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van den Broek AK, van Schip A, Visser CE, Bos JC, Prins JM, van Hest RM. Population pharmacokinetic/pharmacodynamic target attainment of ceftriaxone 2 g once daily in non-critically ill hospitalized adult patients during the acute phase of infection. Br J Clin Pharmacol 2023; 89:3262-3272. [PMID: 37309251 DOI: 10.1111/bcp.15819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/14/2023] Open
Abstract
AIMS Pharmacokinetic/pharmacodynamic target attainment of ceftriaxone is compromised in intensive care unit (ICU) patients and non-ICU hospitalized patients in Beira, Mozambique. Whether this also accounts for non-ICU patients in a high-income setting is unknown. We therefore assessed the probability of target attainment (PTA) of the currently recommended dosing regimen of 2 g every 24 h (q24h) in this patient group. METHODS We performed a multicentre population pharmacokinetic study in hospitalized non-ICU adult patients empirically treated with intravenous ceftriaxone. During both the acute phase of infection (i.e. first 24 h of treatment) and convalescence, a maximum of 4 random blood samples were obtained per patient for ceftriaxone total and unbound concentration measurements. PTA was calculated using NONMEM and was defined as the percentage of patients of which the unbound ceftriaxone concentration exceeded the minimum inhibitory concentration (MIC) for >50% of the first dosing interval of 24 h. Monte Carlo simulations were performed to determine PTA for different estimated glomerular filtration rates (eGFR; CKD-EPI) and MICs. PTA >90% was considered adequate. RESULTS Forty-one patients provided 252 ceftriaxone total and 253 unbound concentrations. The median eGFR was 65 mL/min/1.73 m2 (5th to 95th percentile 36-122). With the recommended dose of 2 g q24h, PTA >90% was achieved for bacteria with an MIC ≤2 mg/L. Simulations showed that PTA was insufficient for an MIC of 4 mg/L in case the eGFR was 122 mL/min/1.73 m2 (PTA 56.9%) and for an MIC of 8 mg/L regardless of eGFR. CONCLUSION The PTA of 2 g q24h ceftriaxone dosing is adequate for common pathogens during the acute phase of infection in non-ICU patients.
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Affiliation(s)
- Annemieke K van den Broek
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anne van Schip
- Department of Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Caroline E Visser
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeannet C Bos
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Department of Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Gharbharan A, Jordans CCE, GeurtsvanKessel C, den Hollander JG, Karim F, Mollema FPN, Stalenhoef-Schukken JE, Dofferhoff A, Ludwig I, Koster A, Hassing RJ, Bos JC, van Pottelberge GR, Vlasveld IN, Ammerlaan HSM, van Leeuwen-Segarceanu EM, Miedema J, van der Eerden M, Schrama TJ, Papageorgiou G, Te Boekhorst P, Swaneveld FH, Mueller YM, Schreurs MWJ, van Kampen JJA, Rockx B, Okba NMA, Katsikis PD, Koopmans MPG, Haagmans BL, Rokx C, Rijnders BJA. Effects of potent neutralizing antibodies from convalescent plasma in patients hospitalized for severe SARS-CoV-2 infection. Nat Commun 2021; 12:3189. [PMID: 34045486 PMCID: PMC8160346 DOI: 10.1038/s41467-021-23469-2] [Citation(s) in RCA: 115] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/31/2021] [Indexed: 02/08/2023] Open
Abstract
In a randomized clinical trial of 86 hospitalized COVID-19 patients comparing standard care to treatment with 300mL convalescent plasma containing high titers of neutralizing SARS-CoV-2 antibodies, no overall clinical benefit was observed. Using a comprehensive translational approach, we unravel the virological and immunological responses following treatment to disentangle which COVID-19 patients may benefit and should be the focus of future studies. Convalescent plasma is safe, does not improve survival, has no effect on the disease course, nor does plasma enhance viral clearance in the respiratory tract, influence SARS-CoV-2 antibody development or serum proinflammatory cytokines levels. Here, we show that the vast majority of patients already had potent neutralizing SARS-CoV-2 antibodies at hospital admission and with comparable titers to carefully selected plasma donors. This resulted in the decision to terminate the trial prematurely. Treatment with convalescent plasma should be studied early in the disease course or at least preceding autologous humoral response development.
