Laparoscopic Roux-en-Y feeding jejunostomy as a long-term solution for severe feeding problems in children.

Enteral feeding is a common problem in children with gastric emptying disorders. Traditional feeding methods in these patients often show a high rate of complications and maintenance issues. Laparoscopic Roux-en-Y feeding jejunostomy (LRFJ) has been described in a few patients as a minimal invasive option for enteral access in these children. The aim of this study is to evaluate the outcomes of the LRFJ procedure in our tertiary referral center. We conducted a retrospective case-series including all patients, aged 0-18 years old, that underwent a LFRJ procedure between August 2011 and December 2020 for the indication of oral feeding intolerance due to delayed gastric emptying. Outcomes evaluated were complications (short and long term) and parenteral satisfaction. In total, 12 children were identified that underwent LRFJ for the indication of oral feeding intolerance due to delayed gastric emptying. A total of 16 complications were noted in 8/12 patients (67%). Severity classified by Clavien-Dindo were grade I (n = 13), grade II (n = 1), and grade IIIB (n = 2). In 11/12 patients, parents were satisfied with the results. CONCLUSIONS: Although minor complications after LRFJ are common in our patients, this technique is a safe solution in patients with gastric emptying disorders leading to a definitive method of enteral feeding and high parenteral satisfaction. WHAT IS KNOWN: • Traditional tube feeding in children (duodenal, PEG-J-tubes) with severe delayed gastric emptying can be challenging with a high rate of complications and maintenance issues. • Open loop jejunostomy and Roux-en-Y jejunostomy are alternative, permanent methods of feeding but either invasive or are accompanied by severe complications. Little is known in the literature about laparoscopic Roux-en-Y feeding jejunostomy. WHAT IS NEW: • Laparoscopic Roux-en-Y feeding jejunostomy is a permanent, safe and minimal invasive alternative option for enteral feeding in children with severe delayed gastric emptying..

The role of a simple questionnaire predicting treatment success in children with ACNES.

BACKGROUND: Some children with chronic abdominal wall pain or groin pain do not have an inguinal hernia but suffer from anterior cutaneous nerve entrapment syndrome (ACNES). Diagnosing ACNES is challenging, especially in children as a diagnostic gold standard is lacking. A paediatric questionnaire containing 17 simple items was earlier found to discriminate between abdominal pain due or ACNES or IBS. Scores range from 0 points (ACNES very unlikely) to 17 points (ACNES very likely). The present study investigates whether this 17-item questionnaire predicted treatment success in children receiving therapy for ACNES. METHODS: Children < 18 years who presented in a single institute between February 2016 and October 2021 with symptoms and signs suggestive of ACNES completed the questionnaire before intake and treatment. Treatment success after 6-8 weeks was defined as self-reported 'pain-free' (group 1), ' > 50% less pain' (group 2) and ' < 50% less pain' (group 3). Group differences regarding sex, age, BMI, symptoms duration and questionnaire scores were analysed. RESULTS: Data of 145 children (female 78%, mean age 14.7 ± 2.3 years, mean BMI 21.1 ± 3.9) were analysed. All children received a diagnostic trigger point injection using an anaesthetic agent, and 75.5% underwent subsequent surgery for untractable pain. The three groups were comparable regarding sex distribution, age, BMI and symptoms duration. In addition, questionnaire scores were not different (group 1: n = 89, mean score 13.4 ± 2.7, group 2: n = 24, 13.4 ± 2.3 and group 3: n = 32, 13.0 ± 2.7, p > 0.05). CONCLUSIONS: Treatment success was attained in 78% of children undergoing surgery for ACNES. A simple questionnaire scoring items associated with abdominal pain did not predict treatment success.

Distress and post-traumatic stress in parents of patients with congenital gastrointestinal malformations: a cross-sectional cohort study.

