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Background and aimsThe effectiveness of intravenous thrombolysis (IVT) prior to endovascular treatment (EVT) has been investigated in randomized trials and meta-analyses. These studies mainly concerned anterior circulation occlusions. We aimed to investigate clinical, technical, and safety outcomes of IVT prior to EVT in posterior circulation occlusions in a nationwide registry.MethodsPatients were included from the MR CLEAN Registry: a nationwide, prospective, multicenter registry of patients with acute ischemic stroke (AIS) due to a large intracranial vessel occlusion receiving EVT between 2014 and 2019. All patients with a posterior circulation occlusion were included. Primary outcome was a shift towards better functional outcome on the modified Rankin scale (mRS) at 90 days. Secondary outcomes were favorable functional outcome (mRS 0-3), occurrence of symptomatic intracranial hemorrhages (sICH), successful reperfusion (eTICI≥2B), first-attempt successful reperfusion, and mortality at 90 days. Regression analyses with adjustments based on univariate analyses and literature were applied.ResultsA total of 248 patients were included, who received either IVT (n=125) or no IVT (n=123) prior to EVT. Results show no differences in a shift on the mRS (acOR:1.04, 95%CI:0.61-1.76). Although sICH occurred more often in the IVT group (4.8% versus 2.4%), regression analysis did not show a significant difference (aOR:1.65, 95%CI:0.33-8.35). Successful reperfusion, favorable functional outcome, first-attempt successful reperfusion, and mortality did not differ between patients treated with and without IVT.ConclusionsWe found no significant differences in clinical, technical and safety outcomes between patients with a large vessel occlusion in the posterior circulation treated with or without IVT prior to endovascular therapy. Our results are in line with the literature on the anterior circulation.

Contains fulltext : 251517.pdf (Publisher’s version ) (Open Access) OBJECTIVE: International guidelines recommend supervised exercise therapy (SET) as primary treatment for all patients with intermittent claudication (IC), yet primary endovascular revascularisation (ER) might be more effective in patients with iliac artery obstruction. METHODS: This was a multicentre RCT including patients with IC caused by iliac artery stenosis or occlusion (NCT01385774). Patients were allocated randomly to SET or ER stratified for maximum walking distance (MWD) and concomitant SFA disease. Primary endpoints were MWD on a treadmill (3.2 km/h, 10% incline) and disease specific quality of life (VascuQol) after one year. Additional interventions during a mean follow up of 5.5 years were recorded. RESULTS: Between November 2010 and May 2015, 114 patients were allocated to SET, and 126 to ER. The trial was terminated prematurely after 240 patients were included. Compliance with SET was 57/114 (50%) after six months. Ten patients allocated to ER (8%) did not receive this intervention. One year follow up was complete for 90/114 (79%) SET patients and for 104/126 (83%) ER patients. The mean MWD improved from 187 to 561 m in SET patients and from 196 to 574 m in ER patients (p = .69). VascuQol sumscore improved from 4.24 to 5.58 in SET patients, and from 4.28 to 5.88 in ER patients (p = .048). Some 33/114 (29%) SET patients had an ER within one year, and 2/114 (2%) surgical revascularisation (SR). Some 10/126 (8%) ER patients had additional ER within one year and 10/126 (8%) SR. After a mean of 5.5 years, 49% of SET patients and 27% of ER patients underwent an additional intervention for IC. CONCLUSION: Taking into account the many limitations of the SUPER study, both a strategy of primary SET and primary ER improve MWD on a treadmill and disease specific Qol of patients with IC caused by an iliac artery obstruction. It seems reasonable to start with SET in these patients and accept a 30% failure rate, which, of course, must be discussed with the patient. Patients continue to have interventions beyond one year.