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Affiliation(s)
| | | | | | | | - Faiz Karim
- Groene Hart Hospital, Gouda, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | - Jelle Miedema
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Thijs J Schrama
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | | | - Francis H Swaneveld
- Unit of Transfusion Medicine, Sanquin Blood Supply, Amsterdam, The Netherlands
| | - Yvonne M Mueller
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | | | - Barry Rockx
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Nisreen M A Okba
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Peter D Katsikis
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Bart L Haagmans
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Casper Rokx
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
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Blomaard LC, van der Linden CMJ, van der Bol JM, Jansen SWM, Polinder-Bos HA, Willems HC, Festen J, Barten DG, Borgers AJ, Bos JC, van den Bos F, de Brouwer EJM, van Deudekom FJA, van Dijk SC, Emmelot-Vonk MH, Geels RES, van de Glind EMM, de Groot B, Hempenius L, Kamper AM, Kampschreur LM, de Koning MMM, Labots G, Looman R, Lucke JA, Maas HAAM, Mattace-Raso FUS, el Moussaoui R, van Munster BC, van Nieuwkoop C, Oosterwijk L(BLE, Regtuijt M(EM, Robben SHM, Ruiter R, Salarbaks AM, Schouten HJ, Smit OM, Smits RAL, Spies PE, Vreeswijk R, de Vries OJ, Wijngaarden MA, Wyers CE, Mooijaart SP. Frailty is associated with in-hospital mortality in older hospitalised COVID-19 patients in the Netherlands: the COVID-OLD study. Age Ageing 2021; 50:631-640. [PMID: 33951156 PMCID: PMC7929372 DOI: 10.1093/ageing/afab018] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Indexed: 01/04/2023] Open
Abstract
Background During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, older patients had an increased risk of hospitalisation and death. Reports on the association of frailty with poor outcome have been conflicting. Objective The aim of the present study was to investigate the independent association between frailty and in-hospital mortality in older hospitalised COVID-19 patients in the Netherlands. Methods This was a multicentre retrospective cohort study in 15 hospitals in the Netherlands, including all patients aged ≥70 years, who were hospitalised with clinically confirmed COVID-19 between February and May 2020. Data were collected on demographics, co-morbidity, disease severity and Clinical Frailty Scale (CFS). Primary outcome was in-hospital mortality. Results A total of 1,376 patients were included (median age 78 years (interquartile range 74–84), 60% male). In total, 499 (38%) patients died during hospital admission. Parameters indicating presence of frailty (CFS 6–9) were associated with more co-morbidities, shorter symptom duration upon presentation (median 4 versus 7 days), lower oxygen demand and lower levels of C-reactive protein. In multivariable analyses, the CFS was independently associated with in-hospital mortality: compared with patients with CFS 1–3, patients with CFS 4–5 had a two times higher risk (odds ratio (OR) 2.0 (95% confidence interval (CI) 1.3–3.0)) and patients with CFS 6–9 had a three times higher risk of in-hospital mortality (OR 2.8 (95% CI 1.8–4.3)). Conclusions The in-hospital mortality of older hospitalised COVID-19 patients in the Netherlands was 38%. Frailty was independently associated with higher in-hospital mortality, even though COVID-19 patients with frailty presented earlier to the hospital with less severe symptoms.
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Affiliation(s)
- Laura C Blomaard
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Steffy W M Jansen
- Department of Geriatrics, Catharina Hospital, Eindhoven, the Netherlands
| | - Harmke A Polinder-Bos
- Section Geriatrics, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hanna C Willems
- Section Geriatrics, Department of Internal Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | | | - Dennis G Barten
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, the Netherlands
| | - Anke J Borgers
- Department of Geriatrics, Deventer Hospital, Deventer, the Netherlands
| | - Jeannet C Bos
- Department of Internal Medicine, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Frederiek van den Bos
- Department of Geriatrics, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Floor J A van Deudekom
- Department of Internal Medicine and Geriatrics, OLVG Hospital, Amsterdam, the Netherlands
| | - Suzanne C van Dijk
- Department of Geriatric Medicine, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | | | - Raya E S Geels
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
- Department of Geriatrics, Alrijne Hospital, Leiderdorp, the Netherlands
| | | | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Liesbeth Hempenius
- Department of Geriatric Medicine, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Ad M Kamper
- Department of Internal Medicine, Isala Hospital, Zwolle, the Netherlands
| | - Linda M Kampschreur
- Department of Internal Medicine, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Marre M M de Koning
- Department of Geriatric Medicine, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Geert Labots
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Roy Looman
- Section Geriatrics, Department of Internal Medicine, Zaans Medical Center, Zaandam, the Netherlands
| | - Jacinta A Lucke
- Department of Emergency Medicine, Spaarne Gasthuis, Haarlem, the Netherlands
| | - Huub A A M Maas
- Department of Geriatric Medicine, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | | | | | - Barbara C van Munster
- Department of Internal Medicine and Geriatrics, University Medical Center Groningen, Groningen, the Netherlands