BACKGROUND: Congenital gastrointestinal malformation (CGIM) require neonatal surgical treatment and may lead to disease-specific sequelae, which have a potential psychological impact on parents. The aim of this study is to assess distress and symptoms of post-traumatic stress disorder (PTSD) in parents of patients with CGIM. In this cross-sectional study, seventy-nine parents (47 mothers and 32 fathers) of 53 patients with CGIM completed the Distress Thermometer for Parents (DT-P) and the Self Rating Scale for Posttraumatic Stress Disorders (SRS-PTSD) as part of the multidisciplinary follow-up of their children (aged 5-35 months). Group differences were tested between parents and representative Dutch reference groups with regard to rates of (clinical) distress and PTSD, and severity of overall distress and PTSD, for mothers and fathers separately. Mixed model regression models were used to study factors associated with the risk of (clinical) distress, PTSD and with severity of symptoms of PTSD (intrusion, avoidance and hyperarousal). RESULTS: Prevalence of clinical distress was comparable to reference groups for mothers (46%) and fathers (34%). There was no difference in severity of overall distress between both mothers as well as fathers and reference groups. Prevalence of PTSD was significantly higher in mothers (23%) compared to the reference group (5.3%) (OR = 5.51, p < 0.001), not in fathers (6.3% vs 2.2.%). Symptoms of intrusion were commonly reported by all the parents (75%). Longer total length of child's hospital stay was associated with more severe symptoms of intrusion, avoidance and hyperarousal. Child's length of follow-up was negatively associated with severity of intrusion. CONCLUSIONS: Having a child with CGIM has a huge impact on parents, demonstrated by a higher prevalence of PTSD in mothers, but not fathers, compared to parents in the general population. Monitoring of symptoms of PTSD of parents in follow-up is necessary.

Diagnostic accuracy of abdominal ultrasound to detect pathology that needs surgical exploration in children with umbilical discharge.

BACKGROUND: Umbilical discharge is common in children and mostly attributed to infection or granuloma. However, an underlying congenital abnormality warranting surgery might also be present. Ultrasound is the imaging modality of choice to diagnose the presence of a congenital abnormality. The aim of this study is to investigate diagnostic accuracy of the ultrasound to detect pathology requiring surgical excision. METHODS: All patients ≤18 years with umbilical discharge from January 2008 to September 2019 were retrospectively included. Diagnostic accuracy, i.e., sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-), were calculated. RESULTS: Eighty-one patients were included and 56 were operated. The ultrasound was false positive in 10 patients and false negative in 13 patients. The sensitivity of ultrasound was 71.1% (95% CI 55.7-83.6), specificity 72.2% (54.8-85.8), PPV 76.2% (64.7-84.8), NPV 66.7% (54.8-76.8), LR+ 2.6 (1.5-4.5) and LR- 0.40 (0.2-0.7). CONCLUSIONS: This study shows that the diagnostic accuracy of ultrasound for detecting underlying congenital abnormalities warranting surgery for umbilical discharge in the pediatric population is low, even with experienced pediatric radiologists. Therefore, the role of the ultrasound in the diagnostic workup and value in clinical decision making is limited. TYPE OF STUDY: Study of diagnostic test. LEVEL OF EVIDENCE: III.

[Study stress, burnout and physical complaints among dental students]. / Studiestress, burn-out en lichamelijke klachten bij tandheelkundestudenten.

The study of dentistry is known to cause high levels of psychological stress and physical strain. The aim of the present study was to determine the degree to which dental students experience study stress, burnout and physical complaints. The study showed female students experience higher levels of study stress, on average, than male students. Students' mean level of emotional exhaustion was 'high'. In addition, 90% of the students had suffered from physical complaints in the year preceding the survey. A strong correlation was shown to exist between physical complaints and emotional exhaustion, and in addition, a strong wish for more (pre)clinical teacher support correlated with study stress, burnout and physical complaints. It can be concluded that dental students, on average, experience the study as taxing, feel emotionally exhausted and suffer from many physical complaints. In the dental practice, they will be confronted with many taxing factors. In the dental curriculum, therefore, adequate and frequent attention should be given to learning to cope with stressful situations and to maintain physical well-being.

[Burnout and work stress]. / Burn-out en werkdruk bij tandartsen.

