Job van der Palen

Medisch Spectrum Twente, Enschede, Overijssel, Netherlands

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Publications (211)704.7 Total impact

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    ABSTRACT: To explore rehabilitation professionals' opinions about the influence and the pathways of injury compensation (IC) on health and disability in patients with whiplash associated disorder (WAD). Semi-structured interviews were performed among a purposeful selected sample of Dutch expert-professionals in the field of rehabilitation of patients with WAD. Inclusion continued until saturation was reached. Inductive and deductive thematic analyses were performed. Ten rehabilitation expert-professionals (five females), working as physician, psychologist or physiotherapist, were interviewed. All expert-professionals acknowledged that IC can influence rehabilitation, health and disability. The expert-professionals provided three causal pathways; a pathway through prolonged distress, a behavioral pathway, and patient characteristics that may either attenuate or worsen their response. They assess the influence of IC mainly with interview techniques. Most professionals discuss the potential influence of IC with their patients, because they want to give clear information to the patient. Some emphasize that their role is neutral in relation with the IC. Others mention that financial consequences can accompany functional improvement. Rehabilitation expert-professionals believe that IC may affect rehabilitation, health and disability in patients with WAD. Three pathways are mentioned by the experts-professionals. Implications for Rehabilitation According to rehabilitation expert-professionals, an injury compensation (IC) can lead to distress, by creating a (conscious or unconscious) conflict of interests within a patient between striving for compensation on one hand, and recovery on the other hand. Patient characteristics can either attenuate or worsen IC-related distress. Reliable and valid tools need to be developed to assess the influence of IC on health, disability and rehabilitation, and to limit the negative effects. Rehabilitation professionals can discuss the possible unintended effects of IC with their patients to clarify their current situation.
    Disability and Rehabilitation 04/2015; DOI:10.3109/09638288.2015.1035455 · 1.84 Impact Factor
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    ABSTRACT: To study differences in adherence to common inhaled medications in COPD. Adherence of 795 patients was recorded from pharmacy records over 3 years in the COMIC cohort. It was expressed as percentage and deemed good at ≥75-≤125%, sub-optimal ≥50-<75%, and poor <50% (underuse) or >125% (overuse). Most patients used more than one medication, so we present 1379 medication periods. The percentages of patients with good therapy adherence ranged from 43.2 (beclomethasone) -75.8% (tiotropium); suboptimal from 2.3 (budesonide) -23.3% (fluticasone); underuse from 4.4 (formoterol/budesonide) -18.2% (beclomethasone); and overuse from 5.1 (salmeterol) -38.6% (budesonide). Patients using fluticasone or salmeterol/fluticasone have a 2.3 and 2.0-fold increased risk of suboptimal versus good adherence compared to tiotropium. Patients using salmeterol/fluticasone or beclomethasone have a 2.3- and 4.6-fold increased risk of underuse versus good adherence compared to tiotropium. Patients using budesonide, salmeterol/fluticasone, formoterol/budesonide, ciclesonide and beclomethasone have an increased risk of overuse versus good adherence compared to tiotropium. Adherence to inhalation medication is inversely related to lung function. Therapy adherence to inhalation medication for the treatment of COPD is in our study related to the medication prescribed. Tiotropium showed the highest percentage of patients with good adherence, followed by ciclesonide, both dosed once daily. The idea of improving adherence by using combined preparations cannot be confirmed in this study. Further research is needed to investigate the possibilities of improving adherence by changing inhalation medication.