Background Glycoprotein IIb/IIIa inhibitors (GPI) are still used in patients with ST-segment elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI), although discussion about its clinical benefit is ongoing. Methods GPI use was analyzed in this subanalysis of the POPular Genetics trial, which randomized STEMI patients to CYP2C19 genotype-guided treatment (clopidogrel or ticagrelor) or standard treatment with ticagrelor/prasugrel. The composite thrombotic endpoint consisted of cardiovascular death, myocardial infarction (MI), definite stent thrombosis, and stroke at 30 days. The combined bleeding endpoint consisted of Platelet Inhibition and Patient Outcomes (PLATO) major and minor bleeding at 30 days. Univariable and multivariable analyses in addition to a propensity score-matched (PSM) analysis were conducted. Results In total, 2378 patients, of whom 1033 received GPI and 1345 did not, were included. In multivariable analysis, GPI administration was associated with fewer thrombotic events (hazard ratio [HR] 0.22, 95% confidence interval [CI] 0.09-0.55) and MIs (HR 0.24, 95% CI 0.08-0.73). Furthermore, GPI administration was associated with an increase in bleedings (HR 2.02, 95% CI 1.27-3.19), driven by minor bleedings (HR 2.32, 95% CI 1.43-3.76), without a significant difference in major bleedings (HR 0.69, 95% CI 0.19-2.57). In the PSM analysis, no significant association was found. Conclusion In STEMI patients undergoing primary PCI, GPI administration was associated with a reduction in thrombotic events at a cost of an increase in (mostly minor) bleedings in multivariable analysis, while propensity score analysis did not show significant associations.

Objective: To compare cost effectiveness of endovascular revascularisation (ER) and supervised exercise therapy (SET) as primary treatment for patients with intermittent claudication (IC) due to iliac artery obstruction. Methods: Cost utility analysis from a restricted societal perspective and time horizon of 12 months. Patients were included in a multicentre randomised controlled trial (SUPER study, NCT01385774, NTR2648) which compared effectiveness of ER and SET. Health status and health related quality of life (HRQOL) were measured using the Euroqol 5 dimensions 3 levels (EQ5D-3L) and VascuQol-25-NL. Incremental costs were determined per allocated treatment and use of healthcare during follow up. Effectiveness of treatment was determined in quality adjusted life years (QALYs). The difference between treatment groups was calculated by an incremental cost utility ratio (ICER). Results: Some 240 patients were included, and complete follow up was available for 206 patients (ER 111, SET 95). The mean costs for patients allocated to ER were €4 031 and €2 179 for SET, a mean difference of €1 852 (95% bias corrected and accelerated [bca] bootstrap confidence interval 1 185 – 2 646). The difference in QALYs during follow up was 0.09 (95% bcaCI 0.04 – 0.13) in favour of ER. The ICER per QALY was €20 805 (95% bcaCI 11 053 – 45 561). The difference in VascuQol sumscore was 0.64 (95% bcaCI 0.39 – 0.91), again in favour of ER. Conclusion: ER as a primary treatment, results in slightly better health outcome and higher QALYs and HRQOL during 12 months of follow up. Although these differences are statistically significant, clinical relevance must be discussed due to the small differences and relatively high cost of ER as primary treatment.