Work stress and burnout among Dutch dentists have been studied in the past; since then, however, considerable changes have taken place in practicing dentistry. The aim of this study was to investigate whether these changes are reflected in reported burnout and stress. Also, the study sought to investigate whether burnout could be associated with making mistakes during treatment or being confronted with a formal complaint. 500 Dutch dentists were randomly selected for an online survey, 105 of whom responded (21%); 50.5% male and 49.5% female. Higher mean scores on emotional exhaustion (EE) and personal accomplishment (PA) were reported, compared to previous results, and to reference scores from the burnout measuring manual, and lower mean scores on depersonalisation (DP) compared to reference scores. No gender differences were found for burnout. Women reported more work stress on Patient Contacts and Considerations about work. The 36 to 45-year-old age group reported higher mean scores on burnout and work stress. Having been confronted with patient complaints was associated with higher scores on DP, while worrying about making mistakes was associated with higher scores on EE and DP. Burnout is a relevant topic for dentists, which appears to be most prominent at middle age. Recognising, and knowing how to deal with, demanding aspects of work is a crucial means to prevent burnout.

[Revised guideline for acute appendicitis. Amendments to diagnostics and treatment]. / Herziene richtlijn over acute appendicitis.

Recently, the revised guideline 'Guideline for diagnostics and treatment of acute appendicitis' was published by the Dutch Surgical Society. A patient with limited clinical symptoms and low suspicion of appendicitis can be assessed again at a later time, during which ultrasound diagnostics can be repeated. Following an inconclusive ultrasound scan in children who possibly have appendicitis, it is no longer recommended to perform diagnostic laparoscopy; rather, MRI diagnostics are indicated. In young adults with possible appendicitis, in whom a diagnosis cannot be established using ultrasound, the advice is to use MRI diagnostics instead of CT imaging; this particularly applies to women of child-bearing age. For patients with appendicitis an appendectomy remains the recommended treatment, although one can consider treating adults with suspected simple appendicitis with antibiotics alone. It is important that this decision is made in consultation with the patient. Laparoscopic appendectomy reduces the number of wound infections and admission length, and is therefore usually preferred over open method appendectomy. If a patient with appendicitis is 24-28 weeks pregnant,consultation with a specialist centre is indicated regarding the obstetric management and possibly referral.

[Acute appendicitis: treatment in accordance with new guideline]. / Acute appendicitis.

In this clinical lesson we present two patient cases. A 66-year-old female patient with a clinical, biochemical and radiological suspicion of complex appendicitis. The patient undergoes an appendectomy and post-operative recovery is beset with complications. The other case involves a 24-year-old male patient with suspected simple appendicitis. He is successfully treated with antibiotics and without surgery. By using these patients as examples, we discuss the revised clinical guideline for diagnosing and treating acute appendicitis. Besides that, we also discuss the differentiation between simple and complex appendicitis and how this can influence the treatment plan.

[Series: Education and the dentist in 2025. Harmonisation of dental curricula in a European and Dutch perspective]. / Serie: Onderwijs en de tandarts anno 2025. Harmonisatie van de opleidingen tandheelkunde in Europees en Nederlands perspectief.

Coinciding with an increasing tendency of professionals to cross national borders, there is also an increasing need to harmonise curricula. In dentistry in Europe, this tendency is undiminished. By defining international curriculum requirements for dentists, international harmonisation can be strengthened. In the Netherlands, too, harmonisation with European standards has taken place in establishing final achievement levels for dentistry curricula, as defined in a national framework. In a working environment where oral health professionals are confronted with rapid change, for example, in the division of responsibilities, future caregivers should have an optimal educational preparation for their competences, skills and expertise.

Latent growth modeling of IRT versus CTT measured longitudinal latent variables.

