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Acute Effects on TH4 Thoracic Spine Mobilisation Techniques on the Sympathetic Nervous System - a Cross-Over Feasibility Study Abstract. Up to date, empiric evidence about effects of thoracic spine mobilisation (TH4) on the sympathetic nervous system is lacking. The primary goal of this feasibility study was to determine adherence rate, side effects and the protocol as well as the implementation of the study design. The secondary goal was to analyse and interpret acute effects on the sympathetic nervous system after thoracic mobilisation in anterior thrust and posterior thrust on six healthy participants on two following days. The feasibility of this study was adequate. The spine mobilisations did not produce any adverse effects. The anterior thrust spine mobilisations showed a tendency in reducing the heart rate activity.

It is well known that the use of tranylcypromine in combination with amphetamines may induce a potentially lethal hypertensive crisis. That such a complication may also occur when tranylcypromine is combined with khat, however, is less known. We describe the case of a young patient who received a low dose of tranylcypromine combined with a small amount of khat, subsequently developing a subarachnoid hemorrhage.

Veranderingen in het bot rond permucosale implantaten kunnen worden veroorzaakt door biomechanische factoren. Computer­modellen worden gebruikt om plaats en hoogte van spanningen in het bot te berekenen. Bouw van modellen en berekening vindt plaats met behulp van de eindige-elementenmethode. Verdere ontwikkeling van software en hardware maakte het 25 jaar geleden mogelijk om complexere driedimensionale modellen te bouwen. Algemeen doel van het proefschrift uit 1992 was de ontwikkeling van een state-of-the-art computermodel van een edentate onderkaak met tandheelkundige implantaten en vervolgens de invloed van een aantal parameters te berekenen op plaats en hoogte van spanning in het bot. In het oog springende resultaten waren dat er weinig verschil is tussen 2 en 4 implantaten in het interforaminale gebied en dat de lengte van implantaten een verwaarloosbaar effect heeft op de hoogte van de spanning. Klinisch onderzoek heeft na die tijd aangetoond dat deze resultaten overeenkwamen met de ­werkelijkheid., Changes in the bone around permucosal endosseous implants can be caused by biomechanical factors. Computer models are used to calculate the location and magnitude of stresses in the bone. The finite element method is used for the construction and calculation of models. The ongoing development of software and hardware 25 years ago made it possible to construct more complex 3-dimensional models. The general aim of the dissertation was to develop a state-of-the-art computer model of an edentulous mandible with dental implants and then to calculate the influence of a number of parameters on the location and magnitude of stresses in the bone. Conspicuous results were that there is hardly any difference between 2 and 4 implants in the interforaminal region and that the length of implants has a negligible effect on the magnitude of stresses. Clinical studies have subsequently demonstrated that these results are in line with reality.

BACKGROUND: Psychiatry is currently challenged by two main issues, subjectivity and non-exclusivity. AIM: The re-appraisal of phenomenological psychiatry. METHOD: Personal reflection. RESULTS: Phenomenology may contribute to psychiatry by 1. offering a method, 2. focusing on descriptive observation, and 3. taking a neutral stance. CONCLUSION: By emphasizing the subjective experience, phenomenology offers psychiatry an opportunity to become proficient and to distinguish itself from other disciplines through the continued development of insight and understanding of mental disorders.

In the coming decades the western world will experience a double ageing of its population; there will be an increase in both the number of older people and the average age. The increase in life expectancy will also mean more and more older people who suffer from multiple systemic diseases that are treated with medications. At this moment, 45% of those over 65 use 5 or more medications and 20% of those over 75 use as many as 10 or more. The more medications used, the greater the risk of side effects and therefore oral side effects, like symptoms of dry mouth or the development of candidiasis, angioedema, gingival hyperplasia, lichenoid reaction of the oral mucosa, dysgeusia, halitosis and osteonecrosis. Considering the wide range of oral side effects, it is important for dentists to be well aware of the medications being used by older patients as well as having a thorough knowledge of their oral side effects.