INTRODUCTION: The POPular Genetics trial demonstrated that a CYP2C19 genotype-guided P2Y12 inhibitor strategy reduced bleeding rates compared with standard treatment with ticagrelor or prasugrel without increasing thrombotic event rates after primary percutaneous coronary intervention (PCI).OBJECTIVE: In this analysis, we aimed to evaluate the cost effectiveness of a genotype-guided strategy compared with standard treatment with ticagrelor or prasugrel.METHODS: A 1-year decision tree based on the POPular Genetics trial in combination with a lifelong Markov model was developed to compare costs and quality-adjusted life-years (QALYs) between a genotype-guided and a standard P2Y12 inhibitor strategy in patients with myocardial infarction undergoing primary PCI. The cost-effectiveness analysis was conducted from a Dutch healthcare system perspective. Within-trial survival and utility data were combined with lifetime projections to evaluate lifetime cost effectiveness for a cohort of 1000 patients. Costs and utilities were discounted at 4 and 1.5%, respectively, according to Dutch guidelines for health economic studies. Besides deterministic and probabilistic sensitivity analyses, several scenario analyses were also conducted (different time horizons, different discount rates, equal prices for P2Y12 inhibitors, and equal distribution of thrombotic events between the two strategies).RESULTS: Base-case analysis with a hypothetical cohort of 1000 subjects demonstrated 8.98 QALYs gained and €725,550.69 in cost savings for the genotype-guided strategy (dominant). The deterministic and probabilistic sensitivity analysis confirmed the robustness of the model and the cost-effectiveness results. In scenario analyses, the genotype-guided strategy remained dominant.CONCLUSION: In patients undergoing primary PCI, a CYP2C19 genotype-guided strategy compared with standard treatment with ticagrelor or prasugrel resulted in QALYs gained and cost savings.TRIAL REGISTRATION: Clinicaltrials.gov number: NCT01761786, Netherlands trial register number: NL2872.

Background: Guidelines favor ticagrelor or prasugrel over clopidogrel in patients with myocardial infarction. However, the POPular Genetics trial (Patient Outcome After Primary Percutaneous Coronary Intervention [PCI]) showed that in patients with primary PCI, a CYP2C19 genotype–guided strategy was associated with a lower bleeding risk without increasing thrombotic risk, compared with routine ticagrelor/prasugrel treatment. Nevertheless, optimal P2Y 12 inhibitor treatment in specific CYP2C19 genetic subgroups is still a subject of debate. Methods: A prespecified subanalysis of the POPular Genetics trial was performed, using patients in whom CYP2C19 *2, *3, and *17 genotypes was determined. Two different analyses were planned. The first assessed the effect of the CYP2C19 *17 allele in clopidogrel-treated patients. The second compared the effect of clopidogrel in noncarriers of a loss-of-function allele with ticagrelor/prasugrel–treated patients, irrespective of CYP2C19 genotype. Main outcomes were a thrombotic outcome (cardiovascular death, myocardial infarction, stent thrombosis, and stroke) and a bleeding outcome (PLATO [Platelet Inhibition and Patient Outcomes] major and minor bleeding) after 12 months. Results: A total of 2429 patients were used for analyses. In the first analysis, the CYP2C19 *17 polymorphism was not found to have a significant influence on thrombotic (adjusted hazard ratio, 0.95 [95% CI, 0.45–2.02]) or bleeding outcomes (adjusted hazard ratio, 0.74 [95% CI, 0.48–1.18]). In the second analysis, clopidogrel was associated with a lower number of bleeding events compared with ticagrelor/prasugrel (9.9% versus 11.7%, adjusted hazard ratio, 0.74 [95% CI, 0.56–0.96]), without a significant increase in thrombotic events (3.4% versus 2.5%, adjusted hazard ratio, 1.14 [95% CI, 0.68–1.90]). Conclusions: In patients with primary PCI not carrying a CYP2C19 loss-of-function allele, the use of clopidogrel compared with ticagrelor or prasugrel was associated with lower bleeding rates, without an increase in thrombotic events. No effect on clinical outcomes was found for the CYP2C19 *17 polymorphism. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01761786. URL: https://www.trialregister.nl/ ; Unique identifier: NL2872.

