischemic stroke between men and women may affect prehospital identification of anterior circulation large vessel occlusion (aLVO). We assessed sex differences in diagnostic performance of 8 prehospital scales to detect aLVO. METHODS We analyzed pooled individual patient data from 2 prospective cohort studies (LPSS [Leiden Prehospital Stroke Study] and PRESTO [Prehospital Triage of Patients With Suspected Stroke Study]) conducted in the Netherlands between 2018 and 2019, including consecutive patients ≥18 years suspected of acute stroke who presented within 6 hours after symptom onset. Ambulance paramedics assessed clinical items from 8 prehospital aLVO detection scales: Los Angeles Motor Scale, Rapid Arterial Occlusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Cincinnati Prehospital Stroke Scale, Prehospital Acute Stroke Severity, gaze-face-arm-speech-time, Conveniently Grasped Field Assessment Stroke Triage, and Face-Arm-Speech-Time Plus Severe Arm or Leg Motor Deficit. We assessed the diagnostic performance of these scales for identifying aLVO at prespecified cut points for men and women. RESULTS Of 2358 patients with suspected stroke (median age, 73 years; 47% women), 231 (10%) had aLVO (100/1114 [9%] women and 131/1244 [11%] men). The area under the curve of the scales ranged from 0.70 (95% CI, 0.65-0.75) to 0.77 (95% CI, 0.73-0.82) in women versus 0.69 (95% CI, 0.64-0.73) to 0.75 (95% CI, 0.71-0.79) in men. Positive predictive values ranged from 0.23 (95% CI, 0.20-0.27) to 0.29 (95% CI, 0.26-0.31) in women versus 0.29 (95% CI, 0.24-0.33) to 0.37 (95% CI, 0.32-0.43) in men. Negative predictive values were similar (0.95 [95% CI, 0.94-0.96] to 0.98 [95% CI, 0.97-0.98] in women versus 0.94 [95% CI, 0.93-0.95] to 0.96 [95% CI, 0.94-0.97] in men). Sensitivity of the scales was slightly higher in women than in men (0.53 [95% CI, 0.43-0.63] to 0.76 [95% CI, 0.68-0.84] versus 0.49 [95% CI, 0.40-0.57] to 0.63 [95% CI, 0.55-0.73]), whereas specificity was lower (0.79 [95% CI, 0.76-0.81] to 0.87 [95% CI, 0.84-0.89] versus 0.82 [95% CI, 0.79-0.84] to 0.90 [95% CI, 0.88-0.91]). Rapid arterial occlusion evaluation showed the highest positive predictive values in both sexes (0.29 in women and 0.37 in men), reflecting the different event rates. CONCLUSIONS aLVO scales show similar diagnostic performance in both sexes. The rapid arterial occlusion evaluation scale may help optimize prehospital transport decision-making in men as well as in women with suspected stroke.
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Affiliation(s)
- Mariam Ali
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
| | - Luuk Dekker
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
| | - Jasper D Daems
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Public Health (J.D.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Erik W van Zwet
- Department of Biomedical Data Sciences (E.W.v.Z., E.W.S.), Leiden University Medical Center, the Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences (E.W.v.Z., E.W.S.), Leiden University Medical Center, the Netherlands
| | - Martijne H C Duvekot
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., H.K.)
| | - T Truc My Nguyen
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
| | - Walid Moudrous
- Department of Neurology, Maasstad Hospital, Rotterdam, the Netherlands (W.M.)
| | - Ruben M van de Wijdeven
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marieke C Visser
- Department of Neurology (M.C.V.)
- Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands (M.C.V.)
| | - Karlijn F de Laat
- Department of Neurology, Haga Hospital, the Hague, the Netherlands (K.F.d.L.)
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., H.K.)
| | - Ido R van den Wijngaard
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
- Department of Neurology, Haaglanden Medical Center, the Hague, the Netherlands (I.R.v.d.W.)
- University Neurovascular Center Leiden-The Hague, the Netherlands (I.R.v.d.W., N.D.K.)
| | - Diederik W J Dippel
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
- University Neurovascular Center Leiden-The Hague, the Netherlands (I.R.v.d.W., N.D.K.)
| | - Marieke J H Wermer
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
- Department of Neurology, University Medical Centre Groningen, University of Groningen, the Netherlands (M.J.H.W.)
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7
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van Zwet EW, Tian L, Tibshirani R. Evaluating a shrinkage estimator for the treatment effect in clinical trials. Stat Med 2024; 43:855-868. [PMID: 38111969 DOI: 10.1002/sim.9992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 11/21/2023] [Accepted: 12/03/2023] [Indexed: 12/20/2023]
Abstract
The main objective of most clinical trials is to estimate the effect of some treatment compared to a control condition. We define the signal-to-noise ratio (SNR) as the ratio of the true treatment effect to the SE of its estimate. In a previous publication in this journal, we estimated the distribution of the SNR among the clinical trials in the Cochrane Database of Systematic Reviews (CDSR). We found that the SNR is often low, which implies that the power against the true effect is also low in many trials. Here we use the fact that the CDSR is a collection of meta-analyses to quantitatively assess the consequences. Among trials that have reached statistical significance we find considerable overoptimism of the usual unbiased estimator and under-coverage of the associated confidence interval. Previously, we have proposed a novel shrinkage estimator to address this "winner's curse." We compare the performance of our shrinkage estimator to the usual unbiased estimator in terms of the root mean squared error, the coverage and the bias of the magnitude. We find superior performance of the shrinkage estimator both conditionally and unconditionally on statistical significance.
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Affiliation(s)
- Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Lu Tian
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California, USA
| | - Robert Tibshirani
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California, USA
- Department of Statistics, Stanford University, Stanford, California, USA
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8
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Chung PK, Schornagel FAJ, Soede W, van Zwet EW, Kroes ACM, Oudesluys-Murphy AM, Vossen ACTM. Valganciclovir in Infants with Hearing Loss and Clinically Inapparent Congenital Cytomegalovirus Infection: A Nonrandomized Controlled Trial. J Pediatr 2024; 268:113945. [PMID: 38336204 DOI: 10.1016/j.jpeds.2024.113945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 12/29/2023] [Accepted: 02/04/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE To assess the efficacy of valganciclovir in infants with hearing loss and clinically inapparent congenital cytomegalovirus infection (cCMV), as there is no consensus on treatment of this group. STUDY DESIGN A nationwide, nonrandomized controlled trial, comparing 6 weeks of oral valganciclovir to no treatment in infants with cCMV, recruited after newborn hearing screening resulted in referral to an audiologist. The choice whether to treat was left to parents of subjects. Eligible subjects were full term infants aged <13 weeks with sensorineural hearing loss and diagnosed with cCMV through dried blood spot testing. The primary outcome, measured by linear and ordinal logistic regression, was change in best-ear hearing from baseline to follow-up at 18-22 months of age. RESULTS Thirty-seven participants were included in the final analysis, of whom 25 were in the treatment group and 12 in the control group. The majority of subjects in both groups had neuroimaging abnormalities, which were mostly mild. Hearing deterioration was more likely in the control group compared with the treatment group (common OR 0.10, 95% CI 0.02-0.45, P = .003). Mean best-ear hearing deteriorated by 13.7 dB in the control group, compared with improvement of 3.3 dB in the treatment group (difference 17 dB, 95% CI 2.6 - 31.4, P = .02). CONCLUSIONS We investigated treatment in children with hearing loss and clinically inapparent cCMV. Although our study was nonrandomized, it is the first prospective and controlled trial in this population. Valganciclovir-treated children with hearing loss and inapparent cCMV had less hearing deterioration at 18 through 22 months of age than control subjects. EUDRACT REGISTRY NUMBER 2013-003068-30.
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Affiliation(s)
- Pui Khi Chung
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Fleurtje A J Schornagel
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands; SBOH, Utrecht, The Netherlands
| | - Wim Soede
- Department of Otorhinolaryngology and Head & Neck Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Aloys C M Kroes
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Ann C T M Vossen
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
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9
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de Vries Lentsch S, van der Arend BWH, de Boer I, van Zwet EW, MaassenVanDenBrink A, Terwindt GM. Depression and treatment with anti-calcitonin gene related peptide (CGRP) (ligand or receptor) antibodies for migraine. Eur J Neurol 2024; 31:e16106. [PMID: 37847221 DOI: 10.1111/ene.16106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/04/2023] [Accepted: 10/01/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND AND PURPOSE The aim was to evaluate the effect of anti-calcitonin gene related peptide (CGRP) (ligand or receptor) antibodies on depressive symptoms in subjects with migraine and to determine whether depressive symptoms predict treatment response. METHODS Patients with migraine treated with erenumab and fremanezumab at the Leiden Headache Centre completed daily E-headache diaries. A control group was included. Depressive symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS) and the Center for Epidemiological Studies Depression Scale (CES-D) questionnaires at baseline (T0) and after 3 months (T1). First, the effect of treatment on the reduction in HADS-D and CES-D scores was assessed, with reduction in depression scores as the dependent variable and reduction in monthly migraine days (MMD) and treatment with anti-CGRP medication as independent variables. Second, depression as a predictor of treatment response was investigated, using the absolute reduction in MMD as a dependent variable and age, gender, MMD, active depression, impact, stress and locus of control scores as independent variables. RESULTS In total, n = 108 patients were treated with erenumab, n = 90 with fremanezumab and n = 68 were without active treatment. Treatment with anti-CGRP medication was positively associated with a reduction in the HADS-D (β = 1.65, p = 0.01) compared to control, independent of MMD reduction. However, the same effect was not found for the CES-D (β = 2.15, p = 0.21). Active depression predicted poorer response to erenumab (p = 0.02) but not to fremanezumab (p = 0.09). CONCLUSION Anti-CGRP (ligand or receptor) monoclonals lead to improvement of depressive symptoms in individuals with migraine, independent of migraine reduction. Depression may predict treatment response to erenumab but not to fremanezumab.
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Affiliation(s)
| | - Britt W H van der Arend
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Irene de Boer
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
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10
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Sprenger GP, van Zwet EW, Bakels HS, Achterberg WP, Roos RA, de Bot ST. Prevalence and burden of pain across the entire spectrum of Huntington's disease. J Neurol Neurosurg Psychiatry 2024:jnnp-2023-332992. [PMID: 38290837 DOI: 10.1136/jnnp-2023-332992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/09/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Pain is an important symptom in Huntington's disease (HD), however, not systematically studied and understood. The objective of the current study is to assess the prevalence of pain, pain interference in daily activities, painful conditions, analgesic use and the severity of the pain burden across different disease stages and 'Age at symptom Onset' groups. Additionally, the association between pain and disease burden was investigated. METHODS A cross-sectional analysis was conducted within two large data sets, which included different types of pain scales. Multivariable logistic regression analyses and analyses of variance were performed to compare the pain levels with those in the general population. The analyses were adjusted for sex and age. Locally Estimated Scatterplot Smoothing was used to test the association between pain and the HD pathology score: a measure of disease burden. RESULTS The mean prevalence of pain in the HD population was 40% and for pain interference around 35% in both data sets. Patients in the early, middle and late stage of HD experience more pain burden compared with what is reported in patients with chronic pain (p<0.01). A positive and significant association was demonstrated between pain and disease burden. Patients in late stage HD with pain use significantly less analgesics compared with the general population (5% vs 13%, respectively (p<0.01)). CONCLUSIONS Pain is a prevalent and important symptom in HD. Severe pain burden in the HD population is present and positively associated with disease burden. Risk for undertreatment with analgesics is nevertheless present. Awareness of pain in HD needs to be increased, both clinically and scientifically.
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Affiliation(s)
- Gregory P Sprenger
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Huntington Center, Amstelring, Amsterdam, The Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Hannah S Bakels
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- Huntington Center overduin, Topaz, Leiden, The Netherlands
| | - Raymund A Roos
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Susanne T de Bot
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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11
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Schipper MR, Vlegels N, van Harten TW, Rasing I, Koemans EA, Voigt S, de Luca A, Kaushik K, van Etten ES, van Zwet EW, Terwindt GM, Biessels GJ, van Osch MJP, van Walderveen MAA, Wermer MJH. Microstructural white matter integrity in relation to vascular reactivity in Dutch-type hereditary cerebral amyloid angiopathy. J Cereb Blood Flow Metab 2023; 43:2144-2155. [PMID: 37708241 PMCID: PMC10925868 DOI: 10.1177/0271678x231200425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/04/2023] [Accepted: 08/07/2023] [Indexed: 09/16/2023]
Abstract
Cerebral Amyloid Angiopathy (CAA) is characterized by cerebrovascular amyloid-β accumulation leading to hallmark cortical MRI markers, such as vascular reactivity, but white matter is also affected. By studying the relationship in different disease stages of Dutch-type CAA (D-CAA), we tested the relation between vascular reactivity and microstructural white matter integrity loss. In a cross-sectional study in D-CAA, 3 T MRI was performed with Blood-Oxygen-Level-Dependent (BOLD) fMRI upon visual activation to assess vascular reactivity and diffusion tensor imaging to assess microstructural white matter integrity through Peak Width of Skeletonized Mean Diffusivity (PSMD). We assessed the relationship between BOLD parameters - amplitude, time-to-peak (TTP), and time-to-baseline (TTB) - and PSMD, with linear and quadratic regression modeling. In total, 25 participants were included (15/10 pre-symptomatic/symptomatic; mean age 36/59 y). A lowered BOLD amplitude (unstandardized β = 0.64, 95%CI [0.10, 1.18], p = 0.02, Adjusted R2 = 0.48), was quadratically associated with increased PSMD levels. A delayed BOLD response, with prolonged TTP (β = 8.34 × 10-6, 95%CI [1.84 × 10-6, 1.48 × 10-5], p = 0.02, Adj. R2 = 0.25) and TTB (β = 6.57 × 10-6, 95%CI [1.92 × 10-6, 1.12 × 10-5], p = 0.008, Adj. R2 = 0.29), was linearly associated with increased PSMD. In D-CAA subjects, predominantly in the symptomatic stage, impaired cerebrovascular reactivity is related to microstructural white matter integrity loss. Future longitudinal studies are needed to investigate whether this relation is causal.
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Affiliation(s)
- Manon R Schipper
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Naomi Vlegels
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
| | - Thijs W van Harten
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ingeborg Rasing
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Emma A Koemans
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sabine Voigt
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alberto de Luca
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Image Sciences Institute, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kanishk Kaushik
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ellis S van Etten
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Biostatistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Geert Jan Biessels
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Matthias JP van Osch
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Marieke JH Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
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12
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van Rossum IA, de Lange FJ, Benditt DG, van Zwet EW, van Houwelingen M, Thijs RD, van Dijk JG. Variability of cardioinhibition in vasovagal syncope: differences between subgroups during cardioinhibition and beyond. Clin Auton Res 2023; 33:749-755. [PMID: 37874434 PMCID: PMC10751252 DOI: 10.1007/s10286-023-00991-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/30/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE We compared hemodynamic parameters between subjects with marked, intermediate and minimal cardioinhibition during vasovagal syncope. METHODS The study included subjects with a decrease in heart rate while experiencing a complete vasovagal syncope during tilt-table testing. The subjects were classified as having marked, intermediate or minimal cardioinhibition, based on tertile values of the decrease in heart rate. Hemodynamic parameters between these groups were compared before tilt in the supine position, shortly after tilt and during cardioinhibition. RESULTS A total of 149 subjects with a median age of 43 (interquartile range 24-60) years were included in the study. Among the three groups with different levels of cardioinhibition, the highest heart rate was observed in subjects with marked cardioinhibition both before and shortly after tilt and at the start of cardioinhibition. The heart rate decrease in these subjects was both larger and faster compared to subjects with minimal and intermediate cardioinhibition. CONCLUSION Subjects with marked cardioinhibition have both a larger and faster decrease in heart rate compared to subjects with intermediate and minimal cardioinhibition, as early as from the start of cardioinhibition. Marked cardioinhibition is related to differences in hemodynamic profiles already present well before the start of cardioinhibition.