| | - Cees van Nieuwkoop
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Leanne (B L E) Oosterwijk
- Section Geriatrics, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Sarah H M Robben
- Department of Geriatric Medicine, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Rikje Ruiter
- Department of Internal Medicine, Maasstad Hospital, Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Aisha M Salarbaks
- Department of Geriatrics, Hospital Group Twente, Almelo, the Netherlands
| | - Henrike J Schouten
- Department of Geriatric Medicine, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Orla M Smit
- Section Geriatrics, Department of Internal Medicine, Zaans Medical Center, Zaandam, the Netherlands
| | - Rosalinde A L Smits
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Petra E Spies
- Department of Geriatric Medicine, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Ralph Vreeswijk
- Department of Geriatrics, Spaarne Gasthuis, Haarlem, the Netherlands
| | - Oscar J de Vries
- Department of Internal Medicine and Geriatrics, OLVG Hospital, Amsterdam, the Netherlands
| | - Marjolein A Wijngaarden
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Caroline E Wyers
- Department of Internal Medicine, VieCuri Medical Center, Venlo, the Netherlands
| | - Simon P Mooijaart
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
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Bos JC, van Hest RM, Mistício MC, Nunguiane G, Lang CN, Beirão JC, Mathôt RAA, Prins JM. Pharmacokinetics and Pharmacodynamic Target Attainment of Benzylpenicillin in an Adult Severely Ill Sub-Saharan African Patient Population. Clin Infect Dis 2019; 66:1261-1269. [PMID: 29112711 DOI: 10.1093/cid/cix961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 11/01/2017] [Indexed: 12/14/2022] Open
Abstract
Background In intensive care (ICU) patients, systemic exposure of β-lactam antibiotics can be altered, and positive clinical outcome is associated with increasing fT > MIC ratios. In sub-Saharan African hospitals, benzylpenicillin (PEN) is frequently used for the empiric treatment of severe pneumococcal infections. Pharmacokinetic data for non-ICU hospitalized populations are lacking. Methods We performed a population pharmacokinetic (PPK) study in an adult Mozambican hospital population treated intravenously with PEN from October 2014 through November 2015. Four blood samples/patient were collected for total PEN (PENt) and unbound PEN (PENu) concentration measurement. We developed a PPK model through nonlinear mixed-effects analysis and performed simulations for different patient variable, dosing, and pharmacodynamic target scenarios. Results One hundred twelve participants yielded 387 PENt and 53 PENu concentrations. The median body mass index was 18.3 (range, 10.5-31.3) kg/m2 and the median albumin concentration and creatinine clearance (CrCl) were 29 (range, 12-44) g/L and 80 (range, 3-195) mL/minute, respectively. In a 1-compartment model, CrCl was positively correlated with PENt clearance. For infections with a microorganism with a minimum inhibitory concentration (MIC) of 1 mg/L, simulations demonstrated that with 3 million IU (1.8 g) every 6 hours, 74.1% would have a PENu concentration greater than the MIC during half of the dosing interval (fT > MIC = 50%), whereas this was 24.8% for the fT > MIC = 100% target. For pathogens with an MIC of 0.06 mg/L, these percentages were 98.2% and 72.3%, respectively. Conclusions Severely ill adult sub-Saharan African patients may be at high risk for underexposure to PENu during routine intermittent bolus dosing, especially when their renal function is intact and when infected with pathogens with intermediate susceptibility.
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Affiliation(s)
- Jeannet C Bos
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Reinier M van Hest
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Mabor C Mistício
- Research Center for Infectious Diseases of the Faculty of Health Sciences, Catholic University of Mozambique, Beira
| | - Ginto Nunguiane
- Research Center for Infectious Diseases of the Faculty of Health Sciences, Catholic University of Mozambique, Beira
| | - Cláudia N Lang
- Research Center for Infectious Diseases of the Faculty of Health Sciences, Catholic University of Mozambique, Beira
| | - José C Beirão
- Research Center for Infectious Diseases of the Faculty of Health Sciences, Catholic University of Mozambique, Beira
| | - Ron A A Mathôt
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, The Netherlands
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Bos JC, Prins JM, Mistício MC, Nunguiane G, Lang CN, Beirão JC, Mathôt RAA, van Hest RM. Pharmacokinetics and pharmacodynamic target attainment of ceftriaxone in adult severely ill sub-Saharan African patients: a population pharmacokinetic modelling study. J Antimicrob Chemother 2018. [DOI: 10.1093/jac/dky071] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Jeannet C Bos
- Academic Medical Centre (AMC), University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Jan M Prins
- Academic Medical Centre (AMC), University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Mabor C Mistício
- Catholic University of Mozambique (UCM), Research Centre for Infectious Diseases of the Faculty of Health Sciences (CIDI), Rua Marquês do Soveral 960, CP 821, Beira, Mozambique
| | - Ginto Nunguiane
- Catholic University of Mozambique (UCM), Research Centre for Infectious Diseases of the Faculty of Health Sciences (CIDI), Rua Marquês do Soveral 960, CP 821, Beira, Mozambique
| | - Cláudia N Lang
- Catholic University of Mozambique (UCM), Research Centre for Infectious Diseases of the Faculty of Health Sciences (CIDI), Rua Marquês do Soveral 960, CP 821, Beira, Mozambique