Latent growth models are often used to measure individual trajectories representing change over time. The characteristics of the individual trajectories depend on the variability in the longitudinal outcomes. In many medical and epidemiological studies, the individual health outcomes cannot be observed directly and are indirectly observed through indicators (i.e. items of a questionnaire). An item response theory or a classical test theory measurement model is required, but the choice can influence the latent growth estimates. In this study, under various conditions, this influence is directly assessed by estimating latent growth parameters on a common scale for item response theory and classical test theory using a novel plausible value method in combination with Markov chain Monte Carlo. The latent outcomes are considered missing data and plausible values are generated from the corresponding posterior distribution, separately for item response theory and classical test theory. These plausible values are linearly transformed to a common scale. A Markov chain Monte Carlo method was developed to simultaneously estimate the latent growth and measurement model parameters using this plausible value technique. It is shown that estimated individual trajectories using item response theory, compared to classical test theory to measure outcomes, provide a more detailed description of individual change over time, since item response patterns (item response theory) are more informative about the health measurements than sum scores (classical test theory).

Rapidly progressive amyotrophic lateral sclerosis is associated with microglial reactivity and small heat shock protein expression in reactive astrocytes.

AIMS: Amyotrophic lateral sclerosis (ALS) is a chronic neurodegenerative disease characterized by progressive loss of motor neurons, muscle weakness, spasticity, paralysis and death usually within 2-5 years of onset. Neuroinflammation is a hallmark of ALS pathology characterized by activation of glial cells, which respond by upregulating small heat shock proteins (HSPBs), but the exact underlying pathological mechanisms are still largely unknown. Here, we investigated the association between ALS disease duration, lower motor neuron loss, TARDNA-binding protein 43 (TDP-43) pathology, neuroinflammation and HSPB expression. METHODS: With immunohistochemistry, we examined HSPB1, HSPB5, HSPB6, HSPB8 and HSP16.2 expression in cervical, thoracic and sacral spinal cord regions in 12 ALS cases, seven with short disease duration (SDD), five with moderate disease duration (MDD), and ten age-matched controls. Expression was quantified using ImageJ to examine HSP expression, motor neuron numbers, microglial and astrocyte density and phosphorylated TDP-43 (pTDP-43+) inclusions. RESULTS: SDD was associated with elevated HSPB5 and 8 expression in lateral tract astrocytes, while HSP16.2 expression was increased in astrocytes in MDD cases. SDD cases had higher numbers of motor neurons and microglial activation than MDD cases, but similar levels of motor neurons with pTDP-43+ inclusions. CONCLUSIONS: Increased expression of several HSPBs in lateral column astrocytes suggests that astrocytes play a role in the pathogenesis of ALS. SDD is associated with increased microgliosis, HSPB5 and 8 expression in astrocytes, and only minor changes in motor neuron loss. This suggests that the interaction between motor neurons, microglia and astrocytes determines neuronal fate and functional decline in ALS.

Heat shock proteins are differentially expressed in brain and spinal cord: implications for multiple sclerosis.

Multiple sclerosis (MS) is a chronic neurodegenerative disease characterized by demyelination, inflammation and neurodegeneration throughout the central nervous system. Although spinal cord pathology is an important factor contributing to disease progression, few studies have examined MS lesions in the spinal cord and how they differ from brain lesions. In this study we have compared brain and spinal cord white (WM) and grey (GM) matter from MS and control tissues, focusing on small heat shock proteins (HSPB) and HSP16.2. Western blotting was used to examine protein levels of HSPB1, HSPB5, HSPB6, HSPB8 and HSP16.2 in brain and spinal cord from MS and age-matched non-neurological controls. Immunohistochemistry was used to examine expression of the HSPs in MS spinal cord lesions and controls. Expression levels were quantified using ImageJ. Western blotting revealed significantly higher levels of HSPB1, HSPB6 and HSPB8 in MS and control spinal cord compared to brain tissues. No differences in HSPB5 and HSP16.2 protein levels were observed, although HSPB5 protein levels were higher in brain WM versus GM. In MS spinal cord lesions, increased HSPB1 and HSPB5 expression was observed in astrocytes, and increased neuronal expression of HSP16.2 was observed in normal-appearing GM and type 1 GM lesions. The high constitutive expression of several HSPBs in spinal cord and increased expression of HSPBs and HSP16.2 in MS illustrate differences between brain and spinal cord in health and upon demyelination. Regional differences in HSP expression may reflect differences in astrocyte cytoskeleton composition and influence inflammation, possibly affecting the effectiveness of pharmacological agents.