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Affiliation(s)
- Ineke A van Rossum
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300, Leiden, The Netherlands.
| | - Frederik J de Lange
- Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - David G Benditt
- Cardiac Arrhythmia Center, Cardiovascular Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marc van Houwelingen
- Department of Experimental Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300, Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300, Leiden, The Netherlands
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13
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Brandt RB, Wilbrink LA, de Coo IF, Haan J, Mulleners WM, Huygen FJPM, van Zwet EW, Ferrari MD, Fronczek R. A prospective open label 2-8 year extension of the randomised controlled ICON trial on the long-term efficacy and safety of occipital nerve stimulation in medically intractable chronic cluster headache. EBioMedicine 2023; 98:104895. [PMID: 38007947 PMCID: PMC10755111 DOI: 10.1016/j.ebiom.2023.104895] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND We demonstrated in the randomised controlled ICON study that 48-week treatment of medically intractable chronic cluster headache (MICCH) with occipital nerve stimulation (ONS) is safe and effective. In L-ICON we prospectively evaluate its long-term effectiveness and safety. METHODS ICON participants were enrolled in L-ICON immediately after completing ICON. Therefore, earlier ICON participants could be followed longer than later ones. L-ICON inclusion was stopped after the last ICON participant was enrolled in L-ICON and followed for ≥2 years by completing six-monthly questionnaires on attack frequency, side effects, subjective improvement and whether they would recommend ONS to others. Primary outcome was the change in mean weekly attack frequency 2 years after completion of the ICON study compared to baseline. Missing values for log-transformed attack-frequency were imputed for up to 5 years of follow-up. Descriptive analyses are presented as (pooled) geometric or arithmetic means and 95% confidence intervals. FINDINGS Of 103 eligible participants, 88 (85%) gave informed consent and 73 (83%) were followed for ≥2 year, 61 (69%) ≥ 3 year, 33 (38%) ≥ 5 years and 3 (3%) ≥ 8.5 years. Mean (±SD) follow-up was 4.2 ± 2.2 years for a total of 370 person years (84% of potentially 442 years). The pooled geometric mean (95% CI) weekly attack frequency remained considerably lower after one (4.2; 2.8-6.3), two (5.1; 3.5-7.6) and five years (4.1; 3.0-5.5) compared to baseline (16.2; 14.4-18.3). Of the 49/88 (56%) ICON ≥50% responders, 35/49 (71%) retained this response and 15/39 (38%) ICON non-responders still became a ≥50% responder for at least half the follow-up period. Most participants (69/88; 78% [0.68-0.86]) reported a subjective improvement from baseline at last follow-up and 70/88 (81% [0.70-0.87]) would recommend ONS to others. Hardware-related surgery was required in 44/88 (50%) participants in 112/122 (92%) events (0.35 person-year-1 [0.28-0.41]). We didn't find predictive factors for effectiveness. INTERPRETATION ONS is a safe, well-tolerated and long-term effective treatment for MICCH. FUNDING The Netherlands Organisation for Scientific Research, the Dutch Ministry of Health, the NutsOhra Foundation from the Dutch Health Insurance Companies, and Medtronic.
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Affiliation(s)
- Roemer B Brandt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.
| | | | - Ilse F de Coo
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Department of Medical Rehabilitation, Treant, Emmen, the Netherlands
| | - Joost Haan
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Department of Neurology, Alrijne Hospital, Alphen a/d Rijn, the Netherlands
| | - Wim M Mulleners
- Department of Neurology, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
| | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
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14
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van der Arend BWH, Bloemhof MM, van der Schoor AG, van Zwet EW, Terwindt GM. Effect of COVID vaccination on monthly migraine days: a longitudinal cohort study. Cephalalgia 2023; 43:3331024231198792. [PMID: 37684012 DOI: 10.1177/03331024231198792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
BACKGROUND This longitudinal cohort study aimed to investigate changes in migraine-related outcomes following COVID-19 infection and vaccination. METHODS We identified 547 clinically diagnosed migraine patients from the Leiden Headache Center who kept a headache E-diary during the COVID-19 pandemic (February 2020 to August 2022). We sent a questionnaire to register their COVID-19 infection and/or vaccination dates. After applying inclusion criteria, n = 59 participants could be included in the infection analysis and n = 147 could be included in the vaccination analysis. Primary outcome was the change in monthly migraine days (MMD) between 1 month prior and 1 month post COVID-19 infection or vaccination. Secondary outcome variables were change in monthly headache days (MHD) and monthly acute medication days (MAMD). RESULTS Vaccination against COVID-19 was associated with an increase in MMD (1.06; 95% confidence interval [CI] = 0.57-1.55; p < 0.001), MHD (1.52; 95% CI = 0.91-2.14; p < 0.001) and MAMD (0.72; 95% CI = 0.33-1.12; p < 0.001) in the first month post-vaccination. COVID-19 infection solely increased the number of MAMD (1.11; 95% CI = 0.10-1.62; p < 0.027), but no statistically significant differences in MMD or MHD were observed. CONCLUSIONS Our findings imply that vaccination against COVID-19 is associated with an increase in migraine, indicating a possible role of inflammatory mediators in migraine pathophysiology.
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Affiliation(s)
- Britt W H van der Arend
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Erasmus University, Rotterdam, The Netherlands
| | - Mirthe M Bloemhof
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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15
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Dekker L, Daems JD, Duvekot MHC, Nguyen TTM, Venema E, van Es ACGM, Rozeman AD, Moudrous W, Dorresteijn KRIS, Hensen JHJ, Bosch J, van Zwet EW, de Schryver ELLM, Kloos LMH, de Laat KF, Aerden LAM, van den Wijngaard IR, Dippel DWJ, Kerkhoff H, Wermer MJH, Roozenbeek B, Kruyt ND. Comparison of Prehospital Assessment by Paramedics and In-Hospital Assessment by Physicians in Suspected Stroke Patients: Results From 2 Prospective Cohort Studies. Stroke 2023; 54:2279-2285. [PMID: 37465998 DOI: 10.1161/strokeaha.123.042644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/22/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND It is unknown if ambulance paramedics adequately assess neurological deficits used for prehospital stroke scales to detect anterior large-vessel occlusions. We aimed to compare prehospital assessment of these stroke-related deficits by paramedics with in-hospital assessment by physicians. METHODS We used data from 2 prospective cohort studies: the LPSS (Leiden Prehospital Stroke Study) and PRESTO study (Prehospital Triage of Patients With Suspected Stroke). In both studies, paramedics scored 9 neurological deficits in stroke code patients in the field. Trained physicians scored the National Institutes of Health Stroke Scale (NIHSS) at hospital presentation. Patients with transient ischemic attack were excluded because of the transient nature of symptoms. Spearman rank correlation coefficient (rs) was used to assess correlation between the total prehospital assessment score, defined as the sum of all prehospital items, and the total NIHSS score. Correlation, sensitivity and specificity were calculated for each prehospital item with the corresponding NIHSS item as reference. RESULTS We included 2850 stroke code patients. Of these, 1528 had ischemic stroke, 243 intracranial hemorrhage, and 1079 stroke mimics. Correlation between the total prehospital assessment score and NIHSS score was strong (rs=0.70 [95% CI, 0.68-0.72]). Concerning individual items, prehospital assessment of arm (rs=0.68) and leg (rs=0.64) motor function correlated strongest with corresponding NIHSS items, and had highest sensitivity (arm 95%, leg 93%) and moderate specificity (arm 71%, leg 70%). Neglect (rs=0.31), abnormal speech (rs=0.50), and gaze deviation (rs=0.51) had weakest correlations. Neglect and gaze deviation had lowest sensitivity (52% and 66%) but high specificity (84% and 89%), while abnormal speech had high sensitivity (85%) but lowest specificity (65%). CONCLUSIONS The overall prehospital assessment of stroke code patients correlates strongly with in-hospital assessment. Prehospital assessment of neglect, abnormal speech, and gaze deviation differed most from in-hospital assessment. Focused training on these deficits may improve prehospital triage.
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Affiliation(s)
- Luuk Dekker
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
| | - Jasper D Daems
- Department of Neurology (J.D.D., M.H.C.D., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Public Health (J.D.D., E.V.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Martijne H C Duvekot
- Department of Neurology (J.D.D., M.H.C.D., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., A.D.R., H.K.)
| | - T Truc My Nguyen
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
| | - Esmee Venema
- Department of Public Health (J.D.D., E.V.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Emergency Medicine (E.V.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C G M van Es
- Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands
| | - Anouk D Rozeman
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., A.D.R., H.K.)
| | - Walid Moudrous
- Department of Neurology (W.M.), Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Jan-Hein J Hensen
- Department of Radiology (J.-H.J.H.), Maasstad Hospital, Rotterdam, the Netherlands
| | - Jan Bosch
- Emergency Medical Services Hollands-Midden, Leiden, the Netherlands (J.B.)
| | - Erik W van Zwet
- Department of Medical Statistics (E.W.v.Z.), Leiden University Medical Center, the Netherlands
| | - Els L L M de Schryver
- Department of Neurology, Alrijne Hospital, Leiderdorp, the Netherlands (E.L.L.M.d.S.)
| | - Loet M H Kloos
- Department of Neurology, Groene Hart Hospital, Gouda, the Netherlands (L.M.H.K.)
| | - Karlijn F de Laat
- Department of Neurology, Haga Hospital, The Hague, the Netherlands (K.F.d.L.)
| | - Leo A M Aerden
- Department of Neurology, Reinier de Graaf Gasthuis Hospital, Delft, the Netherlands (L.A.M.A.)
| | - Ido R van den Wijngaard
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology (J.D.D., M.H.C.D., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., A.D.R., H.K.)
| | - Marieke J H Wermer
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands (M.J.H.W.)
| | - Bob Roozenbeek
- Department of Neurology (J.D.D., M.H.C.D., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
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16
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Pijpers JA, Kies DA, van Zwet EW, de Boer I, Terwindt GM. Cutaneous allodynia as predictor for treatment response in chronic migraine: a cohort study. J Headache Pain 2023; 24:118. [PMID: 37644420 PMCID: PMC10466691 DOI: 10.1186/s10194-023-01651-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/10/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Central sensitisation is an important mechanism in migraine chronification. It is presumed to occur in second and third order neurons sequentially, resulting in an analogous spatial distribution of cutaneous allodynia with cephalic and extracephalic symptoms. We investigated whether allodynia, and its subtypes based on spatial distribution and type of stimulus, predict response to treatment in chronic migraine patients. METHODS This study was conducted as part of the CHARM study (NTR3440), a randomized, double-blind, placebo-controlled trial in chronic migraine patients with medication overuse. We included 173 patients. The presence of cutaneous allodynia at baseline was established with the Allodynia Symptom Checklist. Primary endpoint was reversion from chronic to episodic migraine. RESULTS Of all patients, 74.6% reported cutaneous allodynia. Absence of allodynia compared to presence of allodynia was predictive for reversion from chronic to episodic migraine, odds ratio (OR): 2.45 (95% CI: 1.03-5.84), p = 0.042. The predictive value was more pronounced when subdivided for spatial distribution, for participants without allodynia versus cephalic (OR: 4.16 (95% CI: 1.21-14.30), p = 0.024) and extracephalic (OR: 7.32 (95% CI: 1.98- 27.11), p = 0.003) allodynia. Mechanical, but not thermal, allodynia, was associated with outcome. CONCLUSIONS Cutaneous allodynia, an important marker for central sensitization, likely has predictive value for treatment response in chronic migraine.
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Affiliation(s)
- Judith A Pijpers
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Dennis A Kies
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Department Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Erik W van Zwet
- Department Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Irene de Boer
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands.
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Liu Y, Sinke L, Jonkman TH, Slieker RC, van Zwet EW, Daxinger L, Heijmans BT. The inactive X chromosome accumulates widespread epigenetic variability with age. Clin Epigenetics 2023; 15:135. [PMID: 37626340 PMCID: PMC10464315 DOI: 10.1186/s13148-023-01549-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Loss of epigenetic control is a hallmark of aging. Among the most prominent roles of epigenetic mechanisms is the inactivation of one of two copies of the X chromosome in females through DNA methylation. Hence, age-related disruption of X-chromosome inactivation (XCI) may contribute to the aging process in women. METHODS We analyzed 9,777 CpGs on the X chromosome in whole blood samples from 2343 females and 1688 males (Illumina 450k methylation array) and replicated findings in duplicate using one whole blood and one purified monocyte data set (in total, 991/924 females/males). We used double generalized linear models to detect age-related differentially methylated CpGs (aDMCs), whose mean methylation level differs with age, and age-related variably methylated CpGs (aVMCs), whose methylation level becomes more variable with age. RESULTS In females, aDMCs were relatively uncommon (n = 33) and preferentially occurred in regions known to escape XCI. In contrast, many CpGs (n = 987) were found to display an increased variance with age (aVMCs). Of note, the replication rate of aVMCs was also high in purified monocytes (94%), indicating an independence of cell composition. aVMCs accumulated in CpG islands and regions subject to XCI suggesting that they stemmed from the inactive X. In males, carrying an active copy of the X chromosome only, aDMCs (n = 316) were primarily driven by cell composition, while aVMCs replicated well (95%) but were infrequent (n = 37). CONCLUSIONS Our results imply that age-related DNA methylation differences at the inactive X chromosome are dominated by the accumulation of variability.
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Affiliation(s)
- Yunfeng Liu
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Postzone S-5-P, 2333 ZC, Leiden, The Netherlands
| | - Lucy Sinke
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Postzone S-5-P, 2333 ZC, Leiden, The Netherlands
| | - Thomas H Jonkman
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Postzone S-5-P, 2333 ZC, Leiden, The Netherlands
| | - Roderick C Slieker
- Department of Cell and Chemical Biology, Leiden University Medical Center, 2333 ZC, Leiden, The Netherlands
| | - Erik W van Zwet
- Medical Statistics, Department of Biomedical Data Sciences, Leiden University Medical Center, 2333 ZC, Leiden, The Netherlands
| | - Lucia Daxinger
- Department of Human Genetics, Leiden University Medical Center, 2333 ZC, Leiden, The Netherlands
| | - Bastiaan T Heijmans
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Postzone S-5-P, 2333 ZC, Leiden, The Netherlands.
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18
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Groene SG, Gremmen IJ, van Zwet EW, Roest AAW, Haak MC, van Klink JMM, Lopriore E, Heijmans BT, de Bruin C. Fetal growth restriction inhibits childhood growth despite catch-up in discordant identical twins: an observational cohort study. Eur J Endocrinol 2023; 189:183-189. [PMID: 37548178 DOI: 10.1093/ejendo/lvad103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/10/2023] [Accepted: 06/07/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE Research suggests that postnatal catch-up growth after fetal growth restriction (FGR) occurs frequently. Yet, postnatal growth in singletons may be influenced by multiple factors. Identical twins with discordant prenatal growth, termed selective FGR (sFGR), can be regarded as a natural experiment eliminating these sources of bias. DESIGN Observational cohort study. METHODS Monochorionic twins with sFGR born between 2002 and 2017 (aged 3-17 years) were eligible. Growth measurements (height, weight, head circumference, and body mass index) were performed at follow-up. Detailed growth curves documented by a systematic primary care system in the Netherlands were collected. Measurements were converted to standard deviation scores (SDSs). A mixed-effects model was used to assess within-pair SDS difference and individual height SDS relative to target height SDS. RESULTS Forty-seven twin pairs (94 children) were included at a median age of 11 (interquartile range 8-13) years. At the last measurement, smaller twins at birth had a lower height SDS [-0.6 vs -0.3, P < .001, median difference 0.5 (95%CI 0.4-0.7)], lower weight SDS [-0.5 vs -0.1, P < .001, median difference 0.8 (95%CI 0.5-1.0)], and lower head circumference SDS [-0.5 vs 0.2, P < .001, median difference 0.8 (95%CI 0.6-0.9)] compared to larger twins. These differences persisted until the age of 17. Smaller twins showed rapid catch-up growth in the first 2 years and reached their target height range between 8 and 11 years. CONCLUSIONS Identical twins with discordant prenatal growth maintain a modest but significant difference in height, weight, and head circumference, indicating a persistent, inhibitory effect of an adverse intrauterine environment on childhood growth.
