Radboud University Research Articles

Cardiac function in relation to myocardial injury in hospitalised patients with COVID-19.

BackgroundPrevious studies have reported on myocardial injury in patients with coronavirus infectious disease 19 (COVID-19) defined as elevated cardiac biomarkers. Whether elevated biomarkers truly represent myocardial dysfunction is not known. The aim of this study was to explore the incidence of ventricular dysfunction and assess its relationship with biomarker analyses.MethodsThis cross-sectional study ran from April 1 to May 12, 2020, and consisted of all consecutively admitted patients to the Radboud university medical centre nursing ward for COVID-19. Laboratory assessment included high-sensitivity Troponin T and N‑terminal pro-B-type natriuretic peptide (NT-proBNP). Echocardiographic evaluation focused on left and right ventricular systolic function and global longitudinal strain (GLS).ResultsIn total, 51 patients were included, with a median age of 63 years (range 51–68 years) of whom 80% was male. Troponin T was elevated (>14 ng/l) in 47%, and a clinically relevant Troponin T elevation (10 × URL) was found in three patients (6%). NT-proBNP was elevated (>300 pg/ml) in 24 patients (47%), and in four (8%) the NT-proBNP concentration was >1,000 pg/ml. Left ventricular dysfunction (ejection fraction <52% and/or GLS >−18%) was observed in 27%, while right ventricular dysfunction (TAPSE <17 mm and/or RV S’ < 10 cm/s) was seen in 10%. There was no association between elevated Troponin T or NT-proBNP and left or right ventricular dysfunction. Patients with confirmed pulmonary embolism had normal right ventricular function.ConclusionsIn hospitalised patients, it seems that COVID-19 predominantly affects the respiratory system, while cardiac dysfunction occurs less often. Based on a single echocardiographic evaluation, we found no relation between elevated Troponin T or NT-proBNP, and ventricular dysfunction. Echocardiography has limited value in screening for ventricular dysfunction.Electronic supplementary materialThe online version of this article (10.1007/s12471-020-01458-2) contains supplementary material, which is available to authorized users.

Impact of a nutritional supplement (Impryl) on male fertility: study protocol of a multicentre, randomised, double-blind, placebo-controlled clinical trial (SUppleMent Male fERtility, SUMMER trial)

IntroductionInfertility is a worldwide problem and about 10%–15% of all couples will be affected by the inability to have children. In approximately 50% of infertile couples, a male factor is...

External validation of deep learning-based contouring of head and neck organs at risk.

Background and purposeHead and neck (HN) radiotherapy can benefit from automatic delineation of tumor and surrounding organs because of the complex anatomy and the regular need for adaptation. The aim of this study was to assess the performance of a commercially available deep learning contouring (DLC) model on an external validation set.Materials and methodsThe CT-based DLC model, trained at the University Medical Center Groningen (UMCG), was applied to an independent set of 58 patients from the Radboud University Medical Center (RUMC). DLC results were compared to the RUMC manual reference using the Dice similarity coefficient (DSC) and 95th percentile of Hausdorff distance (HD95). Craniocaudal spatial information was added by calculating binned measures. In addition, a qualitative evaluation compared the acceptance of manual and DLC contours in both groups of observers.ResultsGood correspondence was shown for the mandible (DSC 0.90; HD95 3.6 mm). Performance was reasonable for the glandular OARs, brainstem and oral cavity (DSC 0.78–0.85, HD95 3.7–7.3 mm). The other aerodigestive tract OARs showed only moderate agreement (DSC 0.53–0.65, HD95 around 9 mm). The binned measures displayed the largest deviations caudally and/or cranially.ConclusionsThis study demonstrates that the DLC model can provide a reasonable starting point for delineation when applied to an independent patient cohort. The qualitative evaluation did not reveal large differences in the interpretation of contouring guidelines between RUMC and UMCG observers.