Imaging in pediatric appendicitis is key to a low normal appendix percentage: a national audit on the outcome of appendectomy for appendicitis in children.

PURPOSE: A laparoscopic approach for emergency appendectomy is increasingly used, in pediatric patients as well. The objective of this study is to audit the current state of diagnostic work-up, surgical techniques and its outcome in children with acute appendicitis. METHODS: A prospective consecutive observational cohort study was carried out in a 2-month study period. All patients under 18 years that were operated for suspected acute appendicitis were included. Primary outcome was the infectious complication rate after open and laparoscopic approach; secondary outcomes were preoperative use of imaging and post-operative predictive value of imaging, normal appendix rate and children with a postoperative ileus. RESULTS: A total of 541 children were operated for suspected acute appendicitis in 62 Dutch hospitals. Preoperative imaging was used in 98.9% of children. The normal appendix rate was 3.1%. In 523 children an appendectomy was performed. Laparoscopy was used in 61% of the patients and conversion rate was 1.7%. Complicated appendicitis was diagnosed in 29.4% of children. Overall 30-day complication rate was 11.9% and similar after open and laparoscopic. No difference was found in superficial surgical site infections, nor in intra-abdominal abscesses between the open and laparoscopic approach. Complicated appendicitis is an independent risk factor for infectious complications. CONCLUSION: The laparoscopic approach is most frequently used, except for young children. Superficial surgical site infections are more frequent after open surgery only in patients with complicated appendicitis. The normal appendix rate is low, most likely because of routine preoperative imaging.

Brain endothelial cell expression of SPARCL-1 is specific to chronic multiple sclerosis lesions and is regulated by inflammatory mediators in vitro.

AIMS: Cell matrix modulating protein SPARCL-1 is highly expressed by astrocytes during CNS development and following acute CNS damage. Applying NanoLC-MS/MS to CSF of RRMS and SPMS patients, we identified SPARCL-1 as differentially expressed between these two stages of MS, suggesting a potential as CSF biomarker to differentiate RRMS from SPMS and a role in MS pathogenesis. METHODS: This study examines the potential of SPARCL-1 as CSF biomarker discriminating RRMS from SPMS in three independent cohorts (n = 249), analyses its expression pattern in MS lesions (n = 26), and studies its regulation in cultured human brain microvasculature endothelial cells (BEC) after exposure to MS-relevant inflammatory mediators. RESULTS: SPARCL-1 expression in CSF was significantly higher in SPMS compared to RRMS in a Dutch cohort of 76 patients. This finding was not replicated in 2 additional cohorts of MS patients from Sweden (n = 81) and Switzerland (n = 92). In chronic MS lesions, but not active lesions or NAWM, a vessel expression pattern of SPARCL-1 was observed in addition to the expression by astrocytes. EC were found to express SPARCL-1 in chronic MS lesions, and SPARCL-1 expression was regulated by MS-relevant inflammatory mediators in cultured human BEC. CONCLUSIONS: Conflicting results of SPARCL-1's differential expression in CSF of three independent cohorts of RRMS and SPMS patients precludes its use as biomarker for disease progression. The expression of SPARCL-1 by BEC in chronic MS lesions together with its regulation by inflammatory mediators in vitro suggest a role for SPARCL-1 in MS neuropathology, possibly at the brain vascular level.

Pre-treatment cortisol awakening response predicts symptom reduction in posttraumatic stress disorder after treatment.