The Dental Satisfaction Questionnaire (DSQ) is a questionnaire consisting of 31 items assessing patient satisfaction with dental attendance. By means of factor analysis (principal component analysis), the number of items of the DSQ was reduced to 13, which together constitute the DSQ-13-youth. The first objective was to investigate the psychometric properties of the DSQ-13-youth; the second was to compare the satisfaction scores on the various dimensions between and within subgroups (23-year-olds, 17-year-olds and parents of 5-year-olds). The DSQ-13-youth has 4 domains measuring patient satisfaction with dental attendance. The internal consistency of those domains was high; the correlation between the domains low to moderate and the factor structure was highly congruent in the various subgroups. The differences in satisfaction scores between and within subgroups were small. The DSQ-13-youth is a reliable instrument to assess patient satisfaction with dental attendance among adolescents, young adults and the parents of young children in urban areas.

BACKGROUND: Brain stimulation is the most direct form of neuromodulation. Direct brain stimulation is an older procedure that has taken various forms, but 'non-invasive brain stimulation' is a more recent development.AIM: To provide an overview of the current arsenal of non-invasive brain stimulation techniques.METHOD: We discuss the underlying principles, the pros and cons, and the applicability of non-invasive brain stimulation in experimental research and treatment of neuropsychiatric disorders.RESULTS: Non-invasive brain stimulation is a direct form of neuromodulation, which is not invasive, harmful or painful. Its effects are in principle temporary, which makes the technique suitable for experimental research. At the same time, temporary effects can have lasting clinical consequences, if they target neuroplasticity to aid rehabilitation or alleviate symptoms.CONCLUSION: Whereas the value of non-invasive brain stimulation for research purposes is undisputed, its efficacy and value as a treatment for neuropsychiatric disorders are still being debated. Nevertheless, the accumulated evidence about the clinical efficacy of the treatment for certain disorders is sufficiently compelling to start thinking about European regulations and standard medical insurance coverage.

Dental erosion occurs often among adolescents and young adults in the Netherlands. This problem requires attention because its consequences are irreversible. In this study (part of the 'Dental Research and Practice in the North Netherlands' project) a questionnaire was distributed to 331 young adults (age 20 to 25) from 25 dental practices. The goal of the study was to find out how much young adults know about dental erosion and how they wish to receive dental information. The results show that much is still unknown about dental erosion among young adults and that the extent of knowledge depended of the level of education and on information on dental erosion that had already been received. Participants preferred to receive information in a conversation with an oral healthcare professional, with the support of printed matter.

In this study, a comparison was made between disease-specific (oral health-related) quality of life (OHQoL), measured with the OHIP-14 questionnaire, and generic (general health-related) quality of life (GHQoL), measured with the EQ5D-5L questionnaire, in patients with and without extreme dental treatment anxiety. A total of 76 patients who could not be treated due to extreme dental treatment anxiety were referred to a centre for special dentistry. These patients were matched, according to age, gender and socioeconomic status, with participants in an epidemiological study on oral health (n = 1125). Wilcoxon signed-rank tests were used on both groups to compare GHQoL and OHQoL. The total OHIP score was higher (representing a lower quality of life) in the patient group than in the control group. Anxiety patients scored higher on all 7 domains of the OHIP-14. With respect to general quality of life, patients with extreme treatment anxiety were found to report lower utility scores than the matched control group. With these results, a total disease burden of 74,000 disability-adjusted life years (DALYs) was calculated for extreme treatment anxiety in the Netherlands. The findings of this study reveal that having extreme dental treatment anxiety results in a significant disease burden in the Netherlands.

Huntington's disease (hd) is characterised by a triad of neuropsychiatric symptoms, motor disturbances and cognitive decline. If initial symptoms are of neuropsychiatric nature they maybe misinterpreted, which can lead to delayed diagnosis. Three examples of delayed hd diagnosis in a psychiatric setting are discussed.

Polypharmacy is the consequence of multimorbidity. Both phenomena may cause functional limitations and/or frailty and/or care dependency in older people. In the human body, a medicament undergoes at least 3 important actions: absorption, distribution and elimination. These actions may proceed aberrantly in older people. Following interaction with receptors, a medicament triggers a chain reaction in the human body. The receptors and each link of the chain reaction may be subject to changes due to diseases as well as ageing. This, particularly, is the case with regard to medications directed towards the central nervous system and the cardiovascular system. Furthermore, interactions may occur between various medications mutually and between medications on the one hand and on the other hand food and water intake, self-medication with herbs, and diseases. Moreover, older people usually experience more adverse effects of medications when compared to younger people. This is due to altered body actions and reactions, polypharmacy and the many possible interactions. In older people, utilisation and intake of medications often give rise to problems that can be divided into medicament-related, patient-related, care- and care provider-related and other problems.