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Affiliation(s)
- Sophie G Groene
- Neonatology, Department of Pediatrics, Leiden University Medical Center, Willem-Alexander Children's Hospital, Leiden, The Netherlands
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Irma J Gremmen
- Neonatology, Department of Pediatrics, Leiden University Medical Center, Willem-Alexander Children's Hospital, Leiden, The Netherlands
| | - Erik W van Zwet
- Medical Statistics, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Arno A W Roest
- Pediatric Cardiology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique C Haak
- Fetal Therapy, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanine M M van Klink
- Neonatology, Department of Pediatrics, Leiden University Medical Center, Willem-Alexander Children's Hospital, Leiden, The Netherlands
| | - Enrico Lopriore
- Neonatology, Department of Pediatrics, Leiden University Medical Center, Willem-Alexander Children's Hospital, Leiden, The Netherlands
| | - Bastiaan T Heijmans
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Christiaan de Bruin
- Pediatric Endocrinology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
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19
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Duvekot MHC, Garcia BL, Dekker L, Nguyen TM, Wijngaard IRVD, Laat KFD, Schryver ELLMD, Kloos LMH, Aerden LAM, Zylicz SA, Bosch J, van Belle E, Zwet EWV, Rozeman AD, Moudrous W, Vermeij FH, Lingsma HF, Bakker J, van Doormaal PJ, van Es ACGM, van der Lugt A, Wermer MJH, Dippel DWJ, Kerkhoff H, Roozenbeek B, Kruyt ND, Venema E. Prehospital stroke triage: a modeling study on the impact of triage tools in different regions. PREHOSP EMERG CARE 2023:1-15. [PMID: 37219931 DOI: 10.1080/10903127.2023.2215859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND AND PURPOSE Direct transportation to a thrombectomy-capable intervention center is beneficial for patients with ischemic stroke due to large vessel occlusion (LVO), but can delay intravenous thrombolytics (IVT). The aim of this modeling study was to estimate the effect of prehospital triage strategies on treatment delays and overtriage in different regions. METHODS We used data from two prospective cohort studies in the Netherlands: the Leiden Prehospital Stroke Study and the PRESTO study. We included stroke code patients within 6 hours from symptom onset. We modeled outcomes of RACE triage and triage with a personalized decision tool, using drip-and-ship as reference. Main outcomes were overtriage (stroke code patients incorrectly triaged to an intervention center), reduced delay to endovascular thrombectomy (EVT), and delay to IVT. RESULTS We included 1798 stroke code patients from four ambulance regions. Per region, overtriage ranged from 1-13% (RACE triage) and 3-15% (personalized tool). Reduction of delay to EVT varied by region between 24 ± 5 minutes (n = 6) to 78 ± 3 (n = 2), while IVT delay increased with 5 (n = 5) to 15 minutes (n = 21) for non-LVO patients. The personalized tool reduced delay to EVT for more patients (25 ± 4 minutes (n = 8) to 49 ± 13 (n = 5)), while delaying IVT with 3-14 minutes (8-24 patients). In region C, most EVT patients were treated faster (reduction of delay to EVT 31 ± 6 minutes (n = 35), with RACE triage and the personalized tool. CONCLUSIONS In this modeling study, we showed that prehospital triage reduced time to EVT without disproportionate IVT delay, compared to a drip-and-ship strategy. The effect of triage strategies and the associated overtriage varied between regions. Implementation of prehospital triage should therefore be considered on a regional level.
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Affiliation(s)
- Martijne H C Duvekot
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bjarty L Garcia
- Department of Public Health and Primary care, Leiden University Medical Center, Leiden, The Netherlands
| | - Luuk Dekker
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Truc My Nguyen
- Department of Neurology, Haga Hospital, The Hague, the Netherlands
| | - Ido R van den Wijngaard
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
| | | | | | - Loet M H Kloos
- Department of Neurology, Groene Hart Hospital, Gouda, the Netherlands
| | - Leo A M Aerden
- Department of Neurology, Reinier De Graaf Gasthuis, Delft, the Netherlands
| | - Stas A Zylicz
- Department of Neurology, LangeLand Hospital, Zoetermeer, the Netherlands
| | - Jan Bosch
- Ambulance services Holland-Midden, Leiden, the Netherlands
| | - Eduard van Belle
- Emergency Medical Services Haaglanden, The Hague, the Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Anouk D Rozeman
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Walid Moudrous
- Department of Neurology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Frédérique H Vermeij
- Department of Neurology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jeannette Bakker
- Department of Radiology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C G M van Es
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Aad van der Lugt
- Department of Emergency Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Esmee Venema
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Emergency Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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20
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Candel BGJ, Raven W, Nissen SK, Morsink MEB, Gaakeer MI, Brabrand M, van Zwet EW, de Jonge E, de Groot B. THE ASSOCIATION BETWEEN SYSTOLIC BLOOD PRESSURE AND HEART RATE IN EMERGENCY DEPARTMENT PATIENTS: A MULTICENTER COHORT STUDY. J Emerg Med 2023:S0736-4679(23)00255-X. [PMID: 37394368 DOI: 10.1016/j.jemermed.2023.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/25/2023] [Accepted: 04/10/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Guidelines and textbooks assert that tachycardia is an early and reliable sign of hypotension, and an increased heart rate (HR) is believed to be an early warning sign for the development of shock, although this response may change by aging, pain, and stress. OBJECTIVE To assess the unadjusted and adjusted associations between systolic blood pressure (SBP) and HR in emergency department (ED) patients of different age categories (18-50 years; 50-80 years; > 80 years). METHODS A multicenter cohort study using the Netherlands Emergency department Evaluation Database (NEED) including all ED patients ≥ 18 years from three hospitals in whom HR and SBP were registered at arrival to the ED. Findings were validated in a Danish cohort including ED patients. In addition, a separate cohort was used including ED patients with a suspected infection who were hospitalized from whom measurement of SBP and HR were available prior to, during, and after ED treatment. Associations between SBP and HR were visualized and quantified with scatterplots and regression coefficients (95% confidence interval [CI]). RESULTS A total of 81,750 ED patients were included from the NEED, and a total of 2358 patients with a suspected infection. No associations were found between SBP and HR in any age category (18-50 years: -0.03 beats/min/10 mm Hg, 95% CI -0.13-0.07, 51-80 years: -0.43 beats/min/10 mm Hg, 95% CI -0.38 to -0.50, > 80 years: -0.61 beats/min/10 mm Hg, 95% CI -0.53 to -0.71), nor in different subgroups of ED patient. No increase in HR existed with a decreasing SBP during ED treatment in ED patients with a suspected infection. CONCLUSION No association between SBP and HR existed in ED patients of any age category, nor in ED patients who were hospitalized with a suspected infection, even during and after ED treatment. Emergency physicians may be misled by traditional concepts about HR disturbances because tachycardia may be absent in hypotension.
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Affiliation(s)
- Bart G J Candel
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, the Netherlands; Department of Emergency Medicine, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Centre South West Jutland, University of Southern Denmark, Esbjerg, Denmark; Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Marlies E B Morsink
- Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal de Ruyter Hospital, Goes, the Netherlands
| | - Mikkel Brabrand
- Institute of Regional Health Research, Centre South West Jutland, University of Southern Denmark, Esbjerg, Denmark; Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Erik W van Zwet
- Department of Biostatistics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, the Netherlands; Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
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21
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Miah IP, Blanter A, Tank Y, Zwet EWV, Rosendaal FR, Peul WC, Dammers R, Holl DC, Lingsma HF, den Hertog HM, van der Naalt J, Jellema K, der Gaag NAV. Change in Hematoma Size after Dexamethasone Therapy in Chronic Subdural Hematoma Subtypes: A Prospective Study in Symptomatic Patients. J Neurotrauma 2023; 40:228-239. [PMID: 36029208 DOI: 10.1089/neu.2022.0024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The main treatment strategy for chronic subdural hematoma is surgical intervention. When a conservative pharmacological approach is considered in symptomatic patients, mainly dexamethasone therapy is applied. Recent trials revealed dexamethasone therapy to be an ineffective treatment in symptomatic patients with chronic subdural hematoma. Whether the efficacy of dexamethasone therapy differs in radiological hematoma subtypes is unknown. The aim of this substudy was to identify which hematoma subtype might be favorable for dexamethasone therapy. As part of a randomized controlled trial, symptomatic chronic subdural hematoma patients received 19-days dexamethasone therapy. The primary outcome measure was the change in hematoma size as measured on follow-up computed tomography (CT) after 2 weeks of dexamethasone in six hematoma (architectural and density) subtypes: homogeneous total, laminar, separated and trabecular architecture types, and hematoma without hyperdense components (homogeneous hypodense, isodense) and with hyperdense components (homogeneous hyperdense, mixed density). We analyzed hematoma thickness, midline shift, and volume using multi-variable linear regression adjusting for age, sex and baseline value of the specific radiological parameter. From September 2016 until February 2021, 85 patients were included with a total of 114 chronic subdural hematoma. The mean age was 76 years and 25% were women. Larger decrease in hematoma thickness and midline shift was revealed in hematoma without hyperdense components compared with hematoma with hyperdense components (adjusted [adj.] b -2.2 mm, 95% confidence interval [CI] -4.1 to -0.3 and adj. b -1.3 mm, 95% CI -2.7 to 0.0 respectively). Additional surgery was performed in 57% of patients with the highest observed rate (81%) in separated hematoma. Largest hematoma reduction and better clinical improvement was observed in chronic subdural hematoma without hyperdense components after dexamethasone therapy. Evaluation of these parameters can be part of an individualized treatment strategy.
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Affiliation(s)
- Ishita P Miah
- Department of Neurology, Amphia Hospital, Breda, the Netherlands
- Department of Neurology and Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology and Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands
| | - Anastassia Blanter
- Department of Neurology and Neurosurgery, Haga Teaching Hospital, The Hague, the Netherlands
| | - Yeliz Tank
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Wilco C Peul
- Department of Neurology and Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology and Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands
- Department of Neurology and Neurosurgery, Haga Teaching Hospital, The Hague, the Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Dana C Holl
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health and Medical Decision Making, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
| | - Korné Jellema
- Department of Neurology and Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands
| | - Niels A Van der Gaag
- Department of Neurology and Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology and Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands
- Department of Neurology and Neurosurgery, Haga Teaching Hospital, The Hague, the Netherlands
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22
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Brandt RB, Mulleners W, Wilbrink LA, Brandt P, van Zwet EW, Huygen FJ, Ferrari MD, Fronczek R. Intra- and interindividual attack frequency variability of chronic cluster headache. Cephalalgia 2023; 43:3331024221139239. [PMID: 36739508 DOI: 10.1177/03331024221139239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The lack of knowledge about the intra- and interindividual attack frequency variability in chronic cluster headache complicates power and sample size calculations for baseline periods of trials, and consensus on their most optimal duration. METHODS We analyzed the 12-week baseline of the ICON trial (occipital nerve stimulation in medically intractable chronic cluster headache) for: (i) weekly vs. instantaneous recording of attack frequency; (ii) intra-individual and seasonal variability of attack frequency; and (iii) the smallest number of weeks to obtain a reliable estimate of baseline attack frequency. RESULTS Weekly median (14.4 [8.2-24.0]) and instantaneous (14.2 [8.0-24.5]) attack frequency recordings were similar (p = 0.20; Bland-Altman plot). Median weekly attack frequency was 15.3 (range 4.2-140) and highest during spring (p = 0.001) compared to the other seasons. Relative attack frequency variability decreased with increasing attack frequency (p = 0.010). We tabulated the weekly attack frequency estimation accuracies compared to, and the associated deviations from, the 12-week gold standard for different lengths of the observation period. CONCLUSION Weekly retrospective attack frequency recording is as good as instantaneous recording and more convenient. Attack frequency is highest in spring. Participants with ≥3 daily attacks show less attack frequency variability than those with <3 daily attacks. An optimal balance between 90% accuracy and feasibility is achieved at a baseline period of seven weeks.The ICON trial is registered in ClinicalTrials.gov under number NCT01151631.
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Affiliation(s)
- Roemer B Brandt
- Department of Neurology, 4501, Leiden University Medical Center, Leiden, The Netherlands
| | - Wim Mulleners
- Department of Neurology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Paul Brandt
- Department of Electronic Systems, Technical University Eindhoven, The Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - Frank Jpm Huygen
- Department of Anaesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - Michel D Ferrari
- Department of Neurology, 4501, Leiden University Medical Center, Leiden, The Netherlands
| | - Rolf Fronczek
- Department of Neurology, 4501, Leiden University Medical Center, Leiden, The Netherlands
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23
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Koemans EA, Castello JP, Rasing I, Abramson JR, Voigt S, Perosa V, van Harten TW, van Zwet EW, Terwindt GM, Gurol ME, Rosand J, Greenberg SM, van Walderveen MA, Biffi A, Viswanathan A, Wermer MJ. Sex Differences in Onset and Progression of Cerebral Amyloid Angiopathy. Stroke 2023; 54:306-314. [PMID: 36689586 PMCID: PMC9855754 DOI: 10.1161/strokeaha.122.040823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/02/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cerebral Amyloid Angiopathy (CAA) disease course is highly variable even in hereditary forms. Sex may be a possible modifying factor. We investigated biological sex differences in clinical disease course and magnetic resonance imaging-markers in sporadic (sCAA) and Dutch-type hereditary CAA (D-CAA). METHODS Patients with D-CAA and sCAA were included from hospital and research databases of the Leiden University Medical Center (2012-2020) and Massachusetts General Hospital (1994-2012). Key outcomes were: sex differences in symptomatic intracerebral hemorrhage (sICH) onset, recurrence and survival (analyzed using Kaplan Meier survival and regression analyses), and sex differences in magnetic resonance imaging-markers in D-CAA (explored using scatterplots), and in sCAA (investigated using regression analysis). RESULTS We included 136 patients with D-CAA (mean age 57 years, 56% women, 64% with previous sICH) and 370 patients with sCAA (mean age 76 years, 51% women, all with previous sICH). Men and women with D-CAA did not differ for sICH onset (median age 54 in men and 56 in women [P=0.13]). Men with D-CAA had a slightly higher number of sICH compared with women (median 2 versus 1; adjusted RR, 1.5 [95% CI, 1.1-1.9]) and a shorter interval between the first and second sICH (median 1.8 years for men and 3.1 years for women, P=0.02). Men with sCAA had their first sICH at an earlier age (median 75 versus 78 years, respectively, P=0.003) and more lobar microbleeds (median 1 versus 0, P=0.022) compared with women with sCAA. No substantial differences were found in the other magnetic resonance imaging markers. Survival after first sICH was comparable between sexes for D-CAA (P=0.12) and sCAA (P=0.23). CONCLUSIONS Men with CAA seem to have an earlier onset (sCAA) and more hemorrhagic disease course (sCAA and D-CAA) compared with women. Future studies are necessary to confirm these findings and determine the underlying role of sex-related factors.
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Affiliation(s)
- Emma A. Koemans
- Department of Neurology, Leiden University Medical Center, the Netherlands (E.A.K., I.R., S.V., G.M.T., M.J.H.W.)
| | - Juan Pablo Castello
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., J.R., A.B.)
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
- Department of Neurology, University of Miami Miller School of Medicine, FL (J.P.C.)
| | - Ingeborg Rasing
- Department of Neurology, Leiden University Medical Center, the Netherlands (E.A.K., I.R., S.V., G.M.T., M.J.H.W.)
| | - Jessica R. Abramson
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., J.R., A.B.)
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
| | - Sabine Voigt
- Department of Neurology, Leiden University Medical Center, the Netherlands (E.A.K., I.R., S.V., G.M.T., M.J.H.W.)
- Department of Radiology, Leiden University Medical Center, the Netherlands (S.V., T.W.v.H., M.A.A.v.W.)
| | - Valentina Perosa
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany (V.P.)
| | - Thijs W. van Harten
- Department of Radiology, Leiden University Medical Center, the Netherlands (S.V., T.W.v.H., M.A.A.v.W.)
| | - Erik W. van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands (E.W.v.Z.)
| | - Gisela M. Terwindt
- Department of Neurology, Leiden University Medical Center, the Netherlands (E.A.K., I.R., S.V., G.M.T., M.J.H.W.)
| | - M. Edip Gurol
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
| | - Jonathan Rosand
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., J.R., A.B.)
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
| | - Steven M. Greenberg
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
| | | | - Alessandro Biffi
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., J.R., A.B.)
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
| | - Anand Viswanathan
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
| | - Marieke J.H. Wermer
- Department of Neurology, Leiden University Medical Center, the Netherlands (E.A.K., I.R., S.V., G.M.T., M.J.H.W.)
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24
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Würdemann FS, van Zwet EW, Krijnen P, Hegeman JH, Schipper IB, van Egmond PW, van Eijk M, van Heijl M, Luyten MC, Schutte BG, Voeten SC, Arends AJ, Heetveld MJ, Trappenburg MC. Is hospital volume related to quality of hip fracture care? Analysis of 43,538 patients and 68 hospitals from the Dutch Hip Fracture Audit. Eur J Trauma Emerg Surg 2023; 49:1525-1534. [PMID: 36670302 DOI: 10.1007/s00068-022-02205-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/17/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE Evidence for a hospital volume-outcome relationship in hip fracture surgery is inconclusive. This study aimed to analyze the association between hospital volume as a continuous parameter and several processes and outcomes of hip fracture care. METHODS Adult patients registered in the nationwide Dutch Hip Fracture Audit (DHFA) between 2018 and 2020 were included. The association between annual hospital volume and turnaround times (time on the emergency ward, surgery < 48 h and length of stay), orthogeriatric co-treatment and case-mix adjusted in-hospital and 30 days mortality was evaluated with generalized linear mixed models with random effects for hospital and treatment year. We used a fifth-degree polynomial to allow for nonlinear effects of hospital volume. P-values were adjusted for multiple comparisons using the Bonferoni method. RESULTS In total, 43,258 patients from 68 hospitals were included. The median annual hospital volume was 202 patients [range 1-546]. Baseline characteristics did not differ with hospital volume. Provision of orthogeriatric co-treatment improved with higher volumes but decreased at > 367 patients per year (p < 0.01). Hospital volume was not significantly associated with mortality outcomes. No evident clinical relation between hospital volume and turnaround times was found. CONCLUSION This is the first study analyzing the effect of hospital volume on hip fracture care, treating volume as a continuous parameter. Mortality and turnaround times showed no clinically relevant association with hospital volume. The provision of orthogeriatric co-treatment, however, increased with increasing volumes up to 367 patients per year, but decreased above this threshold. Future research on the effect of volume on complications and functional outcomes is indicated.