| | - José C Beirão
- Catholic University of Mozambique (UCM), Research Centre for Infectious Diseases of the Faculty of Health Sciences (CIDI), Rua Marquês do Soveral 960, CP 821, Beira, Mozambique
| | - Ron A A Mathôt
- Academic Medical Centre (AMC), University of Amsterdam, Department of Hospital Pharmacy, Division of Clinical Pharmacology, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Reinier M van Hest
- Academic Medical Centre (AMC), University of Amsterdam, Department of Hospital Pharmacy, Division of Clinical Pharmacology, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Bos JC, Mistício MC, Nunguiane G, Mathôt RAA, van Hest RM, Prins JM. Paracetamol clinical dosing routine leads to paracetamol underexposure in an adult severely ill sub-Saharan African hospital population: a drug concentration measurement study. BMC Res Notes 2017; 10:671. [PMID: 29202789 PMCID: PMC5715499 DOI: 10.1186/s13104-017-3016-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 11/28/2017] [Indexed: 12/13/2022] Open
Abstract
Background Hospitals in sub-Saharan Africa (SSA) continue to receive high numbers of severely ill (HIV-infected) patients with physical pain that may suffer from hepatic and renal dysfunction. Paracetamol is widely used for pain relief in this setting but it is unknown whether therapeutic drug concentrations are attained. The aim of this study was to assess the occurrence of therapeutic, sub-therapeutic and toxic paracetamol concentrations in SSA adult hospital population. Methods In a cross-sectional study, plasma paracetamol concentrations were measured in patients with an oral prescription in a referral hospital in Mozambique. From August to November 2015, a maximum of four blood samples were drawn on different time points for paracetamol concentration measurement and biochemical analysis. Study endpoints were the percentage of participants with therapeutic (≥ 10 and ≤ 20 mg/L), sub-therapeutic (< 10 mg/L) and toxic (> 75 mg/L) concentrations. Results Seventy-six patients with a median age of 37 years, a body mass index of 18.2, a haemoglobin concentration of 10.3 g/dL and an albumin of 29 g/L yielded 225 samples. 13.4% of participants had one or more therapeutic paracetamol concentrations. 86.6% had a sub-therapeutic concentration at all time points and 70.2% had two or more concentrations below the lower limit of quantification. No potentially toxic concentrations were found. Conclusions Routine oral dosing practices in a SSA hospital resulted in substantial underexposure to paracetamol. Palliation is likely to be sub-standard and oral palliative drug pharmacokinetics and dispensing procedures in this setting need further investigation.
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Affiliation(s)
- Jeannet C Bos
- Division of Infectious Diseases, Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Mabor C Mistício
- Faculty of Health Sciences, Research Centre for Infectious Diseases (CIDI), Catholic University of Mozambique, Rua Marquês do Soveral 960, C.P. 821, Beira, Mozambique
| | - Ginto Nunguiane
- Faculty of Health Sciences, Research Centre for Infectious Diseases (CIDI), Catholic University of Mozambique, Rua Marquês do Soveral 960, C.P. 821, Beira, Mozambique
| | - Ron A A Mathôt
- Division of Clinical Pharmacology, Department of Hospital Pharmacy, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Division of Clinical Pharmacology, Department of Hospital Pharmacy, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan M Prins
- Division of Infectious Diseases, Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Bos JC, Beishuizen SJ, Madeira GC, Gomonda EDS, Cossa EO, Macome AC, van Steenwijk RP, Schultsz C, Prins JM. Antimicrobial susceptibility of Streptococcus pneumoniae in adult patients with pneumococcal pneumonia in an urban hospital in Mozambique. BMC Res Notes 2014; 7:110. [PMID: 24568650 PMCID: PMC3939630 DOI: 10.1186/1756-0500-7-110] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 02/04/2014] [Indexed: 11/10/2022] Open
Abstract
Background Streptococcus pneumoniae is the leading cause of community–acquired pneumonia in Africa. Antimicrobial resistance of S. pneumoniae to penicillin and other commonly used antibiotics has increased worldwide. However, prevalence data from the African region are sparse, especially with regard to adults. Findings In this study, adult patients presenting at an urban referral hospital in central Mozambique were screened for pneumococcal pneumonia during an 8-week period in 2010: Patients with a respiratory syndrome underwent chest radiography and a sputum sample was collected for pneumococcal culture and antimicrobial susceptibility testing. A urine sample was tested for the presence of pneumococcal antigen. 177 patients with a respiratory syndrome were included. Overall, 41/177 (23%) patients fulfilled criteria for definite or probable pneumococcal pneumonia and in the group of patients with a positive chest x-ray this concerned 35/86 (41%) patients. 166 sputum cultures yielded 16 pneumococcal strains. One mg oxacillin disc testing identified potential penicillin resistance in 7/16 (44%) strains. Penicillin minimal inhibitory concentrations (MICs) were measured for 15 of these strains and ranged from <0.016-0.75 mg/L. No MICs >2 mg/L were found, but 3/15 (20%) pneumococcal strains had MICs >0.5 mg/L. All pneumococci were sensitive to erythromycin as measured by disc diffusion testing, whereas 44% was resistant to trimethoprim-sulfametoxazole. Conclusions The proportion of pneumonia cases attributable to pneumococcus appeared to be high. Whilst none of the S. pneumoniae strains tested were penicillin resistant, standard penicillin dosing for pneumonia may be insufficient given the observed range of pneumococcal penicillin MICs.