    COPD Journal of Chronic Obstructive Pulmonary Disease 03/2015; DOI:10.3109/15412555.2014.995292 · 2.62 Impact Factor
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    ABSTRACT: Acute exacerbations of chronic obstructive pulmonary disease (COPD) are often treated with antibiotics. Theoretically, to be maximally effective, the antibiotic concentration at sites of infection should exceed the minimum inhibitory concentration at which 90% of the growth of potential pathogens is inhibited (MIC90). A previous study showed that most hospitalized COPD patients had sputum amoxicillin concentrations <LMIC90 when treated with amoxicillin/clavulanic acid. Those with adequate sputum concentrations had better clinical outcomes. Low amoxicillin concentrations can be caused by beta-lactamase activity in the lungs. This study investigated whether patients with sputum amoxicillin concentrations <MIC90 had higher beta-lactamase activity in sputum than patients with a concentration ≥MIC90. In total, 23 patients hospitalized for acute exacerbations of COPD and treated with amoxicillin/clavulanic acid were included. Sputum and serum samples were collected at day 3 of treatment to determine beta-lactamase activity in sputum and amoxicillin concentrations in both sputum and serum. We found no difference in beta-lactamase activity between patients with sputum amoxicillin concentrations <MIC90 and ≥MIC90 (P=0.79). Multivariate logistic regression analysis showed no significant relationship between beta-lactamase activity and sputum amoxicillin concentrations <MIC90 or ≥MIC90 (odds ratio 0.53; 95% confidence interval 0.23-1.2; P=0.13). Amoxicillin concentrations were <MIC90 in 78% of sputum samples and in 30% of serum samples. In patients treated with amoxicillin/clavulanic acid for an acute exacerbation of COPD, sputum beta-lactamase activity did not differ between those with sputum amoxicillin concentrations <MIC90 or ≥MIC90. The finding that the majority of patients had sputum amoxicillin concentrations <MIC90 suggests that current treatment with antibiotics for acute exacerbations of COPD should be optimized.
    International Journal of COPD 03/2015; 10:455-461. DOI:10.2147/COPD.S70355 · 2.73 Impact Factor
  • R Visser, J van der Palen, F H C de Jongh, B J Thio
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    ABSTRACT: Pulmonary medication is mostly delivered in the form of medical aerosols to minimize systemic side effects. A major drawback of inhaled medication is that the majority of inhaled particles impacts in the oropharynx at the sharp bend of the airway. Stretching the airway by a forward leaning body posture with the neck extended ("sniffing position") may improve pulmonary deposition and clinical effects. 41 asthmatic children who were planned for standard reversibility testing at the pulmonary function lab, alternately inhaled 200 μgr salbutamol with an Autohaler(®) in the standard or in the forward leaning body posture. Forced Expiratory Volume in 1 s (FEV1), Forced Vital Capacity (FVC), Peak Expiratory Flow (PEF), Mean Expiratory Flow at 25% of vital capacity (MEF25) and Mean Expiratory Flow at 75% of vital capacity (MEF75) were analysed. The children in the forward leaning body posture group showed a significantly higher mean FEV1 reversibility than the control group after inhalation of 200 μgr salbutamol (10.2% versus 4.1%, p = 0.019). Additionally, mean MEF75 was significantly more reversible in the forward leaning body posture group versus the standard body posture group (32.2% resp. 8.9%, p = 0.013). This pilot study showed a higher reversibility of FEV1 and MEF75 after inhaling salbutamol in a forward leaning body posture compared to the standard body posture in asthmatic children. This suggests that pulmonary effects of salbutamol can be improved by inhaling in a forward leaning body posture with the neck extended. This effect is possibly due to a higher pulmonary deposition of salbutamol and should be confirmed in a randomized controlled trial. Copyright © 2015 Elsevier Ltd. All rights reserved.
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    ABSTRACT: The aim of the present study is to look at the mitotic activity index (MAI) as a prognostic factor in a prospective population-based cohort of lymph node-negative invasive breast cancer patients. Analyses were based on 2,048 breast-conserving therapies in 1,971 patients, node-negative, and without any form of adjuvant systemic therapy with long-term follow-up. The 15-year distant metastases-free survival (DMFS) for women ≤55 years was 88.3 % for low MAI values (≤12) versus 73.4 % for high MAI values (>12); (HR 2.8; 95 % CI 1.8–4.4; p 55-years, the MAI was not an independent significant factor. We also confirmed the above findings for disease-specific survival. When multi-gene assays are not available, the MAI remains a robust prognostic marker in women younger than 55 years of age with early node-negative breast cancer.
    Breast Cancer Research and Treatment 12/2014; 149(2). DOI:10.1007/s10549-014-3244-8 · 4.20 Impact Factor
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    ABSTRACT: Cost-effectiveness analyses (CEAs) of behavioral interventions typically use physical outcome criteria. However, any progress in cognitive antecedents of behavior change may be seen as a beneficial outcome of an intervention. The aim of this study is to explore the feasibility and validity of incorporating cognitive parameters of behavior change in CEAs. The CEA from a randomized controlled trial on smoking cessation was reanalyzed. First, relevant cognitive antecedents of behavior change in this dataset were identified. Then, transition probabilities between combined states of smoking and cognitions at 6 weeks and corresponding 6 months smoking status were obtained from the dataset. These rates were extrapolated to the period from 6 to 12 months in a decision analytic model. Simulated results were compared with the 12 months’ observed cost-effectiveness results. Self-efficacy was the strongest time-varying predictor of smoking cessation. Twelve months’ observed CEA results for the multiple tailoring intervention versus usual care showed €3188 had to be paid for each additional quitter versus €10,600 in the simulated model. The simulated CEA showed largely similar but somewhat more conservative results. Using self-efficacy to enhance the estimation of the true behavioral outcome seems a feasible and valid way to estimate future cost-effectiveness.