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Affiliation(s)
- Franka S Würdemann
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands. .,Dutch Institute for Clinical Auditing, Scientific Bureau, Rijnsburgerweg 10, 2333 AA, Leiden, The Netherlands.
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Johannes H Hegeman
- Department of Trauma Surgery, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP, Almelo, The Netherlands
| | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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25
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Harder AV, Onderwater GL, van Dongen RM, Heijink M, van Zwet EW, Giera M, van den Maagdenberg AM, Terwindt GM. Prostaglandin-E 2 levels over the course of glyceryl trinitrate provoked migraine attacks. Neurobiol Pain 2022; 13:100112. [PMID: 36636095 PMCID: PMC9829921 DOI: 10.1016/j.ynpai.2022.100112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 12/29/2022]
Abstract
Administration of glyceryl trinitrate (GTN), a donor of nitric oxide, can induce migraine-like attacks in subjects with migraine. Provocation with GTN typically follows a biphasic pattern; it induces immediate headache in subjects with migraine, as well as in healthy controls, whereafter only subjects with migraine may develop a migraine-like headache several hours later. Interestingly, intravenous infusion with prostaglandin-E2 (PGE2) can also provoke a migraine-like headache, but seems to have a more rapid onset compared to GTN. The aim of the study was to shed light on the mechanistic aspect PGE2 has in migraine attack development. Therefore, PGE2 plasma levels were measured towards the (pre)ictal state of an attack, which we provoked with GTN. Blood samples from women with migraine (n = 37) and age-matched female controls (n = 25) were obtained before and ∼ 140 min and ∼ 320 min after GTN infusion. PGE2 levels were measured using liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis. Data was analyzed using a generalized linear mixed-effect model. Immediate headache after GTN infusion occurred in 85 % of migraine participants and in 75 % of controls. A delayed onset migraine-like attack was observed in 82 % of migraine subjects and in none of the controls. PGE2 levels were not different between the interictal and preictal state (P = 0.527) nor between interictal and ictal state (defined as having migraine-like headache) (P = 0.141). Hence, no evidence was found that a rise in PGE2 is an essential step in the initiation of GTN-induced migraine-like attacks.
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Affiliation(s)
- Aster V.E. Harder
- Department of Neurology, Leiden University Medical Center, Leiden, The
Netherlands,Department of Human Genetics, Leiden University Medical Center, Leiden,
The Netherlands
| | | | - Robin M. van Dongen
- Department of Neurology, Leiden University Medical Center, Leiden, The
Netherlands
| | - Marieke Heijink
- Center for Proteomics and Metabolomics, Leiden University Medical Center,
Leiden, The Netherlands
| | - Erik W. van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center,
Leiden, The Netherlands
| | - Martin Giera
- Center for Proteomics and Metabolomics, Leiden University Medical Center,
Leiden, The Netherlands
| | - Arn M.J.M. van den Maagdenberg
- Department of Neurology, Leiden University Medical Center, Leiden, The
Netherlands,Department of Human Genetics, Leiden University Medical Center, Leiden,
The Netherlands
| | - Gisela M. Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The
Netherlands,Corresponding author at: Leiden University Medical Center, Department of
Neurology, P.O. 9600, 2300 WB Leiden, The Netherlands.
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26
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Bossers SM, Verheul R, van Zwet EW, Bloemers FW, Giannakopoulos GF, Loer SA, Schwarte LA, Schober P. Prehospital Intubation of Patients with Severe Traumatic Brain Injury: A Dutch Nationwide Trauma Registry Analysis. PREHOSP EMERG CARE 2022:1-7. [PMID: 36074561 DOI: 10.1080/10903127.2022.2119494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
ObjectivePatients with severe traumatic brain injury (TBI) are commonly intubated during prehospital treatment despite a lack of evidence that this is beneficial. Accumulating evidence even suggests that prehospital intubation may be hazardous, in particular when performed by inexperienced EMS clinicians. To expand the limited knowledge base, we studied the relationship between prehospital intubation and hospital mortality in patients with severe TBI in a large Dutch trauma database. We specifically hypothesized that the relationship differs depending on whether a physician-based emergency medical service (EMS) was involved in the treatment, as opposed to intubation by paramedics.MethodsA retrospective analysis was performed using the Dutch Nationwide Trauma Registry that includes all trauma patients in the Netherlands who are admitted to any hospital with an emergency department. All patients treated for severe TBI (Head Abbreviated Injury Scale score ≥4) between January 2015 and December 2019 were selected. Multivariable logistic regression was used to assess the relationship between prehospital intubation and mortality while adjusting for potential confounders. An interaction term between prehospital intubation and the involvement of physician-based EMS was added to the model. Complete case analysis as well as multiple imputation were performed.Results8946 patients (62% male, median age 63 years) were analyzed. The hospital mortality was 26.4%. Overall, a relationship between prehospital intubation and higher mortality was observed (complete case: OR 1.86, 95%CI 1.35-2.57, P < 0.001; multiple imputation: OR 1.92, 95%CI 1.56-2.36, P < 0.001). Adding the interaction revealed that the relationship of prehospital intubation may depend on whether physician-based EMS is involved in the treatment (complete case: P = 0.044; multiple imputation: P = 0.062). Physician-based EMS involvement attenuated but did not completely remove the detrimental association between prehospital intubation and mortality.ConclusionThe data do not support the common practice of prehospital intubation. The effect of prehospital intubation on mortality might depend on EMS clinician experience, and it seems prudent to involve prehospital personnel well proficient in prehospital intubation whenever intubation is potentially required. The decision to perform prehospital intubation should not merely be based on the largely unsupported dogma that it is generally needed in severe TBI, but should rather individually weigh potential benefits and harms.
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Affiliation(s)
- Sebastiaan M Bossers
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Anesthesiology, Amsterdam, the Netherlands
| | - Robert Verheul
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Anesthesiology, Amsterdam, the Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
| | - Frank W Bloemers
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Georgios F Giannakopoulos
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands.,Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, the Netherlands
| | - Stephan A Loer
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Anesthesiology, Amsterdam, the Netherlands
| | - Lothar A Schwarte
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Anesthesiology, Amsterdam, the Netherlands.,Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, the Netherlands
| | - Patrick Schober
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Anesthesiology, Amsterdam, the Netherlands.,Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, the Netherlands
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27
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van Os HJA, Kanning JP, Wermer MJH, Chavannes NH, Numans ME, Ruigrok YM, van Zwet EW, Putter H, Steyerberg EW, Groenwold RHH. Developing Clinical Prediction Models Using Primary Care Electronic Health Record Data: The Impact of Data Preparation Choices on Model Performance. Front Epidemiol 2022; 2:871630. [PMID: 38455328 PMCID: PMC10910909 DOI: 10.3389/fepid.2022.871630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/11/2022] [Indexed: 03/09/2024]
Abstract
Objective To quantify prediction model performance in relation to data preparation choices when using electronic health records (EHR). Study Design and Setting Cox proportional hazards models were developed for predicting the first-ever main adverse cardiovascular events using Dutch primary care EHR data. The reference model was based on a 1-year run-in period, cardiovascular events were defined based on both EHR diagnosis and medication codes, and missing values were multiply imputed. We compared data preparation choices based on (i) length of the run-in period (2- or 3-year run-in); (ii) outcome definition (EHR diagnosis codes or medication codes only); and (iii) methods addressing missing values (mean imputation or complete case analysis) by making variations on the derivation set and testing their impact in a validation set. Results We included 89,491 patients in whom 6,736 first-ever main adverse cardiovascular events occurred during a median follow-up of 8 years. Outcome definition based only on diagnosis codes led to a systematic underestimation of risk (calibration curve intercept: 0.84; 95% CI: 0.83-0.84), while complete case analysis led to overestimation (calibration curve intercept: -0.52; 95% CI: -0.53 to -0.51). Differences in the length of the run-in period showed no relevant impact on calibration and discrimination. Conclusion Data preparation choices regarding outcome definition or methods to address missing values can have a substantial impact on the calibration of predictions, hampering reliable clinical decision support. This study further illustrates the urgency of transparent reporting of modeling choices in an EHR data setting.
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Affiliation(s)
- Hendrikus J. A. van Os
- Department of Neurology, Leiden University Medical Hospital, Leiden, Netherlands
- National eHealth Living Lab, Leiden University Medical Hospital, Leiden, Netherlands
- Department of Public Health & Primary Care, Leiden University Medical Hospital, Leiden, Netherlands
| | - Jos P. Kanning
- Department of Neurology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marieke J. H. Wermer
- Department of Neurology, Leiden University Medical Hospital, Leiden, Netherlands
| | - Niels H. Chavannes
- National eHealth Living Lab, Leiden University Medical Hospital, Leiden, Netherlands
- Department of Public Health & Primary Care, Leiden University Medical Hospital, Leiden, Netherlands
| | - Mattijs E. Numans
- Department of Public Health & Primary Care, Leiden University Medical Hospital, Leiden, Netherlands
| | - Ynte M. Ruigrok
- Department of Neurology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Erik W. van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Hospital, Leiden, Netherlands
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Hospital, Leiden, Netherlands
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Hospital, Leiden, Netherlands
| | - Rolf H. H. Groenwold
- Department of Biomedical Data Sciences, Leiden University Medical Hospital, Leiden, Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Hospital, Leiden, Netherlands
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28
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van Zwet EW, Goodman SN. How large should the next study be? Predictive power and sample size requirements for replication studies. Stat Med 2022; 41:3090-3101. [PMID: 35396714 PMCID: PMC9325423 DOI: 10.1002/sim.9406] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 12/13/2022]
Abstract
We use information derived from over 40K trials in the Cochrane Collaboration database of systematic reviews (CDSR) to compute the replication probability, or predictive power of an experiment given its observed (two‐sided) P‐value. We find that an exact replication of a marginally significant result with P=.05 has less than 30% chance of again reaching significance. Moreover, the replication of a result with P=.005 still has only 50% chance of significance. We also compute the probability that the direction (sign) of the estimated effect is correct, which is closely related to the type S error of Gelman and Tuerlinckx. We find that if an estimated effect has P=.05, there is a 93% probability that its sign is correct. If P=.005, then that probability is 99%. Finally, we compute the required sample size for a replication study to achieve some specified power conditional on the p‐value of the original study. We find that the replication of a result with P=.05 requires a sample size more than 16 times larger than the original study to achieve 80% power, while P=.005 requires at least 3.5 times larger sample size. These findings confirm that failure to replicate the statistical significance of a trial does not necessarily indicate that the original result was a fluke.
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Affiliation(s)
- Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Steven N Goodman
- Departments of Epidemiology and Population Health and of Medicine, Stanford University, Stanford, California, USA.,Stanford Program on Research Rigor and Reproducibility (SPORR), Stanford University School of Medicine, Stanford, California, USA.,Meta-research Innovation Center at Stanford (METRICS), USA
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Singh RD, van Dijck JTJM, van Essen TA, Lingsma HF, Polinder SS, Kompanje EJO, van Zwet EW, Steyerberg EW, de Ruiter GCW, Depreitere B, Peul WC. Randomized Evaluation of Surgery in Elderly with Traumatic Acute SubDural Hematoma (RESET-ASDH trial): study protocol for a pragmatic randomized controlled trial with multicenter parallel group design. Trials 2022; 23:242. [PMID: 35351178 PMCID: PMC8962939 DOI: 10.1186/s13063-022-06184-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDH METHODS: In total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024. DISCUSSION The study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered. TRIAL REGISTRATION Nederlands Trial Register (NTR), Trial NL9012 . CLINICALTRIALS gov, Trial NCT04648436 .
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Affiliation(s)
- Ranjit D Singh
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Jeroen T J M van Dijck
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Thomas A van Essen
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Hester F Lingsma
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Suzanne S Polinder
- Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Godard C W de Ruiter
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | | | - Wilco C Peul
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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Putter H, Eikema DJ, de Wreede LC, McGrath E, Sánchez-Ortega I, Saccardi R, Snowden JA, van Zwet EW. Benchmarking survival outcomes: A funnel plot for survival data. Stat Methods Med Res 2022; 31:1171-1183. [PMID: 35257603 PMCID: PMC9245152 DOI: 10.1177/09622802221084130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Benchmarking is commonly used in many healthcare settings to monitor clinical performance, with the aim of increasing cost-effectiveness and safe care of patients. The funnel plot is a popular tool in visualizing the performance of a healthcare center in relation to other centers and to a target, taking into account statistical uncertainty. In this paper, we develop a methodology for constructing funnel plots for survival data. The method takes into account censoring and can deal with differences in censoring distributions across centers. Practical issues in implementing the methodology are discussed, particularly in the setting of benchmarking clinical outcomes for hematopoietic stem cell transplantation. A simulation study is performed to assess the performance of the funnel plots under several scenarios. Our methodology is illustrated using data from the European Society for Blood and Marrow Transplantation benchmarking project.
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Affiliation(s)
- Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
| | - Dirk-Jan Eikema
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
| | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
| | | | | | | | - John A Snowden
- Department of Haematology, 7318Sheffield Teaching Hospitals NHS Foundation Trust, UK
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
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31
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Al Mohamad D, Goeman JJ, van Zwet EW. Simultaneous confidence intervals for ranks with application to ranking institutions. Biometrics 2022; 78:238-247. [DOI: 10.1111/biom.13419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Diaa Al Mohamad
- Department of Biomedical Data Sciences Leiden University Medical Center Leiden The Netherlands
| | - Jelle J. Goeman
- Department of Biomedical Data Sciences Leiden University Medical Center Leiden The Netherlands
| | - Erik W. van Zwet
- Department of Biomedical Data Sciences Leiden University Medical Center Leiden The Netherlands
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Pijpers JA, Kies DA, van Zwet EW, Rosendaal FR, Terwindt GM. Behavioural intervention in medication overuse headache: a concealed double‐blind randomised controlled trial a concealed double‐blind randomised controlled trial a concealed double‐blind randomised controlled trial. Eur J Neurol 2022; 29:1496-1504. [PMID: 35064733 PMCID: PMC9306639 DOI: 10.1111/ene.15256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/19/2022] [Indexed: 11/29/2022]
Abstract
Background and purpose Medication overuse headache is a prevalent disorder, with a strong biobehavioural component. Hence, behavioural interventions might effectuate reduction of the overused medication. We assessed in a double‐blind manner the efficacy of a behavioural intervention during medication withdrawal therapy. Methods In this concealed, double‐blind, randomized controlled trial in medication overuse headache, conducted at the Leiden University Medical Centre, we compared the effect of maximal versus minimal behavioural intervention by a headache nurse during withdrawal therapy. Maximal intervention consisted of an intensive contact schedule, comprising education, motivational interviewing, and value‐based activity planning during 12 weeks of withdrawal therapy. Minimal intervention consisted of a short contact only. Patients were unaware of the existence of these treatment arms, as the trial was concealed in another trial investigating botulinum toxin A. Endpoints were successful withdrawal and monthly days of acute medication use after the withdrawal period. Results We enrolled 179 patients (90 maximal, 89 minimal intervention). At Week 12, most patients achieved withdrawal in both groups (82/90 [93%] maximal intervention vs. 75/89 [86%] minimal intervention, odds ratio = 2.44, 95% confidence interval [CI] = 0.83–7.23, p = 0.107). At Week 24, patients in the maximal intervention group had fewer medication days (mean difference = −2.23, 95% CI = −3.76 to −0.70, p = 0.005). This difference receded over time. Change in monthly migraine days did not differ between groups (−6.75 vs. −6.22). Conclusions This trial suggests modest benefit of behavioural intervention by a headache nurse during withdrawal therapy for medication overuse headache, to reduce acute medication use during and shortly after intervention, but extension seems warranted for a prolonged effect
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Affiliation(s)
- Judith A Pijpers
- Dept. Neurology Leiden University Medical Center Leiden The Netherlands
| | - Dennis A Kies
- Dept. Neurology Leiden University Medical Center Leiden The Netherlands
- Dept. Radiology Leiden University Medical Center Leiden The Netherlands
| | - Erik W van Zwet
- Dept. Medical Statistics Leiden University Medical Center Leiden The Netherlands
| | - Frits R. Rosendaal
- Dept. Clinical Epidemiology Leiden University Medical Center Leiden The Netherlands
| | - Gisela M Terwindt
- Dept. Neurology Leiden University Medical Center Leiden The Netherlands
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Candel BG, Duijzer R, Gaakeer MI, Ter Avest E, Sir Ö, Lameijer H, Hessels R, Reijnen R, van Zwet EW, de Jonge E, de Groot B. The association between vital signs and clinical outcomes in emergency department patients of different age categories. Emerg Med J 2022; 39:903-911. [PMID: 35017189 DOI: 10.1136/emermed-2020-210628] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/07/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Appropriate interpretation of vital signs is essential for risk stratification in the emergency department (ED) but may change with advancing age. In several guidelines, risk scores such as the Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure Assessment (qSOFA) scores, commonly used in emergency medicine practice (as well as critical care) specify a single cut-off or threshold for each of the commonly measured vital signs. Although a single cut-off may be convenient, it is unknown whether a single cut-off for vital signs truly exists and if the association between vital signs and in-hospital mortality differs per age-category. AIMS To assess the association between initial vital signs and case-mix adjusted in-hospital mortality in different age categories. METHODS Observational multicentre cohort study using the Netherlands Emergency Department Evaluation Database (NEED) in which consecutive ED patients ≥18 years were included between 1 January 2017 and 12 January 2020. The association between vital signs and case-mix adjusted mortality were assessed in three age categories (18-65; 66-80; >80 years) using multivariable logistic regression. Vital signs were each divided into five to six categories, for example, systolic blood pressure (SBP) categories (≤80, 81-100, 101-120, 121-140, >140 mm Hg). RESULTS We included 101 416 patients of whom 2374 (2.3%) died. Adjusted ORs for mortality increased gradually with decreasing SBP and decreasing peripheral oxygen saturation (SpO2). Diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) had quasi-U-shaped associations with mortality. Mortality did not increase for temperatures anywhere in the range between 35.5°C and 42.0°C, with a single cut-off around 35.5°C below which mortality increased. Single cut-offs were also found for MAP <70 mm Hg and respiratory rate >22/min. For all vital signs, older patients had larger increases in absolute mortality compared with younger patients. CONCLUSION For SBP, DBP, SpO2 and HR, no single cut-off existed. The impact of changing vital sign categories on prognosis was larger in older patients. Our results have implications for the interpretation of vital signs in existing risk stratification tools and acute care guidelines.