Dental treatment anxiety is a common fear among children. The dental health care provider is faced with difficult dilemmas about ensuring good oral health for these children in general daily practice. The indicated treatment usually exceeds the capacity of the frightened child, but when treatment is not performed, the child is at risk of serious general health problems and its quality of life could diminish. This article provides an overview of the aetiology of dental treatment anxiety in children. In addition, the dental practitioner is provided with insight into the possibilities that allow him/her to enhance the treatability of the child and reduce anxiety to such an extent that the indicated dental care can be provided. Psychotherapy and cognitive-behavioural techniques, as well as pharmacological therapies, are currently considered the most acceptable and successful treatments for anxiety and phobia. The dental care provider will have to determine a well-motivated and carefully considered course of treatment, always keeping in mind the individual context of the child.

Assessing the quality of the medical learning environment is an important part of the quality cycle of postgraduate medical education programmes. The quality of the medical learning environment is primarily assessed by systematically documenting the experiences of doctors-in-Training (residents). For this purpose, several questionnaires have been developed, two of which have been specifically developed for use in the Dutch clinical learning environment. D-RECT is a commonly-used, 50-item questionnaire (11 subscales), developed from qualitative research on the optimal learning environment for ObGyn residents. SPEED ('Training Thermometer') is a recently developed 15-item, 3-domain (i.e., content, atmosphere and organisation of training) instrument, based on a generic theoretical framework of human interaction. Both D-RECT and SPEED are validated instruments to be used to reliably assess the clinical learning environment for Dutch residents in postgraduate medical education programmes.

Physicians encounter patients who use antithrombotics in virtually every area of medical specialisation. As antithrombotic use is often chronic, it is important for medication monitoring that physicians have sufficient knowledge of the latest developments, even if they do not prescribe antithrombotics themselves. The risk of thrombosis must be weighed against the risk of bleeding in every patient who is eligible to be treated with antithrombotics. In this article we describe the main indications for treatment with antithrombotics based on articles published within the past five years.

More and more elderly patients are being admitted to the hospital. These elderly patients represent a significant proportion of intensive care unit (ICU) admissions. Older ICU patients have a high risk of death during their ICU admission and, if they do survive, a high risk of physical and cognitive decline. In addition, their remaining life expectancy is often limited. In short, elderly patients have less to gain from ICU treatment than young patients. It is therefore important to carefully consider the proportionality of ICU treatment. In this clinical lesson, we discuss aspects of the elderly ICU patient that should be taken into account when considering ICU treatment, in acute situations as well as in outpatient or GP settings.

More and more elderly patients are being admitted to the hospital. These elderly patients represent a significant proportion of intensive care unit (ICU) admissions. Older ICU patients have a high risk of death during their ICU admission and, if they do survive, a high risk of physical and cognitive decline. In addition, their remaining life expectancy is often limited. In short, elderly patients have less to gain from ICU treatment than young patients. It is therefore important to carefully consider the proportionality of ICU treatment. In this clinical lesson, we discuss aspects of the elderly ICU patient that should be taken into account when considering ICU treatment, in acute situations as well as in outpatient or GP settings.

American guideline for geriatric oncology; applicable to Dutch clinical practice? The American Society of Clinical Oncology (ASCO) has recently issued a guideline for geriatric oncology that provides guidance regarding the practical assessment and management of vulnerabilities in older patients undergoing chemotherapy. The recommendations are discussed and a practical framework for implementation in Dutch oncology practice is described.

American guideline for geriatric oncology; applicable to Dutch clinical practice? The American Society of Clinical Oncology (ASCO) has recently issued a guideline for geriatric oncology that provides guidance regarding the practical assessment and management of vulnerabilities in older patients undergoing chemotherapy. The recommendations are discussed and a practical framework for implementation in Dutch oncology practice is described.