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Affiliation(s)
- Jeannet C Bos
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre (AMC), University of Amsterdam, Room F4-217, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands.
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Bos JC, Smalbraak L, Macome AC, Gomes E, van Leth F, Prins JM. TB diagnostic process management of patients in a referral hospital in Mozambique in comparison with the 2007 WHO recommendations for the diagnosis of smear-negative pulmonary TB and extrapulmonary TB. Int Health 2013; 5:302-8. [PMID: 24130098 DOI: 10.1093/inthealth/iht025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In sub-Saharan African countries, the high proportion of smear-negative pulmonary TB (SNTB) and extrapulmonary TB (EPTB) contributes to a delay in TB diagnosis and treatment. We evaluated the TB diagnostic process of adult patients with presumptive TB in a referral hospital in Mozambique according to the 2007 WHO recommendations for the diagnosis and treatment of SNTB and EPTB in HIV-prevalent resource-poor settings. METHODS This was a retrospective, cross-sectional study using medical records of patients admitted in June-July 2009. RESULTS Overall, 514 patient records were screened, providing 234 presumptive TB patients. There were 70 deaths (29.9%). The evaluation of danger signs was never complete. HIV status was known for 175/234 patients (74.8%), 140 (80.0%) of whom were HIV-positive. A sputum smear microscopy (SSM) result was obtained for 59/234 patients (25.2%). SSM results were positive in 8/59 patients (13.6%). Chest radiography was done in 150/234 patients (64.1%) and 103 (68.7%) were abnormal. A total of 66 patients (28.2%) received TB treatment. CONCLUSIONS The TB diagnostic process in this Mozambican hospital remained largely incomplete according to WHO recommendations and few patients with presumptive TB were identified as TB patients. Deficiencies as described should prompt reconsideration of WHO guideline content and feasibility.
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Affiliation(s)
- Jeannet C Bos
- Academic Medical Centre (AMC) of the University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Bos JC, Schultsz C, Vandenbroucke-Grauls CMJ, Speelman P, Prins JM. [Optimising antibiotic policies in the Netherlands. IX. SWAB guidelines for antimicrobial therapy in adults with acute infectious diarrhoea]. Ned Tijdschr Geneeskd 2006; 150:1116-22. [PMID: 16756223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
The 'Stichting Werkgroep Antibioticabeleid' (SWAB; Dutch Working Party on Antibiotic Policy) develops evidence-based guidelines for the use of antibiotics in hospitalised adults. This guideline on acute infectious diarrhoea (AID) concerns the antibiotic treatment of acute infectious inflammation of the gastrointestinal tract, manifesting primarily as diarrhoea. AID can be subdivided into community-acquired diarrhoea, traveller's diarrhoea and hospital-acquired (nosocomial) diarrhoea. In the first 2 categories, the need for antibiotic treatment is generally restricted to individuals with severe illness, dysentery or a predisposition to complications. High rates of primary fluoroquinolone resistance can be found in human Campylobacter isolates from the Netherlands and from other parts of the world. Therefore, if antibiotic treatment is necessary for community-acquired AID or AID in travellers returning to the Netherlands, it is advised to use oral azithromycin for 3 days as empirical treatment. If intravenous treatment is necessary, the combination of ciprofloxacin and erythromycin for 5-7 days may be considered. As soon as the identity of the causative organism is known, antimicrobial treatment should be tailored accordingly.
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Affiliation(s)
- J C Bos
- Academisch Medisch Centrum/Universiteit van Amsterdam
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Bos JC, Toorians AWFT, van Mourik JC, van Schijndel RJMS. Emergency resection of an extra-adrenal phaeochromocytoma: wrong or right? A case report and a review of literature. Neth J Med 2003; 61:258-65. [PMID: 14628962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Phaeochromocytomas are rare neuroendocrine tumours that produce symptoms through excess release of catecholamines. Treatment of choice is elective, complete surgical removal after pretreatment with alpha-adrenergic blocking drugs, to prevent dangerous haemodynamic fluctuations. In rare cases a 'catecholamine crisis' develops presenting with pulmonary oedema and circulatory shock. We report such a case of a patient with familial extra-adrenal phaeochromocytoma who successfully underwent emergency surgery. Pathophysiological mechanisms are discussed. Although pretreatment with alpha-adrenergic blocking drugs seems advisable in terms of morbidity and mortality, the concept is based on theory rather than clinical evidence. Surgical management of a catecholamine crisis is associated with high mortality rates. However, proof of better outcome by avoidance or discontinuation of emergency surgery is not available. Based on literature and on this case, we conclude that emergency surgery in phaeochromocytoma does not have to be structurally avoided and may be considered under life-threatening circumstances.