Editorial introductions

Editorial introductions

Editorial introductions

Editorial introductions

Impact of Failing Insert Coils on the Mechanical Design of the HFML 45 T Hybrid Magnet System

The High Field Magnet Laboratory of the Radboud University is constructing a 45 T hybrid magnet system. Large fault forces may arise in the not so unlikely event of failure of parts of the resistive insert magnet. The measures taken to accept the fault forces dominate the design of the support structures, in particular those coupling the room temperature resistive insert magnet with the superconducting coil in the cryogenic environment. The largest fault forces arise when half of one or several insert coils become electrically short-circuited in a burn-out accident. In case the complete upper or lower half of all the resistive coils collectively disappear, the so-called ultimate axial fault force on the superconducting outsert coil may amount to several MN - calculated in a static approach. Traditionally these ultimate fault forces are reference for the mechanical design to guarantee that the structures can sustain these forces preventing catastrophic failure of the magnet's housing. We will argue that if one takes into account the time dependent behavior of the powering and protection systems after detection of a coil failure, the resulting fault forces will be much smaller than the ultimate fault forces predicted by static approach.

MON-130 Improving the Accuracy and Reliability of Free Thyroxine (FT4) Measurements Through the CDC Clinical Standardization Programs (CSP)

Reliable free thyroxine (FT4) measurements are essential for assessing thyroid function and for correctly diagnosing and treating thyroid disorders. Thyroid hormones play an important role in normal brain development of the fetus, and abnormal FT4 during pregnancy is associated with adverse pregnancy outcomes. Standardization of FT4 measurements, is critical to improving the accuracy and reliability of current methods and thus to improve diagnosis, treatment and prevention of thyroidal illnesses. Currently, there are no serum-based reference materials available for FT4 to assess the accuracy and reliability of FT4 assays. CDC CSP is collaborating with the International Federation of Clinical Chemistry and Laboratory Medicine, and the Partnership for the Accurate Testing for Hormones to address these issues through development of an accurate and sensitive higher-order Reference Measurement Procedure (RMP) for FT4 that will be used to assign target value to serum-based materials. The CDC CSP FT4 reference method is using equilibrium dialysis in combination with liquid chromatography tandem mass spectrometry (LC-MS/MS). FT4 in serum is isolated from the binding proteins in 1 mL equilibrium dialysis cells for 4 hours at 37oC. FT4 is further isolated by extractions prior to LC-MS/MS analysis. To determine the concentration of FT4 in serum, certified primary reference materials are used to prepare calibration materials. Chromatographic separation is achieved using a C18 reverse phase column with a gradient of methanol and water with 0.1% formic acid. Quantification by selective reaction monitoring is performed in the positive mode using electrospray ionization. Two transitions are monitored for each analyte and internal standard, and triplicate injections are used to minimize instrument instability. The within- and between-day imprecision for the CDC RMP are 2.2–3.9% and 1.8–2.6%, respectively. By comparisons with the RMPs at Ghent University in Belgium, Radboud University Medical Center in the Netherlands, and the Reference Material Institute for Clinical Chemistry Standards in Japan, the CDC RMP reported a bias within +2.5% of the mean for all labs. Factors affecting measurement accuracy were investigated, to maximize recovery for optimum performance of the method. FT4 was detectable in all samples, and thus, suitable for analysis of hypo-, eu-, and hyperthyroid patients. A comparison among hypo-, eu-, and hyperthyroid patients of a commercially available immunoassay and the CDC RMP indicated a mean bias of -37.7%. The CDC CSP has also evaluated the RMP for accurate measurement of FT4 in pregnant individuals. This candidate reference method for FT4 in serum demonstrates good accuracy and precision, and can be used as a viable base for accuracy to which routine methods for FT4 can be compared. 1. Van Houcke, S.K., et. al. Clin. Chem. Lab. Med. 2011, 49, 1275–1281.

TcMEP threshold change is superior to A-train detection when predicting facial nerve outcome in CPA tumour surgery