Background The prothrombotic defect factor V Leiden (FVL) may confer higher risk of ST‐segment–elevation myocardial infarction (STEMI), compared with non–ST‐segment–elevation acute coronary syndrome, and may be associated with more myocardial necrosis caused by higher thrombotic burden. Methods and Results Patients without history of cardiovascular disease were selected from 2 clinical trials conducted in patients with acute coronary syndrome. FVL was defined as G‐to‐A substitution at nucleotide 1691 in the factor V (factor V R506Q) gene. Odds ratios were calculated for the association of FVL with STEMI adjusted for age and sex in the overall population and in the subgroups including sex, age (≥70 versus P =0.59) for the association of FVL with STEMI. Subgroup analysis did not show any differences. In patients with STEMI, neither the median peak creatine kinase‐myocardial band nor the peak high‐sensitivity troponin ratio showed any differences between wild‐type and FVL carriers ( P for difference: creatine kinase‐myocardial band=0.33; high sensitivity troponin ratio=0.54). Conclusions In a general population with acute coronary syndrome, FVL did not discriminate between a STEMI or non–ST‐segment–elevation acute coronary syndrome presentation and was unrelated to peak cardiac necrosis markers in patients with STEMI. Registration URL: https://www.clinicaltrials.gov ; Unique identifiers: NCT00391872 and NCT01761786.

Introduction: The POPular Genetics trial demonstrated that a genotype-guided strategy to select antiplatelet therapy in patients with ST-elevation myocardial infarction (STEMI) compared to universal treatment with ticagrelor or prasugrel, resulted in a reduction in bleedings without an increase in the thrombotic risk. The objective of this analysis was to assess the cost-effectiveness of the genotype-guided strategy. Methods: In the POPular Genetics trial, STEMI patients who underwent primary percutaneous coronary intervention were randomized to an intervention or a control arm. In the intervention arm CYP2C19 genetic testing for the *2 and *3 loss-of-function alleles took place. Carriers of a loss-of-function allele were treated with ticagrelor or prasugrel, while noncarriers were treated with clopidogrel. In the control arm patients were treated with ticagrelor or prasugrel. An alongside clinical-trial cost-effectiveness analysis was conducted based on a decision-model with 1000 patients in both groups. A hybrid model, consisting of a 1-year decision tree combined with a 25-years Markov model was developed, to estimate the life-time cost-effectiveness from a societal perspective. Outcome measures were costs, quality-adjusted life-years (QALYs) and incremental cost per QALY gained. Deterministic and probabilistic sensitivity analyses were conducted to account for the uncertainty around the key parameters. In an exploratory analysis the price for ticagrelor and prasugrel was the same as clopidogrel, to simulate the effect of generic ticagrelor and prasugrel in the future. Results: The genotype-guided strategy resulted in 26.87 QALY gained with cost-savings of є601,807 indicating that the genotype-guided strategy is a cost-saving intervention. The exploratory analysis - keeping the price of antithrombotic therapies at the same price level - resulted in cost-savings of є137,980. Deterministic and probabilistic sensitivity analyses confirmed the robustness of the base-case analysis. Conclusion: Based on the POPular Genetics trial, a genotype-guided strategy compared to universal ticagrelor or prasugrel treatment resulted in favorable cost-effectiveness with QALYs gained and cost-savings.

Background In patients with acute coronary syndrome (ACS) shortened duration of dual antiplatelet therapy (DAPT) should be considered in those at high risk of bleeding. Risk scores may be used to assess the bleeding risk, but their predictive value remains unclear. Purpose To externally validate and compare the PRECISE-DAPT and the PARIS bleeding risk scores in patients with ACS. Methods From January 2015 to June 2018, all patients admitted with ACS were consecutively included in a single center, observational, prospective registry with follow-up of at least one year. In all patients, the PRECISE-DAPT and the PARIS risk-score were retrospectively assessed. Primary endpoint was moderate or severe bleeding defined as Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding within one year after ACS. Kaplan-Meier curves showed the probabilty of bleeding during follow-up as assessed by both scores. Score discrimination using c-statistic were calculated and calibration curves were visually assessed. Results 2,729 patients were included for analysis. 93.6% were discharged with ≥2 antithrombotic drugs. At one year follow-up, the event rate of moderate or severe bleeding was 5.5%. High bleeding risk as stratified by both risk scores was associated with higher bleeding rates. Discriminative values for BARC 3 or 5 bleeding at one year were 0.67 [95% CI 0.61–0.72] for the PRECISE-DAPT score and 0.62 [95% CI 0.57–0.68] for the PARIS bleeding score (p=0.31). Conclusion The PRECISE-DAPT and the PARIS bleeding scores both showed adequate discriminative performances in predicting moderate or severe bleeding in this study. Kaplan-meier and ROC-curves Funding Acknowledgement Type of funding source: None