    Health Economics 12/2014; DOI:10.1002/HEC.3119 · 2.14 Impact Factor
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    ABSTRACT: The aim of this paper is to identify which domains of health-related quality of life (HRQoL) are most important for patients with chronic obstructive pulmonary disease (COPD), from the perspective of healthcare professionals (HCPs).
    Quality of Life Research 11/2014; DOI:10.1007/s11136-014-0860-z · 2.86 Impact Factor
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    ABSTRACT: BACKGROUND: Patient-initiated action plans are an important component of COPD self-management (SM) interventions. When integrated into SM interventions, these action plans have proven to be effective in reducing exacerbation severity, hospitalisations, and costs and in improving health status in patients with COPD without severe comorbidities. Because of overlap in symptoms, a self-treatment (ST) approach that focuses solely on traditional symptoms of COPD is inadequate for patients with COPD and comorbidities. The COPE-III SM intervention combines (I) patient-initiated action plans that are tailored to the individual's co-morbid disease(s), and (II) ongoing nurse support. In this paper we provide information regarding the integration of information from two previous COPD SM studies (COPE I and II) in the development of the current COPE-III ST approach. MATERIALS AND METHODS: COPE-III ST materials include daily symptom diaries and action plans that take patient's common comorbidities [chronic heart failure (CHF), anxiety, depression, ischaemic heart disease (IHD), and diabetes] into account. The comorbid diary and action plans components were developed in collaboration with multiple disease-experts. RESULTS: Previous SM studies have highlighted some essential topics that need to be considered when developing a SM or ST approach: 'when to initiate ST', 'how to optimize materials and safety', and 'how to achieve behavioural change'. In the COPE-III study, ST is initiated after a significant change in symptoms. This is consistent with the COPE-II approach and was implemented because disease symptoms are often present even when patients are stable. We have tried to ensure patient safety by providing an easily accessible case-manager to patients throughout their involvement in the study. Furthermore, a psychologist has ensured the use of behavioural change techniques throughout the intervention. CONCLUSIONS: We should continue to learn from our experiences with SM interventions to further optimize future SM and ST interventions. The use of materials that are suitable for different levels of patient literacy and the training of health care providers are other points of improvement.
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    ABSTRACT: Positional therapy (PT) is an effective therapy in positional obstructive sleep apnea syndrome (POSAS) when used, but the compliance of PT is low. The objective of this study was to investigate whether a new kind of PT is effective and can improve compliance. 29 patients were treated with the Sleep Position Trainer (SPT), 26 patients with the Tennis Ball Technique (TBT). At baseline and 1 month polysomnography, Epworth Sleepiness Scale (ESS) and the Quebec Sleep Questionnaire (QSQ) were taken. Daily compliance was objectively measured in both groups. Both therapies prevent supine sleep position to a median of 0% (min-max: SPT 0.0% to 67%, TBT 0.0% to 38.9%), resulting in a treatment success (AHI <5) in 68.0% of the SPT and 42.9% of the TBT patients. The ESS at baseline was <10 in both groups. Sleep quality parameters as wake after sleep onset (WASO; p = 0.001) and awakenings (p = 0.006) improved more in the SPT group. Total QSQ scores (0.4±0.2, p = 0.03) and the QSQ domains nocturnal symptoms (0.7±0.2, p = 0.01) and social interactions (0.8±0.3, p = 0.02) changed in favor of the SPT group. Effective compliance (≥4 h/night + ≥5 days/week) was 75.9% for the SPT and 42.3% for the TBT users (p = 0.01). In mild POSAS with normal EES the new SPT device and the standard TBT are equally effective in reducing respiratory indices. However, compared to the TBT, sleep quality, quality of life, and compliance improved significantly more in the SPT group. © 2014 American Academy of Sleep Medicine.
    Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 11/2014; · 2.83 Impact Factor
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    ABSTRACT: Daily use of inhaled corticosteroids (ICS) reduces exercise induced bronchoconstriction (EIB) in asthmatic children. A high single dose of ICS also provided acute protection against EIB. Objective of this study is to investigate whether a low single dose of ICS offers protection against EIB in asthmatic children. 31 Mild asthmatic children not currently treated with inhaled corticosteroids, 5-16 years, with EIB (fall in FEV0.5/1 ≥ 13%) were included in a prospective intervention study. They performed two ECT's within 2 weeks. Four hours before the second test children inhaled 200 μg beclomethasone-dipropionate (BDP) with a breath-actuated inhaler (BAI). The median fall in FEV0.5/1 after 200 μg BDP was significantly reduced from 30.9% at baseline to 16.0% (P < 0.001). Twenty children (64.5%) showed a good response to 200 μg BDP (≥50% decrease in fall of FEV0.5/1 ), while 8 children showed a moderate response (25-50%), and three children showed no response at all (< 25%). A low single dose ICS offers acute protection against EIB in the majority of asthmatic children not currently treated with inhaled corticosteroids. Pediatr Pulmonol. © 2014 Wiley Periodicals, Inc. © 2014 Wiley Periodicals, Inc.
    Pediatric Pulmonology 11/2014; DOI:10.1002/ppul.23144 · 2.30 Impact Factor
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    ABSTRACT: The Eating Disorder Questionnaire-Online (EDQ-O) is an online self-report questionnaire, which was developed specifically to provide a DSM-IV-TR classification of anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), and eating disorder not otherwise specified (EDNOS), without using a face-to-face clinical interview. The purpose of the present study was to examine the psychometric quality of the EDQ-O. The validity of the EDQ-O was determined by examining the agreement with the diagnoses obtained from the Longitudinal, Expert, and All DATA (LEAD) standard. Participants included 134 new patients of a specialist center for eating disorders located in the Netherlands. Assessment of the validity of the EDQ-O yielded acceptable to good AUC (area under the receiver operating characteristic curve) values with a range from 0.72 to 0.83. Most other diagnostic efficiency statistics were also good except for a low sensitivity for AN (0.44), a low positive predictive value for BN (0.50), and a relatively low sensitivity for BED (0.66). The results of the present study suggest that the EDQ-O performs acceptably as a diagnostic instrument for all DSM-IV-TR eating disorder classifications. However, suggestions are made to further improve the validity of the EDQ-O. Copyright © 2014 Elsevier Inc. All rights reserved.
    Comprehensive Psychiatry 10/2014; 57. DOI:10.1016/j.comppsych.2014.10.019 · 2.26 Impact Factor
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    ABSTRACT: Aims: Drug-eluting stents (DES) were first used on-label - in simple patients with low clinical risk and easily accessible lesions. Currently, DES are increasingly used off-label - in complex patients undergoing percutaneous coronary interventions (PCI) with historically higher event risk. Therefore, our aim was to investigate whether patients with off-label indications for DES use had similar outcomes compared to patients who were treated for on-label indications only. We analysed two-year follow-up data of 1,387 TWENTE trial patients, treated with second-generation everolimus-eluting XIENCE V or zotarolimus-eluting Resolute stents, and compared off-label vs. on-label DES use with regard to the following clinical endpoints: cardiac death, myocardial infarction (MI), periprocedural MI (≤48 hrs), and target vessel revascularisation (TVR). Patients with off-label DES use (n=1,033; 74.5%) had more diabetes (22.9% vs. 17.5%; p=0.032), previous MI (35.9% vs. 22.3%; p<0.001), type B2/C lesions (84.7% vs. 62.7%; p<0.001), and acute coronary syndromes (57.8% vs. 33.3%; p<0.001). Nevertheless, cardiac death and TVR rates were similar to those of patients with on-label DES use (p>0.8). Following off-label DES use, there was a higher incidence of PMI (5.0% vs. 1.4%; p=0.003), of which only 1.1% reached creatine kinase levels >5x the upper limit of normal (ULN). Despite differences in risk profile, patients with off-label DES use did not differ from patients with on-label DES use in clinical endpoints other than periprocedural MI. These largely positive findings underline the favourable safety profile of second-generation DES.
    EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 10/2014; 10(6):664-671. DOI:10.4244/EIJV10I6A117 · 3.76 Impact Factor
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    International Society of Quality of Life Research 21st annual conference, Berlin; 10/2014
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    ABSTRACT: Introduction It is still unknown how best to maintain effects of exercise programmes in COPD in the long-term. We present the long-term effects of a community-based exercise programme incorporated in a self-management programme, compared to a self-management programme only in patients with COPD. Methods All included patients participated in four self-management sessions. Additionally, patients in the intervention group participated in an 11-month community-based exercise programme led by physiotherapists. Patients trained three times/week for five months and two times/week during the subsequent six months. To encourage a behavioural change towards exercise, one of these weekly training sessions was home-based (unsupervised). No formal training was offered to intervention patients in the second year. Results The intervention was assigned to 80 patients, and the control condition to 79 patients. 82.5% and 78.5% of the intervention and control group, respectively, completed 24 months follow-up. Modified intention-to-treat analyses were performed. Although statistically significant after 12 months (35.1 meters (95%CI: 8.4 to 61.8)), the between-group difference on maximal exercise capacity was not statistically significant after 24 months (12.2 meters (95%CI: -16.6 to 41.0). Nevertheless, the between-group difference in daily physical activity was maintained after 24 months (1193 steps/day (95%CI: 203 to 2182)). A beneficial effect was also found on CRQ dyspnoea score but not on other CRQ domains, CCQ and HADS. Conclusions Our intervention was effective in achieving a behavioural change reflected by a sustained increase in daily physical activity, not accompanied by a sustained increase in maximal exercise capacity after two years of follow-up (ISRCTN81447311).
    Respiratory Medicine 10/2014; 108(10). DOI:10.1016/j.rmed.2014.07.016 · 2.92 Impact Factor
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    ABSTRACT: Purpose: To analyze the incidence and prognostic factors of ipsilateral breast tumor recurrence (IBTR) after breast-conserving therapy (BCT) in a large, population-based, single-center study with long-term follow-up. Methods and Materials: We analyzed 3595 cases in which BCT was performed in 3824 women with stage I or II breast cancer. The incidence of IBTR was analyzed over time and was based on IBTR as first event. Results: The 15-year local relapse-free survival was 90.9%. The hazard estimates for IBTR showed a time course with 2 peaks, the first at approximately 5 years and the second, twice as high, at 12 years. Stratifying subjects by age and margin status showed that, for women <= 40 years old with negative margins, adjuvant systemic therapy led to a 5-fold reduced risk of recurrence compared to none, and the presence of lymph vascular space invasion (LVSI) had a 3-fold increased risk compared to its absence. For women >40 years old, the presence of LVSI (hazard ratio [HR] 2.5) and the presence of lobular carcinoma in situ in the lumpectomy specimen (HR 2.3) were the only 2 risk factors. Conclusions: We demonstrated a pattern in risk of IBTR over time, with 2 peaks, first at approximately 5 years and a second, much higher peak at approximately 12 years, especially for women <= 40 years old. For women <= 40 years old with tumor-free resection margins, we noted that the absence of adjuvant systemic therapy and the presence of LVSI were independent prognostic factors of IBTR. For women >40 years old, the presence of LVSI and the presence of lobular carcinoma in situ were independent risk factors. (C) 2014 Elsevier Inc.
    International journal of radiation oncology, biology, physics 08/2014; 89(5):1006-14. DOI:10.1016/j.ijrobp.2014.04.039 · 4.18 Impact Factor
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    Article: Response.
    Chest 08/2014; 146(2):e65-6. DOI:10.1378/chest.14-0788 · 7.13 Impact Factor
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    ABSTRACT: Severe childhood obesity has become a major health problem, and effective, evidence-based interventions are needed. The relative effectiveness of inpatient compared with ambulatory treatment remains unknown.