ObjectSurgery of tumours in the cerebellopontine angle (CPA) can lead to loss of facial nerve function. Different methods of intra-operative nerve monitoring (IOM) (including free-running EMG, direct nerve stimulation and transcranial motor evoked potentials (TcMEP)) have been used to predict facial nerve outcome during surgery. Recent research has shown TcMEP threshold increase and the occurrence of A-trains on the EMG to have great potential in doing so. This study compares these two methods and correlates them to House-Brackmann (HB) scores post-op in patients with tumours in the cerebellopontine angle.MethodForty-three patients (one was operated twice) with large CPA tumours treated surgically in the Radboud University Medical Center between 2015 and 2019 were included in this study. During surgery, TcMEP threshold increases and A-train activity were measured. Because our treatment paradigm aims at facial nerve preservation (accepting residual tumour), TcMEP threshold increase of over 20 mA or occurrence of A-trains were considered as warning signs and used as a guide for terminating surgery. HB scores were measured post-op, at 6 weeks, 6 months and 1 year after surgery. Spearman’s correlation was calculated between the IOM-values and the HB scores for a homogeneous subgroup of 30 patients with vestibular schwannoma (VS) without neurofibromatosis type II (NF-II) and all patients collectively.ResultsTcMEP threshold was successfully measured in 39 (90.7%) procedures. In the homogeneous VS non-NFII group, we found a statistically significant moderate-to-strong correlation between TcMEP threshold increase and House Brackmann score immediately post-op, at 6 weeks, 6 months and 1 year after surgery (Spearman’s rho of 0.79 (p < 0.001), 0.74 (p < 0.001), 0.64 (p < 0.001) and 0.58 (p = 0.002), respectively). For A-trains, no correlation was found. Similar results were found when including all patients with CPA tumours. A threshold increase of < 20 mA was a predictor of good facial nerve outcome.ConclusionThese results show that TcMEP threshold increases are strongly correlated to post-operative HB scores, while A-trains are not. This suggests TcMEP threshold increases can be a valuable predictor for facial nerve outcome in patients with large tumours when facial nerve preservation is prioritized over total resection. In this study, we found no use for A-trains to prevent facial nerve deficits.

Simple MRI score aids prediction of dementia in cerebral small vessel disease.

ObjectiveTo determine whether a simple small vessel disease (SVD) score, which uses information available on rapid visual assessment of clinical MRI scans, predicts risk of cognitive decline and dementia, above that provided by simple clinical measures.MethodsThree prospective longitudinal cohort studies (SCANS [St George's Cognition and Neuroimaging in Stroke], RUN DMC [Radboud University Nijmegen Diffusion Imaging and Magnetic Resonance Imaging Cohort], and the ASPS [Austrian Stroke Prevention Study]), which covered a range of SVD severity from mild and asymptomatic to severe and symptomatic, were included. In all studies, MRI was performed at baseline, cognitive tests repeated during follow-up, and progression to dementia recorded prospectively. Outcome measures were cognitive decline and onset of dementia during follow-up. We determined whether the SVD score predicted risk of cognitive decline and future dementia. We also determined whether using the score to select a group of patients with more severe disease would reduce sample sizes for clinical intervention trials.ResultsIn a pooled analysis of all 3 cohorts, the score improved prediction of dementia (area under the curve [AUC], 0.85; 95% confidence interval [CI], 0.81–0.89) compared with that from clinical risk factors alone (AUC, 0.76; 95% CI, 0.71–0.81). Predictive performance was higher in patients with more severe SVD. Power calculations showed selecting patients with a higher score reduced sample sizes required for hypothetical clinical trials by 40%–66% depending on the outcome measure used.ConclusionsA simple SVD score, easily obtainable from clinical MRI scans and therefore applicable in routine clinical practice, aided prediction of future dementia risk.

Professionalizing peer instructor skills in basic life support training for medical students: A randomized controlled trial

Background:The Radboud university medical center designed an obligatory basic life support and first‐aid course for first‐year medical students.Objectives:We evaluated the value of an additional train‐the‐trainer course following European Resuscitation Council guidelines, which focuses on practical basic life support training and providing feedback, in comparison with standard in‐service instructor training.Methods:This study was a prospective randomized controlled trial. A total of 10 intervention instructors, 14 control instructors, and 337 first‐year medical students participated in the study. Students, blinded for the type of instructor, completed questionnaires evaluating the quality of the basic life support training (theoretical and practical) and provided feedback. The secondary endpoint was the basic life support examination to assess whether the instructors’ training influenced the quality of the participants’ basic life support.Results:The response rate of the questionnaire was 82% on average. No differences were found between intervention and control group concerning theoretical basic life support training. The intervention instructors scored significantly higher on practical basic life support training according to student evaluations (p &lt; 0.001). The pass rate on basic life support examinations did not differ significantly (p = 0.669). Appreciation of given feedback was independent of instructors’ educational training.Conclusion:This study is the first to establish that the 12‐h train‐the‐trainer course following European Resuscitation Council guidelines improves students’ appreciation of practical basic life support training. The additional course did not influence appreciation of theoretical basic life support training or perceived feedback.