Although Ps 23 can be called a psalm of trust, its purpose is to impart comfort in concrete life. In times of sorrow and crisis, this psalm has struck home. The article starts by reading Ps 23 as composition, then turns to the reception history, and finally shows the resonance of this psalm in two contemporary poems. A network of metaphors is built around the shepherd motif. The motif of the shepherd is a central metaphor in this psalm. This motif is also found elsewhere in the OT. The shepherd takes care of his flock. This shepherd is identified as Yahweh. In the structure of Ps 23, v. 4b is the axis, as it is demonstrated by its occurrence precisely in the middle of the psalm. "You are with me." This confession is the heartbeat of the psalm. The second part of v. 4b indicates that the presence of Yahweh is a protective presence. Yahweh is not only the shepherd, but also the host who prepares a table before his guest. Yahweh also anoints the poet's head with oil before the commencement of the meal. The poet's cup overflows. Goodness and love will follow him. All the days of his life, he will experience the presence and protection of Yahweh. In the following part, the reception history of Psalm 23 is elucidated. The echoes of Ps 23 can be heard in two of my poems that were written in Afrikaans and superbly translated into English by the renowned translator, poet and novelist, Leon de Kock. Keywords: Psalm 23, Orientation, Interpretation, Structure, Reception history, Resonance in poetry

Aim: A tailored antiplatelet strategy based on CYP2C19 genotype may reduce atherothrombotic and bleeding events. We describe our experience with CYP2C19 genotyping, using on-site TaqMan or Spartan genotyping or shipment to a central laboratory. Methodology: Data from two ongoing projects were used: Popular Risk Score project (non-urgent percutaneous coronary intervention patients) and the Popular Genetics study (ST-segment elevation myocardial infarction patients). For both projects, the time to genotyping result was calculated. Results: In the Popular Risk Score project (n = 2556), median time from blood collection to genotyping result was 4:04 h. In the Popular Genetics study (n = 1038), median time from randomization to genotyping result was 2:24 h. Conclusion: CYP2C19 genotyping is feasible in everyday clinical practice, both in the acute and non-acute settings.

Background: Patients with acute coronary syndrome (ACS) who are carrying CYP2C19 loss-of-function alleles derive less benefit from clopidogrel treatment. Despite this, in elderly patients, clopidogrel might be preferred over more potent P2Y12 inhibitors due to a lower bleeding risk. Whether CYP2C19 genotype-guided antiplatelet treatment in the elderly could be of benefit has not been studied specifically.Methods: Patients aged 70 years and older with known CYP2C19*2 and *3 genotype were identified from the POPular Genetics and POPular Age trials. Noncarriers of loss-of-function alleles treated with clopidogrel were compared to patients, irrespective of CYP2C19 genotype, treated with ticagrelor and to clopidogrel treated carriers of loss-of-function alleles. We assessed net clinical benefit (all-cause death, myocardial infarction, stroke and Platelet Inhibition and Patient Outcomes (PLATO) major bleeding), atherothrombotic outcomes (cardiovascular & nbsp;death, myocardial infarction, stroke) and bleeding outcomes (PLATO major and minor bleeding).Results: A total of 991 patients were assessed. There was no significant difference in net clinical benefit (17.2% vs. 15.1%, adjusted hazard ratio (adjHR) 1.05, 95% confidence interval (CI) 0.77 & ndash;1.44), atherothrombotic outcomes (9.7% vs. 9.2%, adjHR 1.00, 95%CI 0.66 & ndash;1.50), and bleeding outcomes (17.7% vs. 19.8%, adjHR 0.80, 95%CI 0.62 & ndash;1.12) between clopidogrel in noncarriers of loss-of-function alleles and ticagrelor respectively.Conclusion: In ACS patients aged 70 years and older, there was no significant difference in net clinical benefit and atherothrombotic outcomes between noncarriers of a loss-of-function allele treated with clopidogrel and pa-tients treated with ticagrelor. The bleeding rate was numerically; though not statistically significant, lower in pa-tients using clopidogrel.(c) 2021 Published by Elsevier B.V.