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Affiliation(s)
- J C Bos
- Department of Internal Medicine, Free University Medical Centre, De Boelelaan 1117, Amsterdam, The Netherlands.
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van Vonderen MGA, Bos JC, Prins JM, Wertheim-van Dillen P, Speelman P. Ribavirin in the treatment of severe acute respiratory syndrome (SARS). Neth J Med 2003; 61:238-41. [PMID: 14567520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Affiliation(s)
- M G A van Vonderen
- Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS and Academic Medical Centre, University of Amsterdam, Room F4-217, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Grooteman MP, van Tellingen A, van Houte AJ, Bos JC, Schoorl M, van Limbeek J, Nubé MJ. Hemodialysis-induced degranulation of polymorphonuclear cells: no correlation between membrane markers and degranulation products. Nephron Clin Pract 2000; 85:267-74. [PMID: 10867543 DOI: 10.1159/000045671] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Degranulation of polymorphonuclear leukocytes (PMN) during hemodialysis (HD) is usually assessed by measuring degranulation products. However, this process might also be estimated by the assessment of cell surface markers. In this study, the relationship between the expression of PMN degranulation markers (CD63 and CD66b) and the release of degranulation products [myeloperoxidase (MPO) and lactoferrin (LF)] was investigated during clinical HD in order to evaluate cell surface markers as a useful index of PMN degranulation. METHODS The expression of CD63 and CD66b on PMN and the release of MPO and LF were investigated in 10 chronic HD patients, during both heparin (HDhep) and trisodium citrate anticoagulation (HDcit), in a randomized order. Samples were drawn from both the efferent and afferent lines of the dialyzer at 0, 7.5, and 180 min. RESULTS During HDhep at first passage, a major increase in MPO (from 158 +/- 32 to 448 +/- 177 microg/l, p = 0.001) and LF (from 134 +/- 52 to 260 +/- 120 microg/l, p = 0.01) was found across the dialyzer, whereas marked changes were not observed during HDcit. The expression of CD63 and CD66b increased across the dialyzer during both anticoagulation modalities, but was only significant in the case of HDhep (CD63: mean fluorescence intensity from 247 +/- 61 to 331 +/- 118, p < 0.01; CD66b: mean fluorescence intensity from 340 +/- 76 to 434 +/- 103, p = 0.01). During HDhep a correlation was noted between the degranulation products and markers of both azurophilic and specific granules (MPO and CD63: r = 0.35; p < 0.01; LF and CD66b: r = 0.39, p < 0.01). Significant differences in the expression of CD63 and CD66b between HDhep and HDcit were not observed. When analyzing the combined data for both HDhep and HDcit, no correlation was observed between degranulation products and markers. CONCLUSION Our data suggest that the measurements of cell surface markers may not be a reliable indicator of the degree of HD-induced PMN degranulation.
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Bos JC, Grooteman MP, van Houte AJ, Schoorl M, van Limbeek J, Nubé MJ. Low polymorphonuclear cell degranulation during citrate anticoagulation: a comparison between citrate and heparin dialysis. Nephrol Dial Transplant 1997; 12:1387-93. [PMID: 9249774 DOI: 10.1093/ndt/12.7.1387] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Haemodialysis (HD)-induced bio-incompatibility includes alterations in both cellular elements and humoral factors. As far as polymorphonuclear (PMN) cells are concerned, an increase in both adhesion and degranulation has been reported. However, whereas increased PMN adherence and aggregation is highly linked with early transient complement activation, degranulation seems a continuous process, independent from the formation of complement degradation products. In the process of cell activation, including PMN degranulation, divalent cations (Ca2+) appear to play a pivotal role. As regionally administering citrate creates an almost Ca(2+)-free environment within the dialyser, it is tempting to speculate that Ca2+ dependent phenomena of bio-incompatibility, originating within the dialyser, can be attenuated by substituting conventional heparin for citrate. METHODS Therefore, both anticoagulation modalities were compared in 10 stable patients, undergoing haemodialysis (HD) treatment with cellulose-triacetate membranes (CTA) only. Apart from the intracellular granule products myeloperoxidase (MPO) and lactoferrin (LF), the classical parameters of bio-incompatibility, peripheral blood neutropenia and complement activation, were measured. RESULTS Analysis of MPO and LF gradients across the dialyser (concentration in efferent line-concentration in afferent line) suggested that degranulation is an early process, that occurs mainly within the extracorporeal circuit. Citrate abolished the release of MPO almost completely, whereas LF release was partially inhibited. Neither neutropenia, nor complement activation could be correlated with the occurrence of degranulation. CONCLUSIONS HD-induced PMN degranulation seems largely independent from complement activation, but primarily reliant on Ca2+, at least in the case of CTA membranes.