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Affiliation(s)
- Bart Gj Candel
- Emergency Department, Maxima Medical Centre, Veldhoven, Noord-Brabant, The Netherlands .,Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands
| | - Renée Duijzer
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands
| | - Menno I Gaakeer
- Emergency Department, Admiraal De Ruyter Hospital, Goes, Zeeland, The Netherlands
| | - Ewoud Ter Avest
- Emergency Department, University Medical Centre Groningen, Groningen, The Netherlands
| | - Özcan Sir
- Emergency Department, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Heleen Lameijer
- Emergency Department, Medical Centre Leeuwarden, Leeuwarden, Friesland, The Netherlands
| | - Roger Hessels
- Emergency Department, Elisabeth-TweeSteden Hospital, Tilburg, Noord-Brabant, The Netherlands
| | - Resi Reijnen
- Emergency Department, Medical Centre Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| | - Erik W van Zwet
- Department of Biostatistics, Leiden Universitair Medical Centre, Leiden, Zuid-Holland, The Netherlands
| | - Evert de Jonge
- Intensive Care, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands
| | - Bas de Groot
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands
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Goedmakers CMW, Bartels RHMA, Donk RD, Arts MP, van Zwet EW, Vleggeert-Lankamp CLA. The Clinical Relevance of the Cervical Disc Prosthesis: Combining Clinical Results of Two RCTs. Spine (Phila Pa 1976) 2022; 47:67-75. [PMID: 34474447 DOI: 10.1097/brs.0000000000004113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis was performed on data from 251 patients that were included in two randomized, double-blinded clinical trials comparing clinical results of anterior cervical discectomy and arthroplasty (ACDA) to anterior cervical discectomy and fusion (ACDF), and anterior cervical discectomy (ACD), for single-level disc herniation. OBJECTIVE This study aimed to investigate whether the ACDA procedure offers superior clinical results 2 years after surgery, to either ACDF or ACD without instrumentation, in the entire group of patients or in a particular subgroup of patients. SUMMARY OF BACKGROUND DATA The cervical disc prosthesis was introduced to provide superior clinical outcomes after ACD. METHODS Neck Disability Index (NDI), and subscales of the 36-item short-form health survey (SF-36) and McGill pain score were collected at baseline, 1 year and 2 years after surgery. Reoperations and complications were also evaluated. A preliminary subgroup analysis was performed for age, disc height, body mass index (BMI), smoking, and sex. RESULTS The NDI decreased comparably in all treatment arms to circa 50% of the baseline value and marginal mean NDI differences varied from 0.4 to 1.1 on a 100 point NDI scale, with confidence intervals never exceeding the 20-point minimal clinical important difference (MCID). Secondary outcome parameters showed comparable results. Preliminary subgroup analysis could not demonstrate clinically relevant differences in NDI between treatments after 2 years. CONCLUSION After combining data from two Randomized Controlled Trials it can be concluded that there is no clinical benefit for ACDA, when compared with ACDF or ACD 2 years after surgery. Preliminary subgroup analysis indicated outcomes were similar between treatment groups, and that no subgroup could be appointed that benefited more from either ACD, ACDF, or ACDA.Level of Evidence: 1.
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Affiliation(s)
- Caroline M W Goedmakers
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ronald H M A Bartels
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Roland D Donk
- Department of Orthopaedics, Via Sana Clinics, Nijmegen, the Netherlands
| | - Mark P Arts
- Department of Neurosurgery, Haaglanden Medical Center, the Hague, the Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
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Goedmakers CMW, van Beelen I, Komen F, van Zwet EW, Peul WC, Arts MP, Vleggeert-Lankamp CLA. The impact of mental health on outcome after anterior cervical discectomy: cohort study assessing the influence of mental health using predictive modelling. Acta Neurochir (Wien) 2022; 164:3035-3046. [PMID: 36109365 PMCID: PMC9613752 DOI: 10.1007/s00701-022-05362-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/30/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Depression and anxiety are common mental disorders among patients with chronic pain. It is hypothesised that patients suffering from these disorders benefit less from cervical spine surgery than mentally healthy patients. Therefore, this study aimed to quantify the effect of mental health status on functional outcome after anterior cervical discectomy in a post hoc analysis on RCT data. METHODS One hundred eight patients from the NECK trial, with radiculopathy due to a one-level herniated disc, underwent anterior cervical discectomy and were included into this analysis. Functional outcome was quantified using the Neck Disability Index (NDI), and mental health status was measured using the Hospital Anxiety and Depression Score (HADS) questionnaire. NDI differences were assessed using generalised estimated equations (GEE), crude means, a predictive linear mixed model (LMM) using baseline scores and over time with an explanatory LMM. RESULTS At baseline, 24% and 32% of patients were respectively depressed and anxious and had statistically significant and clinically relevant higher NDI scores during follow-up. However, in those patients in which the HADS returned to normal during follow-up, NDI values decreased comparably to the non-depression or non-anxiety cases. Those patients that demonstrated persisting high HADS values had convincingly worse NDI scores. A predictive LMM showed that combining baseline NDI and HADS scores was highly predictive of NDI during follow-up. The R shiny application enabled the effective, visual communication of results from the predictive LMM. CONCLUSION This study shows that mental health status and disability are strongly associated and provides insight into the size of the effect, as well as a way to use this relation to improve preoperative patient counselling. These findings give rise to the suggestion that incorporating mental health screening in the preoperative assessment of patients could help to adequately manage patients' expectations for functional recovery. TRIAL REGISTRATION Dutch Trial Register Number: NTR1289.
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Affiliation(s)
- Caroline M. W. Goedmakers
- grid.10419.3d0000000089452978Neurosurgical Center Holland, Department of Neurosurgery, Leiden University Medical Center & Haaglanden MC & Haga Teaching Hospital, Albinusdreef 2, Leiden, 2300 RC the Netherlands ,grid.38142.3c000000041936754XComputational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Ilse van Beelen
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Floor Komen
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik W. van Zwet
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Wilco C. Peul
- grid.10419.3d0000000089452978Neurosurgical Center Holland, Department of Neurosurgery, Leiden University Medical Center & Haaglanden MC & Haga Teaching Hospital, Albinusdreef 2, Leiden, 2300 RC the Netherlands
| | - Mark P. Arts
- grid.10419.3d0000000089452978Neurosurgical Center Holland, Department of Neurosurgery, Leiden University Medical Center & Haaglanden MC & Haga Teaching Hospital, Albinusdreef 2, Leiden, 2300 RC the Netherlands
| | - Carmen L. A. Vleggeert-Lankamp
- grid.10419.3d0000000089452978Neurosurgical Center Holland, Department of Neurosurgery, Leiden University Medical Center & Haaglanden MC & Haga Teaching Hospital, Albinusdreef 2, Leiden, 2300 RC the Netherlands ,grid.416219.90000 0004 0568 6419Department of Neurosurgery, Spaarne Gasthuis, Haarlem, Hoofddorp the Netherlands
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Voigt S, Amlal S, Koemans EA, Rasing I, van Etten ES, van Zwet EW, van Buchem MA, Terwindt GM, van Walderveen MA, Wermer MJ. Spatial and temporal intracerebral hemorrhage patterns in Dutch-type hereditary cerebral amyloid angiopathy. Int J Stroke 2021; 17:793-798. [PMID: 34791949 PMCID: PMC9373023 DOI: 10.1177/17474930211057022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Aim To investigate whether there is a topographical and temporal pattern of index
and recurrent intracerebral hemorrhages (ICH) in Dutch-type hereditary
Cerebral Amyloid Angiopathy (D-CAA) to increase our understanding on
CAA-related ICH development. Methods We included patients with DNA confirmed D-CAA or a history with ≥1 lobar ICH
and ≥1 first-degree relative with D-CAA. Topographical pattern was studied
by location (proportion frontal/parietal/temporal/occipital;
infra/supratentorial and occurrence ratios relative to lobe volume) and
volume of index and recurrent ICHs were determined on CT. Temporal pattern
was examined by time between recurrent ICHs was retrieved from medical
records. Results We included 72 patients with D-CAA (mean age at index ICH 55 years) with in
total 214 ICH. The median follow-up time was 7 years (range 0.8 to 28
years). All ICH were lobar and supratentorial. The index ICH was most
frequently located in the occipital lobe (34% vs. 22% in the other three
lobes; with index ICH occurrence ratios relative to lobe volume of 1.9 for
occipital, 1.0 for temporal, 1.2 for parietal, and 0.5 for frontal,
p = 0.001). In 16/47 (34%) patients with multiple ICH, the second ICH was
located in the same lobe as the index ICH. The median time-interval between
subsequent ICH was #1-2 ICH 27 months, #2-3 ICH 14 months, and #3-4 ICH 7
months (p = 0.6) There was no difference in volume between index and
recurrent ICHs. Conclusions We found that index and recurrent ICHs in D-CAA have a preference for the
occipital lobe and are least frequent in the frontal lobe, which adds to the
existing knowledge of histopathological studies on amyloid load in CAA.
Surprisingly, there was no acceleration in time nor gradual increase of
hematoma volume between subsequent ICHs.
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Affiliation(s)
- Sabine Voigt
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | - Siham Amlal
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | - Emma A Koemans
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | - Ingeborg Rasing
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | - Ellis S van Etten
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center, the Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | | | - Marieke Jh Wermer
- Department of Neurology, Leiden University Medical Center, the Netherlands
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Kalkers K, Schols JMGA, van Zwet EW, Roos RAC. Falls, Fear of Falling, and Preventive Measures in Huntington's Disease: The Perspectives of Individuals with Huntington's Disease and Caregivers in Long-Term Care. J Huntingtons Dis 2021; 10:493-503. [PMID: 34719503 DOI: 10.3233/jhd-210493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Falls are common in Huntington's disease (HD), which can have serious consequences and may therefore lead to fear of falling (FoF). There is little knowledge about falls or FoF in individuals with HD or about formal and informal caregivers' fear about falls in individuals with HD. OBJECTIVE To explore prevalence of falls, FoF and fall preventive measures both those applied and those not included in managing falls in individuals with HD and their formal and informal caregivers, and to identify the relationship between FoF and, anxiety, awareness and cognitive functioning respectively. METHODS In a multi-center observational cross-sectional study, care-independent and -dependent individuals with HD and their formal and informal caregivers were recruited from six Dutch nursing homes specialized in HD. The participants were assessed by means of questionnaires enquiring about falls, FoF, awareness of fall risk, cognition, anxiety and fall preventive measures. RESULTS For all included 158 individuals with HD, the fall prevalence over the last 30 days was 28.8%. The prevalence of FoF in individuals with HD, formal caregivers and informal caregivers was 47.6%, 25.6%, and 63.5%, respectively, for care-independent individuals with HD and 46.9%, 26.3%, and 62.0%, respectively, for care-dependent individuals with HD. Anticipatory awareness of fall risks and gender are predictors of FoF in care-independent individuals with HD, though not in the care-dependent group. A combination of fall preventive measures is used in most individuals with HD. CONCLUSION Fall prevalence is high and FoF is common in individuals with HD and their caregivers. Gender and anticipatory awareness are risk factors for FoF. In addition to the use of individual multifactorial fall prevention strategies, it is important to support both formal and informal caregivers in coping with falls.
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Affiliation(s)
- Kristel Kalkers
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Mijzo, Raamsdonksveer, The Netherlands
| | - Jos M G A Schols
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.,Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Raymund A C Roos
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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van Casteren DS, Verhagen IE, van der Arend BWH, van Zwet EW, MaassenVanDenBrink A, Terwindt GM. Comparing Perimenstrual and Nonperimenstrual Migraine Attacks Using an e-Diary. Neurology 2021; 97:e1661-e1671. [PMID: 34493613 PMCID: PMC8605615 DOI: 10.1212/wnl.0000000000012723] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 08/05/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Endogenous and exogenous female sex hormones are considered important contributors to migraine pathophysiology. Previous studies have cautiously suggested that perimenstrual migraine attacks have a longer duration and are associated with higher disability compared to nonperimenstrual attacks, but they showed conflicting results on acute therapy efficacy, pain intensity, and associated symptoms. We compared perimenstrual and nonperimenstrual migraine attack characteristics and assessed premenstrual syndrome (PMS) in women with migraine. METHODS Women with migraine were invited to complete a headache e-diary. Characteristics of perimenstrual attacks and nonperimenstrual attacks were compared. The primary outcome was attack duration. Secondary outcomes were headache intensity, accompanying symptoms, acute medication intake, and pain coping. Mixed effects models were used to account for multiple attacks within patients. PMS was assessed in patients without hormonal contraceptives. Subgroup analyses were performed for women with menstrually related migraine (MRM) and nonmenstrually related migraine (non-MRM) and women with a natural menstrual cycle and women using hormonal contraceptives. RESULTS A representative group of 500 participants completed the e-diary for at least 1 month. Perimenstrual migraine attacks (n = 998) compared with nonperimenstrual attacks (n = 4097) were associated with longer duration (20.0 vs 16.1 hours, 95% confidence interval 0.2-0.4), higher recurrence risk (odds ratio [OR] 2.4 [2.0-2.9]), increased triptan intake (OR 1.2 [1.1-1.4]), higher headache intensity (OR 1.4 [1.2-1.7]), less pain coping (mean difference -0.2 [-0.3 to -0.1]), more pronounced photophobia (OR 1.3 [1.2-1.4]) and phonophobia (OR 1.2 [1.1-1.4]), and less aura (OR 0.8 [0.6-1.0]). In total, 396/500 women completed the diary for ≥3 consecutive menstrual cycles, of whom 56% (221/396) fulfilled MRM criteria. Differences in attack characteristics became more pronounced when focusing on women with MRM and women using hormonal contraceptives. Prevalence of PMS was not different for women with MRM compared to non-MRM (11% vs 15%). DISCUSSION The longer duration of perimenstrual migraine attacks in women (with MRM) is associated with higher recurrence risk and increased triptan use. This may increase the risk of medication overuse and emphasizes the need to develop female-specific prophylactic treatment.