In the Netherlands, child abuse is a national problem and often not recognized in medical settings. As a consequence, it has become mandatory to use a screening instrument for child abuse at emergency departments and out-of-hours primary care services. Since the revised Reporting Code has come into force, there is renewed interest for a national approach on screening for child abuse. The question is how valid existing screening instruments are and how they help the medical professional to suspect child abuse. In this article, we elaborate on the value of available screening instruments and their consequences for daily practice. Because of the limited validity of available screening instruments, we recommend replacing them with a simple reminder to increase awareness of child abuse. A nationwide approach to child abuse in the medical setting should be implemented, with mandatory training on child abuse as its cornerstone.

In the Netherlands, child abuse is a national problem and often not recognized in medical settings. As a consequence, it has become mandatory to use a screening instrument for child abuse at emergency departments and out-of-hours primary care services. Since the revised Reporting Code has come into force, there is renewed interest for a national approach on screening for child abuse. The question is how valid existing screening instruments are and how they help the medical professional to suspect child abuse. In this article, we elaborate on the value of available screening instruments and their consequences for daily practice. Because of the limited validity of available screening instruments, we recommend replacing them with a simple reminder to increase awareness of child abuse. A nationwide approach to child abuse in the medical setting should be implemented, with mandatory training on child abuse as its cornerstone.

BACKGROUND: Syphilis (lues) is a sexually transmitted infection caused by the spirochete Treponema pallidum. In adolescents, the diagnosis of primary syphilis can be made promptly by taking a sexual medical history and inspecting the glans penis. CASE DESCRIPTION: A 17-year-old male was referred to the paediatric oncology centre for additional diagnostics due to inguinal lymphadenopathy, with a strong suspicion of a malignant lymphoma. None of the physicians took a sexual medical history or investigated the glans penis, as a result of which essential information was lacking. The combination of inguinal lymphadenopathy and the ultrasound findings for the inguinal region made the physicians only consider a malignancy. However, it actually concerned a reactive lymphadenopathy associated with primary syphilis. CONCLUSION: This case demonstrates that a full medical history and thorough physical examination can prevent the need for costly and invasive diagnostics.

BACKGROUND: Syphilis (lues) is a sexually transmitted infection caused by the spirochete Treponema pallidum. In adolescents, the diagnosis of primary syphilis can be made promptly by taking a sexual medical history and inspecting the glans penis. CASE DESCRIPTION: A 17-year-old male was referred to the paediatric oncology centre for additional diagnostics due to inguinal lymphadenopathy, with a strong suspicion of a malignant lymphoma. None of the physicians took a sexual medical history or investigated the glans penis, as a result of which essential information was lacking. The combination of inguinal lymphadenopathy and the ultrasound findings for the inguinal region made the physicians only consider a malignancy. However, it actually concerned a reactive lymphadenopathy associated with primary syphilis. CONCLUSION: This case demonstrates that a full medical history and thorough physical examination can prevent the need for costly and invasive diagnostics.

Early diagnosis of spinal metastases is essential. The neurological condition at the time of diagnosis determines functional outcome. Optimal treatment planning requires a multidisciplinary approach by the general practitioner, internist/oncologist/haematologist, radiotherapist, radiologist, neurologist and the spinal surgeon. Radiation therapy is the most common treatment for patients with spinal metastases. However, in specific cases, surgery or chemotherapy should be the primary treatment. We present three patients with spinal metastases: a 55-year-old woman with back pain and a history of breast cancer, a 71-year-old woman with instability of the spine requiring surgical stabilisation and a 68-year-old man with spinal localisation of multiple myeloma treated with systemic therapy. Their cases illustrate the early symptoms of spinal metastases, the role of spinal stability in treatment decisions and the role of systemic therapy in patients with spinal metastases or haematological tumours located in the spine. Recognising early symptoms and appropriate multidisciplinary treatment planning are essential in improving the functional outcome in patients with spinal metastases.

Early diagnosis of spinal metastases is essential. The neurological condition at the time of diagnosis determines functional outcome. Optimal treatment planning requires a multidisciplinary approach by the general practitioner, internist/oncologist/haematologist, radiotherapist, radiologist, neurologist and the spinal surgeon. Radiation therapy is the most common treatment for patients with spinal metastases. However, in specific cases, surgery or chemotherapy should be the primary treatment. We present three patients with spinal metastases: a 55-year-old woman with back pain and a history of breast cancer, a 71-year-old woman with instability of the spine requiring surgical stabilisation and a 68-year-old man with spinal localisation of multiple myeloma treated with systemic therapy. Their cases illustrate the early symptoms of spinal metastases, the role of spinal stability in treatment decisions and the role of systemic therapy in patients with spinal metastases or haematological tumours located in the spine. Recognising early symptoms and appropriate multidisciplinary treatment planning are essential in improving the functional outcome in patients with spinal metastases.