Students' awareness of LGBT resources in Dutch dental schools.

The aim of this survey-based study was to investigate dental students' perceptions regarding the available services and facilities for LGBT persons in Dutch dental school administrations. A 19-item questionnaire, originally developed in English, was implemented for the study purposes. Translation into Dutch as well as cross-cultural and conceptual adaptation were performed according to well-established guidelines. A link to the survey was sent via e-mail to all registered undergraduate students at the Academic Center for Dentistry Amsterdam (ACTA), and the dental schools of the University of Groningen (RUG) and the Radboud University Medical Center Nijmegen (RUMC). Of the 1,789 students initially invited to participate, 294 completed the online survey. Response rates among dental schools ranged between 7.60% and 20.24%. As a whole, the students of the participating dental schools were not cognizant of existing resources for LGBT students. There were significant differences in students' perceptions across schools, with RUG students being significantly less aware of LGBT resources compared to ACTA and RUMC (P<0.05). Students' perceptions were not significantly influenced by school, sexual preference, and year of study (P>0.05). No significant differences were observed in the responses of LGBT and non-LGBT students (P>0.05). Undergraduate students were generally not aware of LGBT resources in Dutch dental schools. This lack of knowledge calls for attention by dental school administrators, program directors, and faculty to foster a visible, comprehensive, culturally competent environment in dental education settings in The Netherlands.

Self-perceived health problems and unmet care needs of homeless people in the Netherlands : the need for pro-active integrated care

Homeless people suffer from bad health and encounter barriers in accessing services, and live in difficult social circumstances. However, no insight exists in how homeless people in the Netherlands themselves experience their health and unmet care needs in relation to their social Marieke Verheul MSc MD Department of Primary and Community Care Radboud university medical center, Nijmegen, the Netherlands Igor van Laere PhD MD Netherlands Streetdoctors Group, the Netherlands 22 Journal of Social Intervention: Theory and Practice – 2020 – Volume 29, Issue 1 Self-perceived health problems and unmet care needs of homeless people in the Netherlands circumstances. In order to tailor medical and other services to their needs, this study aims to gain insight into the self-perceived health problems, and unmet care needs in relation to the social circumstances of homeless people in the Netherlands.

Serie: Onderwijs en de tandarts anno 2025. Drie opleidingen tandheelkunde in Nederland: drie soorten tandartsen?

In the context of the series on education and the dentist in 2025, the directors of education and training at the 3 dentistry programmes in the Netherlands were asked about the kind of dentist they are training. If, after all, the head of a dental practice is looking for a new colleague and has 3 candidates, each from a different faculty, what can he expect of each of them and are there differences in the 'kind of dentist' they are? In the spring of 2019, Geerling Langenbach and Corine Visscher of the ACTA (Academic Centre for Dentistry Amsterdam), Nico Creugers and Ohlin Cremers of the Radboud University in Nijmegen and Luc van der Sluis and Berdien Kooistra-Akse of the Rijksuniversiteit Groningen were interviewed one after another by Denise van Diermen, guest editor of the series 'Education and the dentist in 2025'.

Impact of the BioFire FilmArray gastrointestinal panel on patient care and infection control.