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Affiliation(s)
- Daphne S van Casteren
- From the Departments of Neurology (D.S.C., I.E.V., B.W.H.A., G.M.T.) and Medical Statistics (E.W.Z.), Leiden University Medical Center; and Division of Vascular Medicine and Pharmacology (D.S.C., I.E.V., B.W.H.A., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Iris E Verhagen
- From the Departments of Neurology (D.S.C., I.E.V., B.W.H.A., G.M.T.) and Medical Statistics (E.W.Z.), Leiden University Medical Center; and Division of Vascular Medicine and Pharmacology (D.S.C., I.E.V., B.W.H.A., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Britt W H van der Arend
- From the Departments of Neurology (D.S.C., I.E.V., B.W.H.A., G.M.T.) and Medical Statistics (E.W.Z.), Leiden University Medical Center; and Division of Vascular Medicine and Pharmacology (D.S.C., I.E.V., B.W.H.A., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Erik W van Zwet
- From the Departments of Neurology (D.S.C., I.E.V., B.W.H.A., G.M.T.) and Medical Statistics (E.W.Z.), Leiden University Medical Center; and Division of Vascular Medicine and Pharmacology (D.S.C., I.E.V., B.W.H.A., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Antoinette MaassenVanDenBrink
- From the Departments of Neurology (D.S.C., I.E.V., B.W.H.A., G.M.T.) and Medical Statistics (E.W.Z.), Leiden University Medical Center; and Division of Vascular Medicine and Pharmacology (D.S.C., I.E.V., B.W.H.A., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gisela M Terwindt
- From the Departments of Neurology (D.S.C., I.E.V., B.W.H.A., G.M.T.) and Medical Statistics (E.W.Z.), Leiden University Medical Center; and Division of Vascular Medicine and Pharmacology (D.S.C., I.E.V., B.W.H.A., A.M.V.D.B.), Erasmus University Medical Center, Rotterdam, the Netherlands
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Naarding KJ, van der Holst M, van Zwet EW, van de Velde NM, de Groot IJM, Verschuuren JJGM, Kan HE, Niks EH. Association of Elbow Flexor MRI Fat Fraction With Loss of Hand-to-Mouth Movement in Patients With Duchenne Muscular Dystrophy. Neurology 2021; 97:e1737-e1742. [PMID: 34493619 PMCID: PMC8605612 DOI: 10.1212/wnl.0000000000012724] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 08/10/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To study the potential of quantitative MRI (qMRI) fat fraction (FF) as a biomarker in nonambulant patients with Duchenne muscular dystrophy (DMD), we assessed the additive predictive value of elbow flexor FF to age at loss of hand-to-mouth movement. METHODS Nonambulant patients with DMD (age ≥8 years) were included. Four-point Dixon MRI scans of the right upper arm were performed at baseline and at the 12-, 18-, or 24-month follow-up. Elbow flexor FFs were determined from 5 central slices. Loss of hand-to-mouth movement was determined at study visits and by phone calls every 4 months. FFs were fitted to a sigmoidal curve by use of a mixed model with random slope to predict individual trajectories. The added predictive value of elbow flexor FF to age at loss of hand-to-mouth movement was calculated from a Cox model with the predicted FF as a time-varying covariate, yielding a hazard ratio. RESULTS Forty-eight MRIs of 20 patients with DMD were included. The hazard ratio of a percent-point increase in elbow flexor FF for the time to loss of hand-to-mouth movement was 1.12 (95% confidence interval 1.04-1.21; p = 0.002). This corresponded to a 3.13-fold increase in the instantaneous risk of loss of hand-to-mouth movement in patients with a 10-percent points higher elbow flexor FF at any age. DISCUSSION In this prospective study, elbow flexor FF predicted loss of hand-to-mouth movement independently of age. qMRI-measured elbow flexor FF can be used as a surrogate endpoint or stratification tool for clinical trials in nonambulant patients with DMD. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that qMRI FF of elbow flexor muscles in patients with DMD predicts loss of hand-to-mouth movement independently of age.
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Affiliation(s)
- Karin J Naarding
- From the Department of Neurology (K.J.N., N.M.v.d.V., J.J.G.M.V., E.H.N.), Duchenne Center Netherlands (K.J.N., M.v.d.H., N.M.v.d.V., I.J.M.d.G., J.J.G.M.V., H.E.K., E.H.N.)Department of Orthopedics, Rehabilitation and Physiotherapy (M.v.d.H.), and Department of Biomedical Data Sciences (E.W.v.Z.), Leiden University Medical Center; and Department of Rehabilitation (I.J.M.d.G.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Menno van der Holst
- From the Department of Neurology (K.J.N., N.M.v.d.V., J.J.G.M.V., E.H.N.), Duchenne Center Netherlands (K.J.N., M.v.d.H., N.M.v.d.V., I.J.M.d.G., J.J.G.M.V., H.E.K., E.H.N.)Department of Orthopedics, Rehabilitation and Physiotherapy (M.v.d.H.), and Department of Biomedical Data Sciences (E.W.v.Z.), Leiden University Medical Center; and Department of Rehabilitation (I.J.M.d.G.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Erik W van Zwet
- From the Department of Neurology (K.J.N., N.M.v.d.V., J.J.G.M.V., E.H.N.), Duchenne Center Netherlands (K.J.N., M.v.d.H., N.M.v.d.V., I.J.M.d.G., J.J.G.M.V., H.E.K., E.H.N.)Department of Orthopedics, Rehabilitation and Physiotherapy (M.v.d.H.), and Department of Biomedical Data Sciences (E.W.v.Z.), Leiden University Medical Center; and Department of Rehabilitation (I.J.M.d.G.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nienke M van de Velde
- From the Department of Neurology (K.J.N., N.M.v.d.V., J.J.G.M.V., E.H.N.), Duchenne Center Netherlands (K.J.N., M.v.d.H., N.M.v.d.V., I.J.M.d.G., J.J.G.M.V., H.E.K., E.H.N.)Department of Orthopedics, Rehabilitation and Physiotherapy (M.v.d.H.), and Department of Biomedical Data Sciences (E.W.v.Z.), Leiden University Medical Center; and Department of Rehabilitation (I.J.M.d.G.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Imelda J M de Groot
- From the Department of Neurology (K.J.N., N.M.v.d.V., J.J.G.M.V., E.H.N.), Duchenne Center Netherlands (K.J.N., M.v.d.H., N.M.v.d.V., I.J.M.d.G., J.J.G.M.V., H.E.K., E.H.N.)Department of Orthopedics, Rehabilitation and Physiotherapy (M.v.d.H.), and Department of Biomedical Data Sciences (E.W.v.Z.), Leiden University Medical Center; and Department of Rehabilitation (I.J.M.d.G.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jan J G M Verschuuren
- From the Department of Neurology (K.J.N., N.M.v.d.V., J.J.G.M.V., E.H.N.), Duchenne Center Netherlands (K.J.N., M.v.d.H., N.M.v.d.V., I.J.M.d.G., J.J.G.M.V., H.E.K., E.H.N.)Department of Orthopedics, Rehabilitation and Physiotherapy (M.v.d.H.), and Department of Biomedical Data Sciences (E.W.v.Z.), Leiden University Medical Center; and Department of Rehabilitation (I.J.M.d.G.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hermien E Kan
- From the Department of Neurology (K.J.N., N.M.v.d.V., J.J.G.M.V., E.H.N.), Duchenne Center Netherlands (K.J.N., M.v.d.H., N.M.v.d.V., I.J.M.d.G., J.J.G.M.V., H.E.K., E.H.N.)Department of Orthopedics, Rehabilitation and Physiotherapy (M.v.d.H.), and Department of Biomedical Data Sciences (E.W.v.Z.), Leiden University Medical Center; and Department of Rehabilitation (I.J.M.d.G.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Erik H Niks
- From the Department of Neurology (K.J.N., N.M.v.d.V., J.J.G.M.V., E.H.N.), Duchenne Center Netherlands (K.J.N., M.v.d.H., N.M.v.d.V., I.J.M.d.G., J.J.G.M.V., H.E.K., E.H.N.)Department of Orthopedics, Rehabilitation and Physiotherapy (M.v.d.H.), and Department of Biomedical Data Sciences (E.W.v.Z.), Leiden University Medical Center; and Department of Rehabilitation (I.J.M.d.G.), Radboud University Medical Center, Nijmegen, the Netherlands.
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van Breeschoten J, van den Eertwegh AJM, de Wreede LC, Hilarius DL, van Zwet EW, Haanen JB, Blank CU, Aarts MJB, van den Berkmortel FWPJ, de Groot JWB, Hospers GAP, Kapiteijn E, Piersma D, van Rijn RS, Stevense-den Boer MAM, van der Veldt AAM, Vreugdenhil G, Boers-Sonderen MJ, Suijkerbuijk KPM, Wouters MWJM. Hospital Variation in Cancer Treatments and Survival OutComes of Advanced Melanoma Patients: Nationwide Quality Assurance in The Netherlands. Cancers (Basel) 2021; 13:5077. [PMID: 34680228 PMCID: PMC8533953 DOI: 10.3390/cancers13205077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/08/2021] [Accepted: 10/08/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND To assure a high quality of care for patients treated in Dutch melanoma centers, hospital variation in treatment patterns and outcomes is evaluated in the Dutch Melanoma Treatment Registry. The aim of this study was to assess center variation in treatments and 2-year survival probabilities of patients diagnosed between 2013 and 2017 in the Netherlands. METHODS We selected patients diagnosed between 2013 and 2017 with unresectable IIIC or stage IV melanoma, registered in the Dutch Melanoma Treatment Registry. Centers' performance on 2-year survival was evaluated using Empirical Bayes estimates calculated in a random effects model. Treatment patterns of the centers with the lowest and highest estimates for 2-year survival were compared. RESULTS For patients diagnosed between 2014 and 2015, significant center variation in 2-year survival probabilities was observed even after correcting for case-mix and treatment with new systemic therapies. The different use of new systemic therapies partially explained the observed variation. From 2016 onwards, no significant difference in 2-year survival was observed between centers. CONCLUSION Our data suggest that between 2014 and 2015, after correcting for patient case-mix, significant variation in 2-year survival probabilities between Dutch melanoma centers existed. The use of new systemic therapies could partially explain this variation. In 2013 and between 2016 and 2017, no significant variation between centers existed.
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Affiliation(s)
- Jesper van Breeschoten
- Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands;
- Department of Medical Oncology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands;
| | - Alfonsus J. M. van den Eertwegh
- Department of Medical Oncology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands;
| | - Liesbeth C. de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Einthovenweg 20, 2333 ZC Leiden, The Netherlands; (L.C.d.W.); (E.W.v.Z.)
| | - Doranne L. Hilarius
- Department of Pharmacy, Rode Kruis Ziekenhuis, Vondellaan 13, 1942 LE Beverwijk, The Netherlands;
| | - Erik W. van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Einthovenweg 20, 2333 ZC Leiden, The Netherlands; (L.C.d.W.); (E.W.v.Z.)
| | - John B. Haanen
- Department of Medical Oncology and Immunology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (J.B.H.); (C.U.B.)
| | - Christian U. Blank
- Department of Medical Oncology and Immunology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (J.B.H.); (C.U.B.)
- Division of Molecular Oncology & Immunology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Maureen J. B. Aarts
- Department of Medical Oncology, GROW School of Oncology and Developmental Biology, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands;
| | | | | | - Geke A. P. Hospers
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
| | - Ellen Kapiteijn
- Department of Medical Oncology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands;
| | - Djura Piersma
- Department of Internal Medicine, Medisch Spectrum Twente, Koningsplein 1, 7512 KZ Enschede, The Netherlands;
| | - Rozemarijn S. van Rijn
- Department of Internal Medicine, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD Leeuwarden, The Netherlands;
| | | | - Astrid A. M. van der Veldt
- Department of Medical Oncology and Radiology & Nuclear Medicine, Erasmus Medical Centre, ‘s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands;
| | - Gerard Vreugdenhil
- Department of Internal Medicine, Maxima Medical Centre, De Run 4600, 5504 DB Eindhoven, The Netherlands;
| | - Marye J. Boers-Sonderen
- Department of Medical Oncology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands;
| | - Karijn P. M. Suijkerbuijk
- Department of Medical Oncology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands;
| | - Michel W. J. M. Wouters
- Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands;
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Einthovenweg 20, 2333 ZC Leiden, The Netherlands; (L.C.d.W.); (E.W.v.Z.)
- Department of Surgical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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Koemans EA, Voigt S, Rasing I, van Harten TW, Jolink WMT, Schreuder FHBM, van Zwet EW, van Buchem MA, van Osch MJP, Terwindt GM, Klijn CJM, van Walderveen MAA, Wermer MJH. Cerebellar Superficial Siderosis in Cerebral Amyloid Angiopathy. Stroke 2021; 53:552-557. [PMID: 34538086 DOI: 10.1161/strokeaha.121.035019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Although evidence accumulates that the cerebellum is involved in cerebral amyloid angiopathy (CAA), cerebellar superficial siderosis is not considered to be a disease marker. The objective of this study is to investigate cerebellar superficial siderosis frequency and its relation to hemorrhagic magnetic resonance imaging markers in patients with sporadic and Dutch-type hereditary CAA and patients with deep perforating arteriopathy-related intracerebral hemorrhage. METHODS We recruited patients from 3 prospective 3 Tesla magnetic resonance imaging studies and scored siderosis and hemorrhages. Cerebellar siderosis was identified as hypointense linear signal loss (black) on susceptibility-weighted or T2*-weighted magnetic resonance imaging which follows at least one folia of the cerebellar cortex (including the vermis). RESULTS We included 50 subjects with Dutch-type hereditary CAA, (mean age 50 years), 45 with sporadic CAA (mean age 72 years), and 43 patients with deep perforating arteriopathy-related intracerebral hemorrhage (mean age 54 years). Cerebellar superficial siderosis was present in 5 out of 50 (10% [95% CI, 2-18]) patients with Dutch-type hereditary CAA, 4/45 (9% [95% CI, 1-17]) patients with sporadic CAA, and 0 out of 43 (0% [95% CI, 0-8]) patients with deep perforating arteriopathy-related intracerebral hemorrhage. Patients with cerebellar superficial siderosis had more supratentorial lobar (median number 9 versus 2, relative risk, 2.9 [95% CI, 2.5-3.4]) and superficial cerebellar macrobleeds (median number 2 versus 0, relative risk, 20.3 [95% CI, 8.6-47.6]) compared with patients without the marker. The frequency of cortical superficial siderosis and superficial cerebellar microbleeds was comparable. CONCLUSIONS We conclude that cerebellar superficial siderosis might be a novel marker for CAA.
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Affiliation(s)
- Emma A Koemans
- Department of Neurology, Leiden University Medical Center, the Netherlands. (E.A.K., S.V., I.R., G.M.T., M.J.H.W.)
| | - Sabine Voigt
- Department of Neurology, Leiden University Medical Center, the Netherlands. (E.A.K., S.V., I.R., G.M.T., M.J.H.W.)
| | - Ingeborg Rasing
- Department of Neurology, Leiden University Medical Center, the Netherlands. (E.A.K., S.V., I.R., G.M.T., M.J.H.W.)
| | - Thijs W van Harten
- Department of Radiology, Leiden University Medical Center, the Netherlands. (T.W.v.H., M.A.v.B., M.J.P.v.O., M.A.A.v.W.)
| | - Wilmar M T Jolink
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, the Netherlands (W.M.T.J.)
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands (F.H.B.M.S., C.J.M.K.)
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands. (E.W.v.Z.)
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center, the Netherlands. (T.W.v.H., M.A.v.B., M.J.P.v.O., M.A.A.v.W.)
| | - Matthias J P van Osch
- Department of Radiology, Leiden University Medical Center, the Netherlands. (T.W.v.H., M.A.v.B., M.J.P.v.O., M.A.A.v.W.)
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, the Netherlands. (E.A.K., S.V., I.R., G.M.T., M.J.H.W.)
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands (F.H.B.M.S., C.J.M.K.)
| | - Marianne A A van Walderveen
- Department of Radiology, Leiden University Medical Center, the Netherlands. (T.W.v.H., M.A.v.B., M.J.P.v.O., M.A.A.v.W.)
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, the Netherlands. (E.A.K., S.V., I.R., G.M.T., M.J.H.W.)