When switching from ticagrelor or prasugrel to clopidogrel early after myocardial infarction (MI), a loading dose is recommended ([1][1],[2][2]). However, this recommendation is based solely on pharmacodynamics studies, whereas studies investigating the effects on clinical outcomes (i.e., stent

OBJECTIVE This study aims to determine frequency and reasons for prematurely discontinuing or switching antiplatelet therapy in elderly patients admitted with non-ST-elevation acute coronary syndrome (NSTE-ACS). METHOD Patients of 75 years or older admitted with suspected NSTE-ACS were included between 2013 and 2016. Information was extracted from the patients' medical files. RESULTS A total of 544 patients were included, 17.3% discontinued aspirin within one year, predominantly (57%) within 30 days. The most common reason was the start of a (non-vitamin-K) oral anticoagulant [(N)OAC], either combined with a P2Y12-inhibitor (43%) or as monotherapy (16%). The P2Y12-inhibitor was discontinued in 31.2% of patients within one year, of which 46% within 30 days. The most common reason was undergoing coronary artery bypass grafting (CABG; 22%). Switching of clopidogrel seldom occurred; however, ticagrelor was switched in 50/179 patients mainly due to dyspnoea (42%). Independent predictors for prematurely discontinuing antiplatelet therapy were undergoing CABG [odds ratio (OR) 3.257 (95% confidence interval [CI] 1.836-5.779)], need for (N)OAC [OR 2.167 (95% CI 1.423-3.300)] and type II ACS as final diagnosis [OR 3.793 (95% CI 1.721-8.361)]. Undergoing percutaneous coronary intervention [OR 0.393 (95% CI 0.243-0.634)] and use of clopidogrel [OR 0.441(95% CI 0.293-0.662)] were independent predictors of continuing antiplatelet therapy. CONCLUSION In elderly patients of at least 75 years with NSTE-ACS, antiplatelet therapy is frequently discontinued prematurely, most often within 30 days. Main reasons for discontinuing are need for (N)OAC, undergoing CABG or type II ACS as final diagnosis and suffering from dyspnoea while on ticagrelor.

This study aims to determine whether genetic variants that influence CYP3A4 expression are associated with platelet reactivity in clopidogrel-treated patients undergoing elective percutaneous coronary intervention (PCI), and to evaluate the influence of statin/fibrate co-medication on these associations. A study cohort was used containing 1124 consecutive elective PCI patients in whom CYP3A4*22 and PPAR-α (G209A and A208G) SNPs were genotyped and the VerifyNow P2Y12 platelet reactivity test was performed. Minor allele frequencies were 0.4% for CYP3A4*22/*22, 6.8% for PPAR-α G209A AA, and 7.0% for PPAR-α A208G GG. CYP3A4*22 was not associated with platelet reactivity. The PPAR-α genetic variants were significantly associated with platelet reactivity (G209A AA: −24.6 PRU [−44.7, −4.6], p = 0.016, A208G GG: −24.6 PRU [−44.3, −4.8], p = 0.015). Validation of these PPAR-α results in two external cohorts, containing 716 and 882 patients, respectively, showed the same direction of effect, although not statistically significant. Subsequently, meta-analysis of all three cohorts showed statistical significance of both variants in statin/fibrate users (p = 0.04 for PPAR-a G209A and p = 0.03 for A208G), with no difference in statin/fibrate non-users. In conclusion, PPAR-α G209A and A208G were associated with lower platelet reactivity in patients undergoing elective PCI who were treated with clopidogrel and statin/fibrate co-medication. Further research is necessary to confirm these findings.