ObjectivesConventional routine PCR testing for gastrointestinal infections is generally based on pathogen related panels specifically requested by clinicians and can be erroneous and time consuming. The BioFire FilmArray gastrointestinal (GI) panel combines 22 pathogens into a single cartridge-based test on a random-access system, thereby reducing the turnaround time to less than 2 hours. We described the clinical impact of implementing the BioFire FilmArray on patients with gastroenteritis in our hospital.MethodsPatients attending a Dutch tertiary care center (Radboud University Medical Center), from whom stool samples were obtained, were eligible for inclusion. The clinicians selected one or a combination of different routinely performed PCR panels (bacterial panel, viral panel, clostridium testing, and three parasitic panels) based on clinical history and symptoms. All samples were in parallel tested with the FilmArray. We retrospectively collected patient data regarding infection control and patient management to assess the potential impact of implementing the FilmArray.ResultsIn total 182 patients were included. Routine PCR detected one or more pathogens in 52 (28.6%) patients compared to 72 (39.6%) using the FilmArray. Turnaround time (including transport) decreased from median 53 hours for the routine PCR to 16 hours for the FilmArray. Twenty-six patients could have been removed from isolation 29 hours sooner, 3.6 antibiotic days could have been saved and in five patients additional imaging testing (including colonoscopies) could have been prevented.ConclusionThe theoretical implementation of the BioFire FilmArray GI panel in patients with clinical suspicion of gastroenteritis resulted in a significant better patient management.

Pelvic floor rehabilitation to improve functional outcome and quality of life after surgery for rectal cancer: study protocol for a randomized controlled trial (FORCE trial)

BackgroundAfter low anterior resection (LAR), up to 90% of patients develop anorectal dysfunction. Especially fecal incontinence has a major impact on the physical, psychological, social, and emotional functioning of the patient but also on the Dutch National Healthcare budget with more than €2000 spent per patient per year. No standardized treatment is available to help these patients. Common treatment nowadays is focused on symptom relief, consisting of lifestyle advices and pharmacotherapy with bulking agents or antidiarrheal medication. Another possibility is pelvic floor rehabilitation (PFR), which is one of the most important treatments for fecal incontinence in general, with success rates of 50–80%. No strong evidence is available for the use of PFR after LAR. This study aims to prove a beneficial effect of PFR on fecal incontinence, quality of life, and costs in rectal cancer patients after sphincter-saving surgery compared to standard treatment.MethodsThe FORCE trial is a multicenter, two-armed, randomized clinical trial. All patients that underwent LAR are recruited from the participating hospitals and randomized for either standard treatment or a standardized PFR program. A total of 128 patients should be randomized. Optimal blinding is not possible. Stratification will be done in variable blocks (gender and additional radiotherapy). The primary endpoint is the Wexner incontinence score; secondary endpoints are health-related and fecal-incontinence-related QoL and cost-effectiveness. Baseline measurements take place before randomization. The primary endpoint is measured 3 months after the start of the intervention, with a 1-year follow-up for sustainability research purposes.DiscussionThe results of this study may substantially improve postoperative care for patients with fecal incontinence or anorectal dysfunction after LAR. This section provides insight in the decisions that were made in the organization of this trial.Trial registrationNetherlands Trial Registration, NTR5469, registered on 03-09-2015.Protocol FORCE trial V18, 19-09-2019.Sponsor Radboud University Medical Center, Nijmegen.

Structural network efficiency predicts cognitive decline in cerebral small vessel disease

Cerebral small vessel disease (SVD) is a common disease in older adults and a major contributor to vascular cognitive impairment and dementia. White matter network damage is a potentially important mechanism by which SVD causes cognitive impairment. Earlier studies showed that a higher degree of white matter network damage, indicated by lower global efficiency (a graph-theory measure assessing efficiency of network information transfer), was associated with lower scores on cognitive performance independent of MRI markers for SVD. However, it is unknown whether this global efficiency index is the strongest predictor for cognitive impairment, as there is a wide range of network measures. Here, we investigate which network measure is the most informative in explaining baseline cognitive performance and decline over a period of 8.7 years in SVD. We used data from the Radboud University Nijmegen Diffusion tensor and MRI Cohort (RUN DMC), which included 436 participants without dementia (65.2 ± 8.8 years) but with evidence of SVD on neuroimaging. Binarized and weighted structural brain networks were reconstructed using diffusion tensor imaging and deterministic streamlining. Using graph-theory, we calculated 21 global network measures and performed linear regression analyses, elastic net analysis and linear mixed effect models to compare these measures. All analyses were adjusted for potential confounders (age, sex, educational level, depressive symptoms and conventional SVD MRI-markers (e.g. white matter hyperintensities (WMH), lacunes of presumed vascular origin and microbleeds). The elastic net analyses showed that, at baseline, global efficiency had the strongest association with cognitive index (CI), while characteristic path length showed the strongest association with psychomotor speed (PMS) and memory. Binary local efficiency showed the strongest association with attention & executive function (A&EF). In addition, linear mixed-effect models demonstrated that baseline global efficiency predicts decline in CI (χ2(1) = 8.18, p = 0.004),PMS (χ2(1) = 7.75, p = 0.005), memory (χ2(1) = 27.28, p = 0.000) over time and that binary local efficiency predicts decline in A&EF (χ2(1) = 8.66, p = 0.003) over time. Our results suggest that among all network measures, network efficiency measures, i.e. global efficiency and local efficiency, are the strongest predictors for cognitive functions at cross-sectional level and also predict faster cognitive decline in SVD, which is in line with earlier findings. These findings suggests that in our study sample network efficiency measures are the most suitable surrogate markers for cognitive performance in patients with cerebral SVD among all network measures and MRI markers, and play a key role in the genesis of cognitive decline in SVD.