Dysfunction of the HPA-axis has frequently been found in the aftermath of trauma exposure with or without PTSD. Decreasing HPA-axis reactivity to different stress cues has been reported during PTSD treatment. The cortisol awakening response (CARi) is a well-validated, standardized measure of HPA-axis reactivity which can be easily acquired in the clinical setting. Whether CARi changes over time in traumatized individuals are specific to PTSD treatment is unknown. Furthermore, a possible role for the baseline CARi in predicting symptom reduction after treatment in PTSD has not been examined before. To answer these questions, a cohort study was conducted in which the awakening cortisol was measured in both PTSD (N=41) and non-PTSD (N=25) combat-exposed male subjects. Measurements took place at inclusion and 6-8 months after inclusion for both the PTSD and the non-PTSD group. During the 6-8 months interval, PTSD patients received trauma-focused focused psychotherapy, whereas non-PTSD patients received no treatment. We found a decrease in the CARi over time in both groups, suggesting it was not specific to PTSD or the effect of treatment. Therefore, caution is warranted when attributing diminished HPA-axis reactivity over time to effects of PTSD treatment. Second, CARi prior to treatment predicted PTSD symptom reduction (CAPS score change) after treatment, and accounted for 10% of the variance, even when adjusted for changes in depressive symptoms and medication use during the study period. A putative role emerges for CARi as a predictive biomarker of symptom reduction in male individuals with combat-related PTSD.

[Mesenteric venous thrombosis during pregnancy; a rare cause of acute ischaemia of the small intestine]. / Veneuze mesenteriale trombose tijdens de zwangerschap.

BACKGROUND: Acute ischaemia of the small intestine is caused by mesenteric venous thrombosis in 5-15% of patients. The non-specific symptoms frequently lead to a diagnostic delay. CASE DESCRIPTION: A 30-year-old pregnant woman presented at the accident and emergency department with progressive abdominal pain, nausea and vomiting. During admission the patient developed signs of peritonitis. Diagnostic laparoscopy revealed a picture of mesenteric venous thrombosis, and we resected 170 cm ischemic small intestine. No underlying cause was identified, apart from the pregnancy. The patient was treated with low-molecular-weight heparin and later gave birth to a healthy child. CONCLUSION: If a patient presents with (unexplained) progressive abdominal symptoms and disproportional abdominal pain without peritonitis, the possibility of intestinal ischaemia should be considered during differential diagnosis.

[Evidence-based clinical guidelines in dental practice 6. Guidelines for clinical practice in dental education]. / Evidencebased klinische praktijkrichtlijnen in de mondzorg 6. Praktijkrichtlijnen in de opleiding tot tandarts.

In response to the initiatives of the Kennisinstituut Mondzorg (Institute for Knowledge Translation in Oral Care), the importance of effective education in the area of guidelines is increasing. Future dentists will, after all, be confronted with new guidelines and need to be able to integrate them in their daily practice. Various guidelines and protocols have been established within the 3 dental schools. For students and instructors, however, the motivation for these guidelines and protocols is not always sufficiently clear. In addition, the terms guideline, clinical practice guideline and protocol are used interchangeably, resulting in terminological confusion. Embedding within and coordination with theoretical education is also still limited in all programmes and it is proposed that the 3 dental schools collaborate on this issue. Finally, it is advised to replace the term 'evidence-based' with 'evidence-informed' because this indicates more clearly that other factors (patients opinion, available financial means, etc.) play a role in the final choice of treatment in a specific situation.

[The well-being of dentists following a complaint procedure]. / Het welbevinden van tandartsen na een klachtenprocedure.

It is known that a patient's complaint can have a serious impact on the well-being of dentists. But little is known on the nature and the extent of this impact. That's why in 2013 an anonymous survey was conducted among 955 dentists and dental specialists, for whom in the period mid-2008 to mid-2013 a complaint was handled through the Complaint Committee of the Royal Dutch Dental Association (KNMT). Altogether, 413 (43%) of them participated in the study. 71% of the respondents reported that the complaint had influenced their professional practice. 52% reported that it had (also) influenced their attitude towards colleagues and patients, and 60% (also) experienced an impact on their mental and/or physical condition. Altogether, 68% reported that they had unpleasant feelings and 75% stated that the treatment relationship with the patient was terminated as a result of the complaint.