The POPular Genetics trial demonstrated that a genotype-guided strategy benefits patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) compared to standard treatment with ticagrelor or prasugrel by reducing bleedings, without increasing

Background and Purpose— Preclinical studies showed that thrombus permeability improves recombinant tissue-type plasminogen activator (r-tPA) efficacy. We hypothesize that thrombus permeability estimated from radiological imaging is associated with improved recanalization after treatment with intravenously administered r-tPA (r-tPA) and with better functional outcome. Methods— We assessed thrombus attenuation increase (TAI) in patients from the Dutch Acute Stroke Study with an occlusion of an intracranial artery on computed tomographic angiography. Patients were included within 9 hours after the stroke onset. After dichotomization of TAI as pervious or impervious, logistic regressions analyses were performed to estimate associations of intravenous r-tPA therapy with complete recanalization and with favorable functional outcome (modified Rankin Scale score of ≤2). Results— Three hundred eight patients matched the inclusion criteria. The median TAI was 20.1 (interquartile range, 8.5–37.8) Hounsfield unit (HU). We found a significant increase in the odds of complete recanalization with increasing TAI for patients treated with intravenous r-tPA ( P =0.030). One hundred thirty-one (42%) thrombi were classified as pervious with TAI of ≥23 HU. In patients with a pervious thrombus, complete recanalization was more frequent after treatment with intravenous r-tPA than after conservative treatment (odds ratio, 6.26; 95% confidence interval, 2.4–16.8; P P =0.47). Favorable outcome was more common in patients with a pervious thrombi than without (odds ratio, 2.1; 95% confidence interval, 1.3–3.4; P =0.001). Conclusions— Thrombus perviousness, as measured on computed tomography in the acute stage of ischemic stroke, is strongly associated with recanalization after intravenous r-tPA treatment and with favorable functional outcome.

Toourknowledge, wepresent the first case in the English literature of kidneyrupture accompanied by massive PVT. Discussion on thetreatment of this patient focused on the question whetherthemassiveportalveinthrombosiswasofacuteonsetormayhave been pre-existent. Anticoagulant therapy would beindicated in case of acute PVT, but the concomitant kidneyrupture is a contra-indication for rigorous anticoagulativetreatment.

This research article is based on the author�s doctoral research into the question of quality criteria for Christian songs. In many Christian congregations today, the question of music is an emotive issue as the service and its music touch the heart of people�s faith life and shapes people�s theology. Of the many issues that were investigated in the dissertation, this article focuses on one question only, the question of the �cognitive� and the �emotive� value of the songs that are sung in a Sunday service. It will be argued that, in �good� songs, there needs to be a good balance between �cognitive� and �emotive� value. The general question is how to identify songs that can nurture faith and sustain people through life. Characteristic of such songs is, amongst many other criteria, a good balance between the cognitive and emotive value of the text and the tune. In the discussion, the author focusses largely on her own Lutheran liturgical and hymnological tradition as well as on the �Praise and Worship� movement which has a dramatic impact on churches all over the world. The author argues that finding songs that balance the emotive and the cognitive component is an effective way to bridge the divides on worship music within a congregation.Intradisciplinary and/or interdisciplinary implications: Within the discipline of hymnological studies, the article opens a ground-breaking new way to analyse and critique music used in worship with objective tools for analysis. This is, as far as the author knows, new for this discipline, and it also has an effect on other disciplines.