Image quality comparison between a phase-contrast synchrotron radiation breast CT and a clinical breast CT: a phantom based study

In this study we compared the image quality of a synchrotron radiation (SR) breast computed tomography (BCT) system with a clinical BCT in terms of contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR), noise power spectrum (NPS), spatial resolution and detail visibility. A breast phantom consisting of several slabs of breast-adipose equivalent material with different embedded targets (i.e., masses, fibers and calcifications) was used. Phantom images were acquired using a dedicated BCT system installed at the Radboud University Medical Center (Nijmegen, The Netherlands) and the SR BCT system at the SYRMEP beamline of Elettra SR facility (Trieste, Italy) based on a photon-counting detector. Images with the SR setup were acquired mimicking the clinical BCT conditions (i.e., energy of 30 keV and radiation dose of 6.5 mGy). Images were reconstructed with an isotropic cubic voxel of 273 µm for the clinical BCT, while for the SR setup two phase-retrieval (PhR) kernels (referred to as “smooth” and “sharp”) were alternatively applied to each projection before tomographic reconstruction, with voxel size of 57 × 57 × 50 µm3. The CNR for the clinical BCT system can be up to 2-times higher than SR system, while the SNR can be 3-times lower than SR system, when the smooth PhR is used. The peak frequency of the NPS for the SR BCT is 2 to 4-times higher (0.9 mm−1 and 1.4 mm−1 with smooth and sharp PhR, respectively) than the clinical BCT (0.4 mm−1). The spatial resolution (MTF10%) was estimated to be 1.3 lp/mm for the clinical BCT, and 5.0 lp/mm and 6.7 lp/mm for the SR BCT with the smooth and sharp PhR, respectively. The smallest fiber visible in the SR BCT has a diameter of 0.15 mm, while for the clinical BCT is 0.41 mm. Calcification clusters with diameter of 0.13 mm are visible in the SR BCT, while the smallest diameter for the clinical BCT is 0.29 mm. As expected, the image quality of the SR BCT outperforms the clinical BCT system, providing images with higher spatial resolution and SNR, and with finer granularity. Nevertheless, this study assesses the image quality gap quantitatively, giving indications on the benefits associated with SR BCT and providing a benchmarking basis for its clinical implementation. In addition, SR-based studies can provide a gold-standard in terms of achievable image quality, constituting an upper-limit to the potential clinical development of a given technique.

Perceptions of interprofessional collaboration in education of dentists and dental hygienists and the impact on dental practice in the Netherlands: A qualitative study