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Affiliation(s)
- J C Bos
- Department of Nephrology, Medical Centre Alkmaar, The Netherlands
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Grooteman MP, Bos JC, van Houte AJ, van Limbeek J, Schoorl M, Nubé MJ. Mechanisms of intra-dialyser granulocyte activation: a sequential dialyser elution study. Nephrol Dial Transplant 1997; 12:492-9. [PMID: 9075130 DOI: 10.1093/ndt/12.3.492] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION During haemodialysis (HD), an early and transient white blood cell (WBC) reduction is noted in the peripheral blood, which has been attributed mainly to the sequestration of polymorphonuclear cells (PMN) in the pulmonary vasculature. However, WBC also adhere to the dialyser, as demonstrated before in an elution study performed after HD. In the present study, we investigated if intradialyser WBC sequestration contributes to the WBC nadir in the blood shortly after the start of HD and whether or not different mechanisms underlie PMN adherence in dialyser and lung. In addition, PMN degranulation was analysed not only in peripheral blood but also in dialyser eluates (DE). SUBJECTS AND METHODS Dialysers were eluted after 7 1/2 (DE-7 1/2) and 180 (DE-180) min of HD in eight patients. Blood samples were taken before HD (t0), and at t7 1/2 and t180. Besides WBC count and differentiation, PMN adhesion (CD11b and CD62L) and degranulation markers (CD63 and CD66b) were assessed by flow cytometry. RESULTS In the blood, a WBC fall was noted at t7 1/2 (from 5.8 to 4.8 x 10(9)/l; absolute about 5 x 10(9) cells). DE contained 3.0 x 10(6) cells at t7 1/2, and 57.2 x 10(6) at t180 (P = 0.015). As for CD11b, at t7 1/2 both in the blood and DE an increased expression was observed, as compared to t0 (P = 0.01); CD11b expression in DE-7 1/2 was higher than in DE-180 (P = 0.025). In contrast, CD62L showed downregulation only in DE both at t7 1/2 (mean fluorescence intensity (MFI) PB 4172 and DE-7 1/2 2353, P = 0.01), and at t180 (MFI 794, P = 0.03 versus DE-7 1/2), when compared to blood at t0. As for degranulation markers, an increase was observed in blood at t7 1/2 (MFI CD63 from 357 to 506, P = 0.02; CD66b from 507 to 794, P = 0.001), in comparison with t0. Eluted PMN at t7 1/2 showed a higher expression of CD63 than PMN in blood at t7 1/2 and DE-180 (MFI in DE-7 1/2 1280 and blood 506, P = 0.003). The expression of CD66b was increased in DE-7 1/2 (MFI 1803 versus blood 794, P = 0.01), and even more in DE-180 (MFI 2763, P = 0.002), when compared to blood. CONCLUSIONS From these data it is concluded first, that intradialyser PMN sequestration does not contribute markedly to the WBC nadir in the circulation. Second, intradialyser PMN trapping appears to result primarily from non-adhesion-molecule-mediated factors, as indicated by an increased expression of CD11b at t7 1/2 on eluted PMN associated with low cell numbers in DE, and normalized CD11b expression at t180 associated with considerably higher cell numbers in DE. Third, HD-induced degranulation seems to be a complex phenomenon. After a rapid transient onset, characterized by an early upregulation of CD63 and CD66b on PMN leaving the dialyser, degranulation continues within the device as indicated by an additional rise in the expression of CD66b on PMN in DE-180.
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Affiliation(s)
- M P Grooteman
- Department of Nephrology, Medical Center Alkmaar, The Netherlands
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Grooteman MP, Nubé MJ, Bos JC, van Limbeek J, Schoorl M, van Houte AJ. Ex vivo elution of hemodialyzers. An additional criterion for the assessment of bioincompatibility. Blood Purif 1996; 14:421-30. [PMID: 8915571 DOI: 10.1159/000170295] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The analysis of hemodialysis (HD)-related bioincompatibility is focused mainly on phenomena observed in peripheral blood. However, since biocompatibility originates inside the dialyzer, white blood cells (WBC) adhering to the dialyzer are probably most subject to the influence of both dialyzer membrane and dialysate. In order to collect membrane-adherent cells, a reliable and reproducible elution technique was developed. After 3 h of HD, blood was returned to the patient with 0.9% NaCl. Then, dialyzers were eluted by recirculation of phosphate-buffered saline (PBS) or PBS/3 mM EDTA for 20 min, with or without prior flushing with 200 ml PBS. Finally, remaining adherent cells were collected by an afterwash with 10% trypsin. These solutions, as well as blood samples, were analyzed for WBC count, viability and differentiation. Random eluate samples were analyzed by flow cytometry, and the influence of elution on PMN activation was tested in a separate control experiment. WBC numbers decreased by flushing before elution, whereas cell numbers were maximal after elution with PBS/3 mM EDTA (30 x 10(6)). Trypsin afterwash resulted in a further yield of 12 x 10(6) cells. The eluates contained 81% PMN (blood 68%, p < 0.01), with a degranulated appearance, and only 12% lymphocytes (blood 21%, p < 0.05); cell viability in the eluates was > 95%. The eluted cells could be analyzed by flow cytometry, and the procedure itself induced only minimal PMN activation. In conclusion, a maximal number of adherent cells, consisting mainly of PMN, was obtained by direct elution with PBS/3 mM EDTA. The method itself did not induce marked PMN activation, and the cells obtained were suitable for further investigations, including flow cytometry.