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Veeger TTJ, van Zwet EW, Al Mohamad D, Naarding KJ, van de Velde NM, Hooijmans MT, Webb AG, Niks EH, de Groot JH, Kan HE. Muscle architecture is associated with muscle fat replacement in Duchenne and Becker muscular dystrophies. Muscle Nerve 2021; 64:576-584. [PMID: 34383334 PMCID: PMC9290788 DOI: 10.1002/mus.27399] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 08/02/2021] [Accepted: 08/07/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION/AIMS Duchenne and Becker muscular dystrophies (DMD and BMD, respectively) are characterized by fat replacement of different skeletal muscles in a specific temporal order. Given the structural role of dystrophin in skeletal muscle mechanics, muscle architecture could be important in the progressive pathophysiology of muscle degeneration. Therefore, the aim of this study was to assess the role of muscle architecture in the progression of fat replacement in DMD and BMD. METHODS We assessed the association between literature-based leg muscle architectural characteristics and muscle fat fraction from 22 DMD and 24 BMD patients. Dixon-based magnetic resonance imaging estimates of fat fractions at baseline and 12 (only DMD) and 24 months were related to fiber length and physiological cross-sectional area (PCSA) using age-controlled linear mixed modeling. RESULTS DMD and BMD muscles with long fibers and BMD muscles with large PCSAs were associated with increased fat fraction. The effect of fiber length was stronger in muscles with larger PCSA. DISCUSSION Muscle architecture may explain the pathophysiology of muscle degeneration in dystrophinopathies, in which proximal muscles with a larger mass (fiber length × PCSA) are more susceptible, confirming the clinical observation of a temporal proximal-to-distal progression. These results give more insight into the mechanical role in the pathophysiology of muscular dystrophies. Ultimately, this new information can be used to help support the selection of current and the development of future therapies.
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Affiliation(s)
- Thom T J Veeger
- C.J. Gorter Center for High Field MRI, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Biostatistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Diaa Al Mohamad
- Department of Biostatistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Karin J Naarding
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Melissa T Hooijmans
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Andrew G Webb
- C.J. Gorter Center for High Field MRI, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik H Niks
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jurriaan H de Groot
- Department of Rehabilitation Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Hermien E Kan
- C.J. Gorter Center for High Field MRI, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Wilbrink LA, de Coo IF, Doesborg PGG, Mulleners WM, Teernstra OPM, Bartels EC, Burger K, Wille F, van Dongen RTM, Kurt E, Spincemaille GH, Haan J, van Zwet EW, Huygen FJPM, Ferrari MD. Safety and efficacy of occipital nerve stimulation for attack prevention in medically intractable chronic cluster headache (ICON): a randomised, double-blind, multicentre, phase 3, electrical dose-controlled trial. Lancet Neurol 2021; 20:515-525. [PMID: 34146510 DOI: 10.1016/s1474-4422(21)00101-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 02/14/2021] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Occipital nerve stimulation (ONS) has shown promising results in small uncontrolled trials in patients with medically intractable chronic cluster headache (MICCH). We aimed to establish whether ONS could serve as an effective treatment for patients with MICCH. METHODS The ONS in MICCH (ICON) study is an investigator-initiated, international, multicentre, randomised, double-blind, phase 3, electrical dose-controlled clinical trial. The study took place at four hospitals in the Netherlands, one hospital in Belgium, one in Germany, and one in Hungary. After 12 weeks' baseline observation, patients with MICCH, at least four attacks per week, and history of being non-responsive to at least three standard preventive drugs, were randomly allocated (at a 1:1 ratio using a computer-generated permuted block) to 24 weeks of occipital nerve stimulation at either 100% or 30% of the individually determined range between paraesthesia threshold and near-discomfort (double-blind study phase). Because ONS causes paraesthesia, preventing masked comparison versus placebo, we compared high-intensity versus low-intensity ONS, which are hypothesised to cause similar paraesthesia, but with different efficacy. In weeks 25-48, participants received individually optimised open-label ONS. The primary outcome was the weekly mean attack frequency in weeks 21-24 compared with baseline across all patients and, if a decrease was shown, to show a group-wise difference. The trial is closed to recruitment (ClinicalTrials.gov NCT01151631). FINDINGS Patients were enrolled between Oct 12, 2010, and Dec 3, 2017. We enrolled 150 patients and randomly assigned 131 (87%) to treatment; 65 (50%) patients to 100% ONS and 66 (50%) to 30% ONS. One of the 66 patients assigned to 30% ONS was not implanted and was therefore excluded from the intention-to-treat analysis. Because the weekly mean attack frequencies at baseline were skewed (median 15·75; IQR 9·44 to 24·75) we used log transformation to analyse the data and medians to present the results. Median weekly mean attack frequencies in the total population decreased from baseline to 7·38 (2·50 to 18·50; p<0·0001) in weeks 21-24, a median change of -5·21 (-11·18 to -0·19; p<0·0001) attacks per week. In the 100% ONS stimulation group, mean attack frequency decreased from 17·58 (9·83 to 29·33) at baseline to 9·50 (3·00 to 21·25) at 21-24 weeks (median change from baseline -4·08, -11·92 to -0·25), and for the 30% ONS stimulation group, mean attack frequency decreased from 15·00 (9·25 to 22·33) to 6·75 (1·50 to 16·50; -6·50, -10·83 to -0·08). The difference in median weekly mean attack frequency between groups at the end of the masked phase in weeks 21-24 was -2·42 (95% CI -5·17 to 3·33). In the masked study phase, 129 adverse events occurred with 100% ONS and 95 occurred with 30% ONS. None of the adverse events was unexpected but 17 with 100% ONS and eight with 30% ONS were labelled as serious, given they required brief hospital admission for minor hardware-related issues. The most common adverse events were local pain, impaired wound healing, neck stiffness, and hardware damage. INTERPRETATION In patients with MICCH, both 100% ONS intensity and 30% ONS intensity substantially reduced attack frequency and were safe and well tolerated. Future research should focus on optimising stimulation protocols and disentangling the underlying mechanism of action. FUNDING The Netherlands Organisation for Scientific Research, the Dutch Ministry of Health, the NutsOhra Foundation from the Dutch Health Insurance Companies, and Medtronic.
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Affiliation(s)
- Leopoldine A Wilbrink
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; Department of Neurology, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Ilse F de Coo
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; Basalt Rehabilitation Centre, the Hague, Netherlands
| | - Patty G G Doesborg
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
| | - Wim M Mulleners
- Department of Neurology, Canisius-Wilhelmina Hospital, Nijmegen, Netherlands
| | - Onno P M Teernstra
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Eveline C Bartels
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Katja Burger
- Department of Anaesthesiology, Alrijne Hospital, Leiderdorp, Netherlands
| | - Frank Wille
- Department of Anaesthesiology, Diakonessenhuis Hospital, Zeist, Netherlands
| | - Robert T M van Dongen
- Department of Anaesthesiology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Erkan Kurt
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Geert H Spincemaille
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Joost Haan
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; Department of Neurology, Alrijne Hospital, Leiderdorp, Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, Netherlands
| | | | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands.
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van de Velde NM, Hooijmans MT, Sardjoe Mishre ASD, Keene KR, Koeks Z, Veeger TTJ, Alleman I, van Zwet EW, Beenakker JWM, Verschuuren JJGM, Kan HE, Niks EH. Selection Approach to Identify the Optimal Biomarker Using Quantitative Muscle MRI and Functional Assessments in Becker Muscular Dystrophy. Neurology 2021; 97:e513-e522. [PMID: 34162720 PMCID: PMC8356376 DOI: 10.1212/wnl.0000000000012233] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 04/29/2021] [Indexed: 12/30/2022] Open
Abstract
Objective To identify the best quantitative fat–water MRI biomarker for disease progression of leg muscles in Becker muscular dystrophy (BMD) by applying a stepwise approach based on standardized response mean (SRM) over 24 months, correlations with baseline ambulatory tests, and reproducibility. Methods Dixon fat–water imaging was performed at baseline (n = 24) and 24 months (n = 20). Fat fractions (FF) were calculated for 3 center slices and the whole muscles for 19 muscles and 6 muscle groups. Contractile cross-sectional area (cCSA) was obtained from the center slice. Functional assessments included knee extension and flexion force and 3 ambulatory tests (North Star Ambulatory Assessment [NSAA], 10-meter run, 6-minute walking test). MRI measures were selected using SRM (≥0.8) and correlation with all ambulatory tests (ρ ≤ −0.8). Measures were evaluated based on intraclass correlation coefficient (ICC) and SD of the difference. Sample sizes were calculated assuming 50% reduction in disease progression over 24 months in a clinical trial with 1:1 randomization. Results Median whole muscle FF increased between 0.2% and 2.6% without consistent cCSA changes. High SRMs and strong functional correlations were found for 8 FF but no cCSA measures. All measures showed excellent ICC (≥0.999) and similar SD of the interrater difference. Whole thigh 3 center slices FF was the best biomarker (SRM 1.04, correlations ρ ≤ −0.81, ICC 1.00, SD 0.23%, sample size 59) based on low SD and acquisition and analysis time. Conclusion In BMD, median FF of all muscles increased over 24 months. Whole thigh 3 center slices FF reduced the sample size by approximately 40% compared to NSAA.
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Affiliation(s)
- Nienke M van de Velde
- From the Department of Neurology (N.M.v.d.V., K.R.K., Z.K., J.J.G.M.V., E.H.N.), C.J. Gorter Center for High-Field MRI, Department of Radiology (M.T.H., A.S.D.S.M., K.R.K., T.T.J.V., J.-W.M.B., H.E.K.), Department of Orthopaedics, Rehabilitation and Physical Therapy (I.A.), Department of Biomedical Data Sciences (E.W.v.Z.), and Department of Ophthalmology (J.-W.M.B.), Leiden University Medical Center, the Netherlands; and Duchenne Center Netherlands (N.M.v.d.V., J.J.G.M.V., H.E.K., E.H.N.), the Netherlands
| | - Melissa T Hooijmans
- From the Department of Neurology (N.M.v.d.V., K.R.K., Z.K., J.J.G.M.V., E.H.N.), C.J. Gorter Center for High-Field MRI, Department of Radiology (M.T.H., A.S.D.S.M., K.R.K., T.T.J.V., J.-W.M.B., H.E.K.), Department of Orthopaedics, Rehabilitation and Physical Therapy (I.A.), Department of Biomedical Data Sciences (E.W.v.Z.), and Department of Ophthalmology (J.-W.M.B.), Leiden University Medical Center, the Netherlands; and Duchenne Center Netherlands (N.M.v.d.V., J.J.G.M.V., H.E.K., E.H.N.), the Netherlands
| | - Aashley S D Sardjoe Mishre
- From the Department of Neurology (N.M.v.d.V., K.R.K., Z.K., J.J.G.M.V., E.H.N.), C.J. Gorter Center for High-Field MRI, Department of Radiology (M.T.H., A.S.D.S.M., K.R.K., T.T.J.V., J.-W.M.B., H.E.K.), Department of Orthopaedics, Rehabilitation and Physical Therapy (I.A.), Department of Biomedical Data Sciences (E.W.v.Z.), and Department of Ophthalmology (J.-W.M.B.), Leiden University Medical Center, the Netherlands; and Duchenne Center Netherlands (N.M.v.d.V., J.J.G.M.V., H.E.K., E.H.N.), the Netherlands
| | - Kevin R Keene
- From the Department of Neurology (N.M.v.d.V., K.R.K., Z.K., J.J.G.M.V., E.H.N.), C.J. Gorter Center for High-Field MRI, Department of Radiology (M.T.H., A.S.D.S.M., K.R.K., T.T.J.V., J.-W.M.B., H.E.K.), Department of Orthopaedics, Rehabilitation and Physical Therapy (I.A.), Department of Biomedical Data Sciences (E.W.v.Z.), and Department of Ophthalmology (J.-W.M.B.), Leiden University Medical Center, the Netherlands; and Duchenne Center Netherlands (N.M.v.d.V., J.J.G.M.V., H.E.K., E.H.N.), the Netherlands
| | - Zaïda Koeks
- From the Department of Neurology (N.M.v.d.V., K.R.K., Z.K., J.J.G.M.V., E.H.N.), C.J. Gorter Center for High-Field MRI, Department of Radiology (M.T.H., A.S.D.S.M., K.R.K., T.T.J.V., J.-W.M.B., H.E.K.), Department of Orthopaedics, Rehabilitation and Physical Therapy (I.A.), Department of Biomedical Data Sciences (E.W.v.Z.), and Department of Ophthalmology (J.-W.M.B.), Leiden University Medical Center, the Netherlands; and Duchenne Center Netherlands (N.M.v.d.V., J.J.G.M.V., H.E.K., E.H.N.), the Netherlands
| | - Thom T J Veeger
- From the Department of Neurology (N.M.v.d.V., K.R.K., Z.K., J.J.G.M.V., E.H.N.), C.J. Gorter Center for High-Field MRI, Department of Radiology (M.T.H., A.S.D.S.M., K.R.K., T.T.J.V., J.-W.M.B., H.E.K.), Department of Orthopaedics, Rehabilitation and Physical Therapy (I.A.), Department of Biomedical Data Sciences (E.W.v.Z.), and Department of Ophthalmology (J.-W.M.B.), Leiden University Medical Center, the Netherlands; and Duchenne Center Netherlands (N.M.v.d.V., J.J.G.M.V., H.E.K., E.H.N.), the Netherlands
| | - Iris Alleman
- From the Department of Neurology (N.M.v.d.V., K.R.K., Z.K., J.J.G.M.V., E.H.N.), C.J. Gorter Center for High-Field MRI, Department of Radiology (M.T.H., A.S.D.S.M., K.R.K., T.T.J.V., J.-W.M.B., H.E.K.), Department of Orthopaedics, Rehabilitation and Physical Therapy (I.A.), Department of Biomedical Data Sciences (E.W.v.Z.), and Department of Ophthalmology (J.-W.M.B.), Leiden University Medical Center, the Netherlands; and Duchenne Center Netherlands (N.M.v.d.V., J.J.G.M.V., H.E.K., E.H.N.), the Netherlands
| | - Erik W van Zwet
- From the Department of Neurology (N.M.v.d.V., K.R.K., Z.K., J.J.G.M.V., E.H.N.), C.J. Gorter Center for High-Field MRI, Department of Radiology (M.T.H., A.S.D.S.M., K.R.K., T.T.J.V., J.-W.M.B., H.E.K.), Department of Orthopaedics, Rehabilitation and Physical Therapy (I.A.), Department of Biomedical Data Sciences (E.W.v.Z.), and Department of Ophthalmology (J.-W.M.B.), Leiden University Medical Center, the Netherlands; and Duchenne Center Netherlands (N.M.v.d.V., J.J.G.M.V., H.E.K., E.H.N.), the Netherlands
| | - Jan-Willem M Beenakker
- From the Department of Neurology (N.M.v.d.V., K.R.K., Z.K., J.J.G.M.V., E.H.N.), C.J. Gorter Center for High-Field MRI, Department of Radiology (M.T.H., A.S.D.S.M., K.R.K., T.T.J.V., J.-W.M.B., H.E.K.), Department of Orthopaedics, Rehabilitation and Physical Therapy (I.A.), Department of Biomedical Data Sciences (E.W.v.Z.), and Department of Ophthalmology (J.-W.M.B.), Leiden University Medical Center, the Netherlands; and Duchenne Center Netherlands (N.M.v.d.V., J.J.G.M.V., H.E.K., E.H.N.), the Netherlands
| | - Jan J G M Verschuuren
- From the Department of Neurology (N.M.v.d.V., K.R.K., Z.K., J.J.G.M.V., E.H.N.), C.J. Gorter Center for High-Field MRI, Department of Radiology (M.T.H., A.S.D.S.M., K.R.K., T.T.J.V., J.-W.M.B., H.E.K.), Department of Orthopaedics, Rehabilitation and Physical Therapy (I.A.), Department of Biomedical Data Sciences (E.W.v.Z.), and Department of Ophthalmology (J.-W.M.B.), Leiden University Medical Center, the Netherlands; and Duchenne Center Netherlands (N.M.v.d.V., J.J.G.M.V., H.E.K., E.H.N.), the Netherlands
| | - Hermien E Kan
- From the Department of Neurology (N.M.v.d.V., K.R.K., Z.K., J.J.G.M.V., E.H.N.), C.J. Gorter Center for High-Field MRI, Department of Radiology (M.T.H., A.S.D.S.M., K.R.K., T.T.J.V., J.-W.M.B., H.E.K.), Department of Orthopaedics, Rehabilitation and Physical Therapy (I.A.), Department of Biomedical Data Sciences (E.W.v.Z.), and Department of Ophthalmology (J.-W.M.B.), Leiden University Medical Center, the Netherlands; and Duchenne Center Netherlands (N.M.v.d.V., J.J.G.M.V., H.E.K., E.H.N.), the Netherlands
| | - Erik H Niks
- From the Department of Neurology (N.M.v.d.V., K.R.K., Z.K., J.J.G.M.V., E.H.N.), C.J. Gorter Center for High-Field MRI, Department of Radiology (M.T.H., A.S.D.S.M., K.R.K., T.T.J.V., J.-W.M.B., H.E.K.), Department of Orthopaedics, Rehabilitation and Physical Therapy (I.A.), Department of Biomedical Data Sciences (E.W.v.Z.), and Department of Ophthalmology (J.-W.M.B.), Leiden University Medical Center, the Netherlands; and Duchenne Center Netherlands (N.M.v.d.V., J.J.G.M.V., H.E.K., E.H.N.), the Netherlands.