IntroductionThe purpose of this study was to evaluate the perceptions of dentists and dental hygienists regarding their own and each other's roles in interprofessional collaboration following a clinical interprofessional educational programme (CIEP) as part of their graduate programme at Radboud university medical center (Radboudumc) and HAN University of Applied Sciences (HAN UAS), Nijmegen, the Netherlands, respectively. Perceptions were obtained at the end of their study (2014) and two years after their graduation (2016).MethodsA qualitative study was conducted using a questionnaire with open‐ended questions. Sixty‐two dentists and thirty‐eight dental hygienists were invited. Theory‐based analyses were applied in combination with principles of Grounded Theory to analyse and synthesise the collected data from the open‐ended questions.ResultsAt baseline, 100% responded. At follow‐up, thirty‐two dentists (51.6%) and twenty‐six dental hygienists (68.4%) responded; twenty‐seven dentists (43.5%) and eighteen dental hygienists (47.4%) were included. Many similarities were found between baseline and follow‐up regarding perceptions of each other's expertise and responsibility, learning from and with each other, and the behaviour of students and the “novice” professionals in interprofessional collaboration. Both dentists and dental hygienists experienced the CIEP as useful for interprofessional collaboration. The “novice” dentists and dental hygienists indicated that in dental practices interprofessional collaboration was less common.ConclusionThe CIEP resulted in more understanding amongst dentists and dental hygienists with regard to interprofessional roles, but in practice the “novice” dentists and dental hygienists face difficulties in applying the interprofessional roles.

Changes in severity and impact of drooling after submandibular gland botulinum neurotoxin A injections in children with neurodevelopmental disabilities.

AimsTo examine changes in objective and subjective drooling severity measures after submandibular botulinum neurotoxin A injection in children with neurodevelopmental disabilities, explore their relationship, and evaluate if clinically relevant responses relate to changes in the impact of drooling.MethodThis longitudinal, observational cohort study involved 160 children (92 males, 68 females; 3–17y, mean 9y 1mo, SD 3y 6mo) treated between 2000 and 2012 at the Radboud University Medical Center, Nijmegen, the Netherlands. Repeated measures analysis of variance was used to compare the 5‐minute Drooling Quotient (DQ5) and Visual Analogue Scale (VAS) for drooling severity pretreatment and posttreatment, and Pearson’s rho to assess their association. A parent questionnaire was used to assess drooling impact in responders (defined as ≥50% reduction in DQ5 and/or ≥2 SD reduction in VAS for drooling severity 8wks postintervention) and non‐responders.ResultsOne hundred and twelve children (70%) were responders. Their mean VAS for drooling severity and DQ5 scores were significantly lower 32 weeks postintervention compared to baseline. At baseline, the VAS for drooling severity‐DQ5 relationship was ‘weak’ (rs=0.15, p=0.060), whereas it was ‘fair’ at 8 weeks (rs=0.43, p=0.000) and 32 weeks (rs=0.30, p=0.000). For responders, a significant change was found regarding the impact of drooling on daily care and social interactions at 8 weeks after intervention; most of these effects were maintained at 32 weeks.InterpretationA clinically relevant response based on a combination of objective and subjective measures of drooling severity was accompanied by positive changes regarding the impact of drooling on daily care and social interactions.What this paper adds Botulinum neurotoxin A injection into the submandibular glands reduced drooling severity in 70% of children with neurodevelopmental disabilities.Objective (5‐minute Drooling Quotient) and subjective (Visual Analogue Scale for drooling severity) measures correlated 8 and 32 weeks after treatment.Objective and subjective measures complemented each other when changes in drooling severity were assessed.Reduced drooling severity was accompanied by positive changes with regard to the impact of drooling.

Advances and Latest Insights in Non-Biologic Systemic Therapeutic Agents in Psoriasis and Atopic Dermatitis

Prof Peter van de Kerkhof, Radboud University Nijmegen Medical Centre, the Netherlands, discussed the very long history, particularly in Germany and the Netherlands, of dimethyl fumarate (a fumaric acid ester [DMF]) in treating psoriasis in adults. However, only recently, with a new DMF product registration in Europe, has clinical research escalated to investigate the most effective clinical use of this agent. Treatment strategies in patients with psoriasis should be personalised, with considerations of the disease, patient characteristics and preferences, as well as current and historical treatments. He presented a case scenario to highlight which patients might benefit most from DMF as a first-line systemic treatment for moderate-to-severe psoriasis. He further discussed the role of acitretin (a synthesised retinoic acid) as monotherapy in pustular psoriasis and erythrodermic psoriasis, and in combination for chronic plaque psoriasis. He concluded that in patients requiring systemic therapy with contraindications for immunosuppressive therapies, DMF and acitretin may provide a unique profile and treatment solution.