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Affiliation(s)
- M P Grooteman
- Department of Nephrology, Medical Center Alkmaar, The Netherlands
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Bos JC, Stoeckart R, Klooswijk AI, van Linge B, Bahadoer R. The surgical anatomy of the superior gluteal nerve and anatomical radiologic bases of the direct lateral approach to the hip. Surg Radiol Anat 1994; 16:253-8. [PMID: 7863411 DOI: 10.1007/bf01627679] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In view of the increasing popularity of the direct lateral approach to the hip joint for hemi- or total hip arthroplasty, the location of the superior gluteal nerve (SGN) was studied. This nerve is in danger when using a transgluteal incision. In 20 embalmed specimens the relation of the SGN to the tip of the greater trochanter (TT) was studied as well as the relation to the iliac crest. For this purpose macroscopy, microscopy and CT were used. In 13 hips a so-called most inferior branch was found at an average of 1 cm distal to the inferior branch, the main trunk of the nerve. There was substantial variation in the course of both the inferior and the most inferior branch of the SGN. In order to prevent nerve damage, proximal extension of the transgluteal incision should be limited to 3 cm cranial to TT. Furthermore the incision has to be confined to the distal one third of the distance TT-iliac crest. In tall people extra care should be taken.
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Affiliation(s)
- J C Bos
- Department of Orthopedics, Antonius Ziekenhuis, Sneek, The Netherlands
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Bos JC. ["The Soul-Searchers"--discussion of circulars of the Secret Committee. With a letter by Freud and Rank]. Psyche (Stuttg) 1994; 48:396-424. [PMID: 8016395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The appearance of Georg Groddeck's novel Der Seelensucher (1921) in the Internationaler Psychoanalytischer Verlag caused a stir among the members of the Secret Committee which, as hitherto unpublished circulars from Committee members testify, then developed into a full-grown controversy. Proceeding from the documents themselves, the author traces the course and the eventual settlement of the difference of opinion over Groddeck's novel. His concern in so doing is not so much to throw light on an episode in the early history of psychoanalysis but rather to take that episode as an instance demonstrating the nature of the discourse mechanisms introduced by Freud to protect the central tenets of his teachings. Bos concludes that these were largely institutional defence mechanisms designed to control the generation of psychoanalytic discourse among the Committee members. In present-day terms, the question arises to what extent psychoanalytic societies and institutions employ such discourse strategies vis-à-vis non-conformists and outsiders.
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Affiliation(s)
- J C Bos
- Universität Utrecht, FB Allgemeine Sozialwissenschaften
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Bos JC, de Waal Malefijt MC, Keessen W. [Congenital hip dislocation; causes and sequelae of late diagnosis]. Ned Tijdschr Geneeskd 1989; 133:890-5. [PMID: 2725750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The causes of late diagnosis of congenital dislocation of the hip were examined retrospectively in a group of 49 children (56 hips affected). It appears that at neonatal examination as well as a further screening during the first year of life, the classical symptoms of this condition are not infrequently missed. The classical tests for the early diagnosis are described and the consequences of late diagnosis are studied. In spite of late detection, the final result of the treatment in most cases is quite favourable. However, this result can only be achieved by prolonged and intensive treatment, including hospitalization and surgery.
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de Waal Malefijt MC, Bos JC, Keessen W. [Surgical treatment of persistent congenital clubfoot in the young child]. Tijdschr Kindergeneeskd 1988; 56:292-7. [PMID: 3238682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
From 1979-1985 seventeen children with twenty-six club-feet were treated. Thirty-four operations have been carried out, divided in three surgical procedures. The heel cord was lengthened in eight feet, a posterior release was done in thirteen feet and a posteromedial release according to Turco was done thirteen times as well. Lengthening of the heel cord seemed to be an insufficient procedure, because six out of eight feet showed a recurrent deformity. The posterior release has given in half of the cases a good result. After posteromedial release we saw in 70% a good or excellent result, when this procedure has been performed between the age of six to twelve months.
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Bos JC, Biemans RG. Subtotal mesh-wrapping in the treatment for abdominal aortic aneurysm. J Cardiovasc Surg (Torino) 1988; 29:522-9. [PMID: 3182919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A new technique for managing abdominal aortic aneurysms is described. This so called "subtotal mesh-wrapping" may be considered for high-risk patients with large or growing aneurysms even those extending proximally to the renal arteries. The results in 19 patients, treated by this method, are discussed. Poor general condition renders peri-operative mortality high. But long-term prognosis is improved and with the abandoning of appendectomy will benefit still more.
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Affiliation(s)
- J C Bos
- Department of Vascular Surgery, De Stadsmaten Hospital, Enschede, The Netherlands
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