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van Breeschoten J, van den Eertwegh AJM, De Wreede L, van Zwet EW, Hilarius D, Haanen JBAG, Blank CU, Aarts MJ, Van Den Berkmortel F, de Groot JW, Hospers G, Kapiteijn E, Piersma D, Van Rijn R, Van Der Veldt AAM, Vreugdenhil G, Stevense M, Boers-Sonderen M, Suijkerbuijk K, Wouters MW. Hospital variation in cancer treatments and survival outcomes of advanced melanoma patients: Nationwide quality assurance in the Netherlands. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e18641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18641 Background: The introduction of new systemic treatments for advanced melanoma has markedly changed the outcome of patients with metastatic melanoma. To assure high quality of care for patients treated in Dutch melanoma centers, hospital variation in treatment patterns and outcomes are evaluated in the Dutch Melanoma Treatment Registry. The aim of this study was to assess center variation in treatments and 2-year survival probabilities of patients diagnosed between 2013-2017 in the Netherlands. Methods: We selected patients diagnosed between 2013-2017 with unresectable stage IIIC or IV melanoma, registered in the Dutch Melanoma Treatment Registry. Centers’ performance on 2-year survival was compared by means of a multivariable Cox proportional hazards model with a random effect for center ID. Variation between centers was expressed by median hazard ratios. Therapy with BRAF/MEK inhibitors, anti-PD-1 antibodies or ipilimumab plus nivolumab was added to the Cox proportional hazards model as a time dependent covariate to assess the influence of new systemic therapies on center variation. Results: Between 2013-2017, 3820 patients were diagnosed with unresectable stage IIIC or IV melanoma. For patients diagnosed between 2013-2015, significant center variation in 2-year survival probabilities was observed. Median hazard ratio was 1.17 (95%CI: 1.09-1.31) for patients diagnosed between 2013-2015 after correcting for case-mix and treatment with BRAF/MEK inhibitors, anti-PD-1 antibodies or ipilimumab plus nivolumab. Use of new systemic therapies had a significant effect on up to 2-year survival (hazard ratio = 0.83, 95%CI (0.73-0.94)) with no use of the new systemic therapies as a reference. From 2016 onwards, no significant difference in 2-years survival was observed between centers. Conclusions: The different use of new cancer treatment of metastatic melanoma had an effect on survival outcomes in the Netherlands. A platform such as the Dutch Melanoma Treatment Registry, in which melanoma centers collaborate and have insight in variation in treatment patterns and outcomes between centers, results in fast implementation of new clinical developments across all Dutch melanoma centers.
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Affiliation(s)
| | | | - Liesbeth De Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, Netherlands
| | - Erik W. van Zwet
- Leiden University Medical Center, Department of Biomedical Data Sciences, Leiden, Netherlands
| | - Doranne Hilarius
- Department of Pharmacy, Rode Kruis Ziekenhuis, Beverwijk, Netherlands
| | | | - Christian U. Blank
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | | | - Geke Hospers
- University of Groningen, University Medical Center Groningen, Department of Medical Oncology, Groningen, Netherlands
| | - Ellen Kapiteijn
- Leiden University Medical Center, Department of Medical Oncology, Leiden, Netherlands
| | | | | | | | | | - Marion Stevense
- Amphia Hospital, Department of Internal Medicine, Breda, Netherlands
| | | | | | - Michel W.J.M. Wouters
- Leiden University Medical Center, Department of Biomedical Data Sciences, Leiden, Netherlands
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van Casteren DS, Verhagen IE, de Boer I, de Vries Lentsch S, Fronczek R, van Zwet EW, MaassenVanDenBrink A, Terwindt GM. E-diary use in clinical headache practice: A prospective observational study. Cephalalgia 2021; 41:1161-1171. [PMID: 33938248 PMCID: PMC8504420 DOI: 10.1177/03331024211010306] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Aim To determine whether our E-diary can be used to diagnose migraine and provide more reliable migraine-related frequency numbers compared to patients’ self-reported estimates. Methods We introduced a self-developed E-diary including automated algorithms differentiating headache and migraine days, indicating whether a patient has migraine. Reliability of the E-diary diagnosis in combination with two previously validated E-questionnaires was compared to a physician’s diagnosis as gold standard in headache patients referred to the Leiden Headache Clinic (n = 596). In a subset of patients with migraine (n = 484), self-estimated migraine-related frequencies were compared to diary-based results. Results The first migraine screening approach including an E-headache questionnaire, and the E-diary revealed a sensitivity of 98% and specificity of 17%. In the second approach, an E-migraine questionnaire was added, resulting in a sensitivity of 79% and specificity of 69%. Mean self-estimated monthly migraine days, non-migrainous headache days and days with acute medication use were different from E-diary-based results (absolute mean difference ± standard deviation respectively 4.7 ± 5.0, 6.2 ± 6.6 and 4.3 ± 4.8). Conclusion The E-diary including algorithms differentiating headache and migraine days showed usefulness in diagnosing migraine. The use emphasised the need for E-diaries to obtain reliable information, as patients do not reliably recall numbers of migraine days and acute medication intake. Adding E-diaries will be helpful in future headache telemedicine.
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Affiliation(s)
- Daphne S van Casteren
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Iris E Verhagen
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Irene de Boer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Simone de Vries Lentsch
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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Alberga AJ, Karthaus EG, van Zwet EW, de Bruin JL, van Herwaarden JA, Wever JJ, Verhagen HJM. Outcomes in Octogenarians and the Effect of Comorbidities After Intact Abdominal Aortic Aneurysm Repair in the Netherlands: A Nationwide Cohort Study. Eur J Vasc Endovasc Surg 2021; 61:920-928. [PMID: 33875325 DOI: 10.1016/j.ejvs.2021.02.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 02/05/2021] [Accepted: 02/23/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Age is an independent risk factor for mortality after both elective open surgical repair (OSR) and endovascular aneurysm repair (EVAR). As a result of an ageing population, and the less invasive nature of EVAR, the number of patients over 80 years (octogenarians) being treated is increasing. The mortality and morbidity following aneurysm surgery are increased for octogenarians. However, the mortality for octogenarians who have either low or high peri-operative risks remains unclear. The aim of this study was to provide peri-operative outcomes of octogenarians vs. non-octogenarians after OSR and EVAR for intact aneurysms, including separate subanalyses for elective and urgent intact repair, based on a nationwide cohort. Furthermore, the influence of comorbidities on peri-operative mortality was examined. METHODS All patients registered in the Dutch Surgical Aneurysm Audit (DSAA) undergoing intact AAA repair between 2013 and 2018, were included. Patient characteristics and peri-operative outcomes (peri-operative mortality, and major complications) of octogenarians vs. non-octogenarians for both OSR and EVAR were compared using descriptive statistics. Multivariable logistic regression analyses were used to examine whether age and the presence of cardiac, pulmonary, or renal comorbidities were associated with mortality. RESULTS This study included 12 054 EVAR patients (3 015 octogenarians), and 3 815 OSR patients (425 octogenarians). Octogenarians in both the EVAR and OSR treatment groups were more often female and had more comorbidities. In both treatment groups, octogenarians had significantly higher mortality rates following intact repair as well as higher major complication rates. Mortality rates of octogenarians were 1.9% after EVAR and 11.8% after OSR. Age ≥ 80 and presence of cardiac, pulmonary, and renal comorbidities were associated with mortality after EVAR and OSR. CONCLUSION Because of the high peri-operative mortality rates of octogenarians, awareness of the presence of comorbidities is essential in the decision making process before offering aneurysm repair to this cohort, especially when OSR is considered.
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Affiliation(s)
- Anna J Alberga
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands.
| | | | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Jan J Wever
- Department of Vascular Surgery, Haga Teaching Hospital, The Hague, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
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Driessen MLS, Sturms LM, van Zwet EW, Bloemers FW, Ten Duis HJ, Edwards MJR, den Hartog D, de Jongh MAC, Leenhouts PA, Poeze M, Schipper IB, Spanjersberg R, Wendt KW, de Wit RJ, van Zutphen SWAM, Leenen LPH. Evaluation of the Berlin polytrauma definition: A Dutch nationwide observational study. J Trauma Acute Care Surg 2021; 90:694-699. [PMID: 33443988 DOI: 10.1097/ta.0000000000003071] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The Berlin polytrauma definition (BPD) was established to identify multiple injury patients with a high risk of mortality. The definition includes injuries with an Abbreviated Injury Scale score of ≥3 in ≥2 body regions (2AIS ≥3) combined with the presence of ≥1 physiological risk factors (PRFs). The PRFs are based on age, Glasgow Coma Scale, hypotension, acidosis, and coagulopathy at specific cutoff values. This study evaluates and compares the BPD with two other multiple injury definitions used to identify patients with high resource utilization and mortality risk, using data from the Dutch National Trauma Register (DNTR). METHODS The evaluation was performed based on 2015 to 2018 DNTR data. First, patient characteristics for 2AIS ≥3, Injury Severity Score (ISS) of ≥16, and BPD patients were compared. Second, the PRFs prevalence and odds ratios of mortality for 2AIS ≥3 patients were compared with those from the Deutsche Gesellschaft für Unfallchirurgie Trauma Register. Subsequently, the association between PRF and mortality was assessed for 2AIS ≥3-DNTR patients and compared with those with an ISS of ≥16. RESULTS The DNTR recorded 300,649 acute trauma admissions. A total of 15,711 patients sustained an ISS of ≥16, and 6,263 patients had suffered a 2AIS ≥3 injury. All individual PRFs were associated with a mortality of >30% in 2AIS ≥3-DNTR patients. The increase in PRFs was associated with a significant increase in mortality for both 2AIS ≥3 and ISS ≥16 patients. A total of 4,264 patients met the BPDs criteria. Overall mortality (27.2%), intensive care unit admission (71.2%), and length of stay were the highest for the BPD group. CONCLUSION This study confirms that the BPD identifies high-risk patients in a population-based registry. The addition of PRFs to the anatomical injury scores improves the identification of severely injured patients with a high risk of mortality. Compared with the ISS ≥16 and 2AIS ≥3 multiple injury definitions, the BPD showed to improve the accuracy of capturing patients with a high medical resource need and mortality rate. LEVEL OF EVIDENCE Epidemiological study, level III.
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Affiliation(s)
- Mitchell L S Driessen
- From the Dutch Network for Emergency Care (M.L.S.D., L.M.S.), Utrecht; Department of Medical Statistics (E.W.v.Z.), Leiden University Medical Center, Leiden; Department of Surgery (F.W.B.), Amsterdam University Medical Center, VU, Amsterdam; Department of Trauma Surgery (M.J.R.E.), Radboud University Medical Center, Nijmegen; Trauma Research Unit, Department of Surgery (D.d.H.), Erasmus MC, University Medical Center Rotterdam, Rotterdam; Brabant Trauma Registry (M.A.C.d.J.), Network Emergency Care Brabant, Tilburg; Department of Surgery (P.A.L.), Amsterdam University Medical Center, AMC, Amsterdam; Department of Surgery (M.P.), Maastricht University Medical Center, Maastricht; Department of Trauma Surgery (I.B.S.), Leiden University Medical Center, Leiden; Department of Trauma Surgery (R.S.), Isala Hospitals, Zwolle; Department of Trauma Surgery (K.W.W.), University Medical Center Groningen, Groningen; Department of Trauma Surgery (R.J.d.W.), Medical Spectrum Twente, Enschede; Department of Surgery Elisabeth Two Cities Hospital (S.W.A.M.v.Z.), Tilburg; and Department of Surgery (L.P.H.L.), University Medical Center Utrecht, Utrecht, the Netherlands
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van Meerten KF, Haan RMA, Dekker IMC, van Zweden HJJ, van Zwet EW, Backus BE. The interobserver agreement of the HEART-score, a multicentre prospective study. Eur J Emerg Med 2021; 28:111-118. [PMID: 33136732 DOI: 10.1097/mej.0000000000000758] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND IMPORTANCE Chest pain is one of the most common presentations to the emergency department (ED). The HEART-score is used to assess the 30-day risk of developing a major adverse cardiac event (MACE). The HEART-score enables clinicians to classify patients in low, intermediate, or high-risk groups though little is known as to whether this can be done reliably and reproducibly in a prehospital setting. OBJECTIVE The aim of this study was to compare the interobserver agreement of the HEART-score between ambulance nurses and ED physicians. DESIGN, SETTINGS, AND PARTICIPANTS Patients ≥18 years, with chest pain of suspected cardiac origin presented by ambulance to the EDs of four regional hospitals, were prospectively enrolled between October 2018 and April 2019. OUTCOMES MEASURE AND ANALYSIS The primary endpoint was interobserver agreement of the HEART-scores calculated by ambulance nurses compared to those calculated by ED physicians. Agreement was measured using Cohen's Kappa (K) both for overall HEART-score and dichotomized HEART categories. A secondary endpoint was the occurrence of a MACE at 30 days after inclusion. MAIN RESULTS A total of 307 patients were enrolled of which 166 patients were male (54%). The mean age was 64.8 years. In 23% (95% confidence interval, 18-27), patients were scored in the low-risk category by both ambulance nurses and ED physicians. The K for the overall HEART-score compared between ambulance nurses and ED physicians was 0.514. The K for the low-risk category versus intermediate and high-risk category was 0.591. Both are defined as 'moderate'. MACE within 30 days occurred in 64 patients (21%). In the low-risk group as defined by the ambulance nurses, there was a 7% risk of MACE compared to an average 5% MACE risk in the ED physician group. CONCLUSIONS The moderate interobserver agreement of the HEART-score does not currently support the use of the HEART-score by ambulance nurses in a prehospital setting. Training for prehospital nurses is vital to ensure that they are able to calculate the HEART-score accurately.
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Affiliation(s)
| | - Rowan M A Haan
- Emergency Department, Albert Schweitzer Ziekenhuis Dordrecht & Zwijndrecht
| | | | | | - Erik W van Zwet
- Department of Medical Statistics, Leids Universitair Medisch Centrum Leiden
| | - Barbra E Backus
- Emergency Department, Leids Universitair Medisch Centrum Leiden
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Dijkink S, van Zwet EW, Krijnen P, Leenen LPH, Bloemers FW, Edwards MJR, Hartog DD, Leenhouts PA, Poeze M, Spanjersberg WR, Wendt KW, De Wit RJ, Van Zuthpen SWAM, Schipper IB. The impact of regionalized trauma care on the distribution of severely injured patients in the Netherlands. Eur J Trauma Emerg Surg 2021; 48:1035-1043. [PMID: 33712892 PMCID: PMC9001217 DOI: 10.1007/s00068-021-01615-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/05/2021] [Indexed: 11/18/2022]
Abstract
Background Twenty years ago, an inclusive trauma system was implemented in the Netherlands. The goal of this study was to evaluate the impact of structured trauma care on the concentration of severely injured patients over time. Methods All severely injured patients (Injury Severity Score [ISS] ≥ 16) documented in the Dutch Trauma Registry (DTR) in the calendar period 2008–2018 were included for analysis. We compared severely injured patients, with and without severe neurotrauma, directly brought to trauma centers (TC) and non-trauma centers (NTC). The proportion of patients being directly transported to a trauma center was determined, as was the total Abbreviated Injury Score (AIS), and ISS. Results The documented number of severely injured patients increased from 2350 in 2008 to 4694 in 2018. During this period, on average, 70% of these patients were directly admitted to a TC (range 63–74%). Patients without severe neurotrauma had a lower chance of being brought to a TC compared to those with severe neurotrauma. Patients directly presented to a TC were more severely injured, reflected by a higher total AIS and ISS, than those directly transported to a NTC. Conclusion Since the introduction of a well-organized trauma system in the Netherlands, trauma care has become progressively centralized, with more severely injured patients being directly presented to a TC. However, still 30% of these patients is initially brought to a NTC. Future research should focus on improving pre-hospital triage to facilitate swift transfer of the right patient to the right hospital.
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Affiliation(s)
- Suzan Dijkink
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Erik W van Zwet
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Michael J R Edwards
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter A Leenhouts
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Klaus W Wendt
- Department of Trauma Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ralph J De Wit
- Department of Trauma Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
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