    JAMA Pediatrics 07/2014; 168(9). DOI:10.1001/jamapediatrics.2014.521 · 4.25 Impact Factor
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    ABSTRACT: Background Numerous instruments are available to measure HRQoL in patients with COPD, covering a wide array of domains ranging from symptoms such as dyspnea, cough and wheezing, to social and emotional functioning. Currently no information or guide is available yet to aid the selection of domains for a particular study or disease population. The aim of this paper is to identify which domains of health-related quality of life (HRQoL) are most important with respect to Chronic Obstructive Pulmonary Disease (COPD), from the patient perspective.Methods Twenty-one Dutch patients with Chronic Obstructive Pulmonary Disease (COPD) were asked to describe important domains impacted by COPD freely; second, they were presented with cues (domains from the Patient-Reported Outcomes Measurement Information System (PROMIS) framework) and were asked to select the domains that were most relevant to them. During the interview, the patients were asked to indicate in which way the selected domains impact their lives. Both the answers to the open question, and the patient statements motivating nomination of PROMIS domains were coded into themes.ResultsThe most relevant (sub)domains of HRQoL for patients with COPD were: physical health (fatigue, physical functioning), social health (instrumental support, ability to participate in social roles and activities, companionship, and emotional support), and coping with COPD.Conclusion We identified which domains of HRQoL are most important to patients with COPD. One of these (coping with COPD) is not explicitly covered by PROMIS, or by traditional questionnaires that are used to measure HRQoL in COPD.
    Health and Quality of Life Outcomes 07/2014; 12(1):106. DOI:10.1186/s12955-014-0106-3 · 2.10 Impact Factor
  • Job van der Palen
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    ABSTRACT: Inhaled corticosteroids and bronchodilators, which are pivotal to the management of respiratory diseases, are delivered by numerous devices, including pressurized metered-dose inhalers and dry-powder inhalers. However, patient adherence to these medications is suboptimal and incorrect inhaler technique is endemic, meaning that insufficient drug quantities are frequently delivered to the lungs. Genuair(®) (Almirall SA, Spain) is a novel, breath-actuated, multidose dry-powder inhaler designed to achieve reliable and effective delivery of inhaled medicines - including aclidinium bromide - to patients with chronic obstructive pulmonary disease. In addition to describing Genuair's design, which incorporates multiple feedback mechanisms in order to confirm effective medication uptake, this article discusses the performance characteristics of the inhaler, its efficiency in terms of drug deposition and the results of recent patient preference and satisfaction studies.
    Therapeutic delivery 07/2014; 5(7):795-806. DOI:10.4155/tde.14.49
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    ABSTRACT: In patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation followed by rectal resection, postoperative morbidity is a significant clinical problem. Pathologic complete tumour response seems to give the best prognosis in the long term. Little is known about the factors that are associated with postoperative complications and pathologic complete response. The aim of this retrospective study was to identify and describe these factors. Ninety-nine consecutive patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation (50 Gy and capecitabine) followed by surgery at our institute between January 2007 and May 2012 were identified. Postoperative complications were graded according to the Clavien-Dindo classification. Pathologic tumour response was categorized as complete response or no/partial response. Postoperative complications occurred in 68 patients (69 %) and grade 3-5 complications in 25 patients (25 %). The 30-day and 90-day mortality were 1 % (n = 1) and 2 % (n = 2), respectively. A young age (p = 0.021) and a preoperative or postoperative blood transfusion (p = 0.015) independently predicted complications. Intraoperative or postoperative blood transfusion (p = 0.007) and ypT0-1 stage (p = 0.037) were independent predictors for grade 3-5 complications. Complete response rate was 22 % (n = 22); 4 % (n = 4) of patients showed no response. No independent factors predicting complete response were found. Neoadjuvant chemoradiation followed by rectal resection is associated with significant postoperative morbidity but minimal postoperative mortality. A complete response rate of 22 % was achieved.
    Journal of Gastrointestinal Surgery 06/2014; 18(9). DOI:10.1007/s11605-014-2559-4 · 2.39 Impact Factor

Publication Stats

3k Citations
704.70 Total Impact Points

Institutions

  • 1994–2015
    • Medisch Spectrum Twente
      • • Medical School Twente
      • • Rradiology Department
      • • Cardiothoracic Surgery
      • • Hospital Medical Spectrum Twente
      • • Cardiology Department
      • • Pulmonary Medicine
      • • Radiotherapy Department
      Enschede, Overijssel, Netherlands
  • 2001–2014
    • Universiteit Twente
      • • Department of Research Methodology, Measurement and Data Analysis (OMD)
      • • Faculty of Behavioral Sciences (BS)
      Enschede, Overijssel, Netherlands
  • 2013
    • Poliklinika Glavić
      Ragusa, Dubrovačko-Neretvanska, Croatia
  • 2012
    • Tactus Addiction Institute
      Deventer, Overijssel, Netherlands
  • 2005
    • University of Washington Seattle
      • Cardiovascular Health Research Unit (CHRU)
      Seattle, WA, United States