5 years ago, we described the emergence of 3D printing in medicine. It was about 3D printing of anatomical structures, patient-specific drilling guides, cutting templates and implants and printing of living cells, growth factors and biomaterials ('bioprinting'). Surgeons are increasingly making use of 3D printing possibilities in preparation of surgeries on patients with complicated anatomies. Using tangible 3D models, it is easier for surgeons to prepare for surgeries and discussions with patients. They can also use 3D models as a tool to help with the training of young surgeons. Permanent titanium implants are increasingly being printed. Bioprinting is still in its infancy and there are no direct clinical applications yet. As we already predicted 5 years ago, many hurdles still have to be taken before broad clinical application of bioprinted products will become a reality.

Since an increasing number of cancer patients is surviving for a long time, there is also more attention for prevention of late undesirable effects of treatments, for example, by applying treatment de-escalation strategies. Unfortunately, it is often not possible to investigate de-escalation strategies in randomised studies. As long as there is no hard evidence for the effectiveness of de-escalation strategies, physicians have a joint responsibility: (a) to apply shared decision making when choosing the best suited treatment; (b) to prospectively collect and evaluate data on hard and soft outcome measures; and (c) to use research results for improving the information needed for shared decision making. Most patients with cancer have explicit choices to make nowadays. In order to make it possible to conduct successful randomised studies into de-escalation strategies in the future, a number of barriers will need to be removed. In addition, practitioners should organise care in ways that make it possible to learn from every patient, in order to develop a stronger basis for decision-making for patients and physicians in the future.

Since an increasing number of cancer patients is surviving for a long time, there is also more attention for prevention of late undesirable effects of treatments, for example, by applying treatment de-escalation strategies. Unfortunately, it is often not possible to investigate de-escalation strategies in randomised studies. As long as there is no hard evidence for the effectiveness of de-escalation strategies, physicians have a joint responsibility: (a) to apply shared decision making when choosing the best suited treatment; (b) to prospectively collect and evaluate data on hard and soft outcome measures; and (c) to use research results for improving the information needed for shared decision making. Most patients with cancer have explicit choices to make nowadays. In order to make it possible to conduct successful randomised studies into de-escalation strategies in the future, a number of barriers will need to be removed. In addition, practitioners should organise care in ways that make it possible to learn from every patient, in order to develop a stronger basis for decision-making for patients and physicians in the future.

5 years ago, we described the emergence of 3D printing in medicine. It was about 3D printing of anatomical structures, patient-specific drilling guides, cutting templates and implants and printing of living cells, growth factors and biomaterials ('bioprinting'). Surgeons are increasingly making use of 3D printing possibilities in preparation of surgeries on patients with complicated anatomies. Using tangible 3D models, it is easier for surgeons to prepare for surgeries and discussions with patients. They can also use 3D models as a tool to help with the training of young surgeons. Permanent titanium implants are increasingly being printed. Bioprinting is still in its infancy and there are no direct clinical applications yet. As we already predicted 5 years ago, many hurdles still have to be taken before broad clinical application of bioprinted products will become a reality.

The Dutch guideline for the preventions of infections in persons with (functional) hypo- or asplenie has been revised, recommending adjustments for the use of vaccinations and antibiotics. The spleen has an important function in the defence against infections. Around 1,000 splenectomies are performed in the Netherlands every year. Three different groups of patients are distinguished: (a) persons with a partially or completely removed spleen after surgery or embolization; (b) persons with congenital asplenia; and (c) a heterogeneous group of patients, who may have functional hyposplenie or asplenia due to an underlying condition or specific treatments. Patients with asplenia have an increased risk of severe infections by encapsulated bacteria, including in particular Streptococcus pneumoniae, but also Haemophilus influenzae type b and Neisseria meningitides may lead to an increased risk S.pneumoniae causes up to 90% of the infections, which makes it the most important infectious agent in patients with asplenia. A number of preventive measures are recommended to prevent infections in patients with hypo- or asplenie, including the use of vaccinations and antibiotics and patient counselling.