The liturgical function of the hymns in the psalmsIn many ways the psalms fulfill a bridging function between divergent denominations that previously avoided each other. In the Hebrew text of the Psalter most of the psalms bear clear titles. None of the titles of the psalms originated together with the actual psalms. Instead, they offer instruction to the reader about the process that led to the compilation of the psalms into collection. The psalms are more than liturgy and liturgy comprises more than merely psalms. Therefore, the psalms cannot simply be clothed in liturgical vestments. Hymns that occur in the Book of Psalms form the focus of this article. It is clear that the praise in the hymns follows different patterns. The article aims to explore the liturgical function of the hymns in the psalms.

Representing language: Bible and poetryIn this article the impact and effect of representing language in the Bible and poetry is considered. The landscape of metaphors is viewed and their different functions are indicated. The language of imagery is explored especially through a closer look at Psalm 23. The picturesque power of selected poems is reflected on. The locale of Psalm 23 in the liturgy is also investigated.

The concept of stewardship in the process of extending the local churchThis study looks at the biblical principal of stewardship in the context of building up the local church. The study starts with the methodological principles of Practical Theology and various models of the process of building up the local church. Traditionally stewardship was regarded as the principle that encouraged Christians to give monetary contributions towards extending the local church. The study makes it clear that a much broader and biblical understanding of stewardship is necessary. It looks at the different dimensions of stewardship and the effect the stewardship principle has on the Christian’s use of resources, time, spiritual gifts, possessions, as well as on creation, life and the Gospel of Jesus Christ.

As a consequence of the bipolar tension between theory and practice, experience (considered in the South African context) influences the church's reflection on Practical Theology. Insight into the economic system of the Mediterranean world helps us to understand the complexities involved in positioning poverty, as well as the role of the New Testament faith community in its interaction with the poor. The social system in the ancient world, within which poverty was encountered, cautions us against taking a simplistic view of the poor. We cannot duplicate social systems and impose them on current situations. The New Testament, which is set against a particular system, speaks of the Kingdom of God as a place where the poor must be cared for. The New Testament (especially the Gospel of John) lets us understand that a church, which has a family orientation as its basis, should provide a home for the poor.

In 1938 the Faculty of Theology Section B was established at the University of Pretoria, which could be likened to a small fountain. As the fountain flowed through the decades of history, it grew and became a river that made a huge impact on the university, the Church and society. The aim of this article, coinciding with the centenary of the University of Pretoria, is to focus on the positive contribution of the Faculty of Theology towards university, church and society. Like any river it went through different stages. There were times of peace and tranquillity, but also times of raging rapids. At certain stages of growth and development both lecturers and students made a huge impact, playing leading roles in Church and society, clearly voicing the call of the Church. The voice of the Faculty was not always welcome and was at times met by strong reaction, which was possibly one of the reasons for the murder of Prof. J.A. Heyns. In 2000 a new era dawned when the stream that became a river was joined by streams of different denominations. This made the river even stronger, with much more impact. This article tells the story of the origin, growth and struggle of the Dutch Reformed Church at the Faculty of Theology at the University of Pretoria from 1938 to 2008.

The exploration of the horizons: Searching for a contemporary homiletic hermeneutics The exploration of the horizons: Searching for a contemporary homiletic hermeneutics In this article, the author takes up the Ricoeurian idea of a dual hermeneutic. The article emphasizes the need for critical homiletics, not only to make the invaluable and necessary recourse to a “hermeneutics of suspicion” but also moves beyond it to a “hermeneutics of recollection” that is sympathetic to religion. The concept of a second naiveté is also considered in relation to the dialectic between the two hermeneutical extremes.

The Psalms in liturgy with reference to Psalm 8 as hymnThe publishing of “Liedboek van die Kerk” (2001) emphasizes the importance of the psalms for liturgy and hymnology. All 150 psalms in “Liedboek” were versified by TT Cloete. This article considers the bridge function of the psalm, the significance and function of the psalms as an open hymnbook and as an anthology, and the literature types found in the psalms. The structure and form of Psalm 8 are analyzed in greater detail. This analysis leads to a literary evaluation and a musicological appreciation of its versification by Cloete.