Direct oral anticoagulants (DOACs) are increasingly being prescribed for stroke prevention in patients with atrial fibrillation or for treating venous thromboembolism. In this short overview, we provide some guidance on possible differences between available DOACs as well as a comparison with traditional treatments using vitamin K antagonists. In the absence of head-to-head trials comparing different DOACs with each other, this is predominantly based on indirect meta-analysis and observational evidence. Thus, this should be interpreted with caution and considered as expert consensus.

Transoral endoscopic thyroidectomy using a vestibular approach (TOETVA) is the first thyroid surgery that leaves no permanent visible external scar. 3 scopes are placed via the mouth, passing the front of the teeth. The thyroid is then reached and removed by passing over the chin. Only patients with a thyroid nodule of up to 3 cm in diameter are eligible for TOETVA. The most important advantage of this new technique, in comparison with conventional thyroid surgery, is the prevention of a potentially disfiguring scar in the neck. A proctoring programme will be put in place to make it possible to implement this new technique all over the country.

Five years ago, robot-assisted transaxillary thyroidectomy (RATT) was introduced in the Netherlands. The major advantage of this technique, when compared to the conventional approach, is the prevention of a potentially disfiguring scar in the neck. In recent years, multiple large cohort studies have demonstrated that the quality of the resection, postoperative complications and functional and oncological outcomes are similar in patients treated with RATT when compared to the open procedure. However, no randomised controlled trials have been performed to confirm these findings. The Utrecht UMC is currently the only centre in the Netherlands that performs RATT. The most important reason for this is that this surgical technique can only be used in high-turnover thyroid centres that also have experience with robot-assisted surgery.

Five years ago, robot-assisted transaxillary thyroidectomy (RATT) was introduced in the Netherlands. The major advantage of this technique, when compared to the conventional approach, is the prevention of a potentially disfiguring scar in the neck. In recent years, multiple large cohort studies have demonstrated that the quality of the resection, postoperative complications and functional and oncological outcomes are similar in patients treated with RATT when compared to the open procedure. However, no randomised controlled trials have been performed to confirm these findings. The Utrecht UMC is currently the only centre in the Netherlands that performs RATT. The most important reason for this is that this surgical technique can only be used in high-turnover thyroid centres that also have experience with robot-assisted surgery.

Transoral endoscopic thyroidectomy using a vestibular approach (TOETVA) is the first thyroid surgery that leaves no permanent visible external scar. 3 scopes are placed via the mouth, passing the front of the teeth. The thyroid is then reached and removed by passing over the chin. Only patients with a thyroid nodule of up to 3 cm in diameter are eligible for TOETVA. The most important advantage of this new technique, in comparison with conventional thyroid surgery, is the prevention of a potentially disfiguring scar in the neck. A proctoring programme will be put in place to make it possible to implement this new technique all over the country.

Technological progress in healthcare offers a plethora of opportunities, but they also raise important issues, such as safety. Every year, around 18,000 electronic implants with a therapeutic function, such as pacemakers and implantable cardioverter defibrillators (ICDs), are implanted in patients in the Netherlands. Most of these devices are able to establish a wireless internet connection to share technical and diagnostic information remotely with healthcare providers. If the access to the device is not sufficiently protected, a security risk arises with potential health risks. Currently, the therapeutic advantages of an ICD outweigh the potential security risks associated with the device. For healthcare providers it is a challenge to conduct a proper risk assessment in this situation. It is therefore important that manufacturers improve estimations of risks associated with their products, that incidents are shared more widely and that independent quality assurance testing is conducted.

Technological progress in healthcare offers a plethora of opportunities, but they also raise important issues, such as safety. Every year, around 18,000 electronic implants with a therapeutic function, such as pacemakers and implantable cardioverter defibrillators (ICDs), are implanted in patients in the Netherlands. Most of these devices are able to establish a wireless internet connection to share technical and diagnostic information remotely with healthcare providers. If the access to the device is not sufficiently protected, a security risk arises with potential health risks. Currently, the therapeutic advantages of an ICD outweigh the potential security risks associated with the device. For healthcare providers it is a challenge to conduct a proper risk assessment in this situation. It is therefore important that manufacturers improve estimations of risks associated with their products, that incidents are shared more widely and that independent quality assurance testing is conducted.