Disruptive behaviour disorders in children: environmental and genetic risk factors.

The early onset mental disorder attention-deficit/hyperactivity disorder (ADHD) is found in 3
to 5 % of the population. Symptoms including inattention, hyperactivity, and impulsivity
characterize this disorder, which results in considerable impairment such as learning
difficulties and problems with social functioning. Examples of the social problems related to
the disorder include problems with parents, peer rejection and unpopularity at school.
[Nijmeijer J.S. et al, 2007]. Moreover, they show high co-morbidity with a number of
psychiatric disorders including oppositional defiant disorder (ODD) and conduct disorder
(CD). Other related disorders are, anxiety disorder, depression, substance abuse, and
pervasive developmental disorder (PDD).
Oppositional defiant and conduct problems are common in young children. The main
characteristics of ODD are negative, argumentative, angry and defiant behavior. Aggression
or serious threats of harm to people or animals; property damage or destruction (e.g. fire
setting, vandalism); frequent violations of household or school rules, laws and persistent lying
to avoid consequences or to obtain tangible goods or privileges, are recognized symptoms of
CD. [Anney et al, 2008] The social problems as a result of CD are an increased risk of peer
rejection, parental abuse, and at later stages, poor school adaptation and dropout, substance
abuse, and juvenile delinquency. [Larsson et al, 2008]
Although the exact etiology of ADHD is unknown, Spencer et al 2007 found
substantial evidence of a genetic background. Up to 75%-80% of ADHD symptoms are due
to genetic factors, 55% for ODD and between 50%-62% for CD. [Grizenko et al2008]. The
focal point of most genetic studies into ADHD, are the genes relating to the dopaminergic
pathways. [Kahn et al, 2003] Besides evidence for genetic risk factors there are also
influences of environmental risk factors in the development of ADHD, ODD and CD. [Retz et
al, 2008] A number of environmental adversities have been found to be associated with
ADHD. These include various pre- and perinatal influences; examples include low birth
weight, high birth weight, substance abuse (smoking or drinking alcohol) during pregnancy
and pregnancy delivery complications.
In complex disorders such as ADHD, ODD and CD, not all phenotypes carrying
susceptible genes actually develop these disorders, unless they are also exposed to specific
environmental factors. This phenomenon of gene -environment interaction is in common use
in medical science. [Thapar, Langley, Owen et al, 2007] Even though genetic and prenatal
and perinatal environmental factors have been implicated in the etiology of disruptive
behaviors, there have only been a small number of behavior and molecular genetic studies that
have investigated the effect of both a genetic vulnerability and perinatal risks.

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IgE bij vroege inflammatoire epidermolysis bullosa acquisita.

Epidermolysis bullosa acquisita (EBA) is a rare, acquired subepidermal autoimmune bullous
disease, characterized by two main types: a classical, mechanobullous type and an inflammatory
one. IgG-, IgA- and sometimes IgM-class autoimmune antibodies target type VII
collagen, a dermal antigen, which constitutes anchoring fibrils that attach the epidermis
to the dermis. A more frequent subepidermal bullous disease, bullous pemphigoid (BP) has
autoantibodies targeting other attachment proteins in the epidermis. Lately, IgE has been
found to play a pathophysiological role in BP. Clinically, inflammatory EBA resembles BP.
Because EBA and BP differ immunologically merely by the antigen that’s targeted, this study
was set up to determine whether IgE-class antibodies could be targeting type VII collagen
as well in the inflammatory EBA type. Indirect immunofluorescence using healthy human
skin, split by 1M NaCl (Salt Split Skin, SSS) was used to find one patient out of a cohort of 42
EBA-patients, whose serum contained IgE-class antibodies that targeted a dermal antigen.
Also, a high total-IgE-level was found in his serum(> 5000 kU/L). 50% ofEBA-patients had
increased(> 115 kU/L) total-IgE-levels. No relation was found between clinical symptoms
and total-IgE-levels. Furthermore, high levels oflgE targeting common food- and airway-allergens
were found in the ‘positive’ patient’s serum. No final conclusion can be drawn based
on these data; additional research into IgE-antigen-specificity is needed, as well as histologicial
reevaluation.

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Follow-up van conservatieve en operatieve behandeling voor POP (pelvic organ prolapse) in Nepal.

In Nepal, the prevalence of POP (pelvic organ prolapse) is very high. Factors probably
contributing to this high prevalence are the heavy household and farm work duties of
women, which continue during pregnancy and delivery, lack of competent attendants
during delivery, lack of spacing between deliveries, tobacco smoking and malnutrition.
POP may cause symptoms limiting activities of daily life: women may have symptoms
during walking, they suffer from abdominal pain, dyspareunia and micturation or
defecation problems. In some women, infections or ulcerations of the protruding organ
occur. Because of these problems and the strong taboos on reproductive issues in Nepal,
this not life-threatening condition can be very invalidating.
A pessary might be very suitable for a country like Nepal because it is effective, safe, and
cheap. No highly educated health workers are needed for fitting a pessary. However,
even basic medical care for prolapse is not available for the majority of women in Nepal.
For this reason, the Dutch NGO (Women for Women Foundation) organizes biannual
gynaecological health camps, in cooperation with the Nepalese NGO RHEST. Women
with gynaecological problems (mainly POP) are counselled and treated. The main
question is, if pessary treatment has effects comparable to those in western countries,
and with the same rates of side effects. Are the satisfying results of surgery for POP in
the West achievable in Nepal? In this study, we evaluate the outcomes of pessary
treatment as well as surgery for POP in Nepalese women.
In 2009, a cohort study with a follow-up period of one year was performed on the
outcomes of POP treatment in free gynaecological health camps held in two villages in
rural Nepal. In total, 60 patients were included (44 pessary, 16 surgery patients). Followup
patients were interviewed and examined gynaecologically, by use of the POP-Q
method. In addition, 12 patients were interviewed to obtain more information about the
impact of prolapse on daily life.
Age and POP-stage were not different between the study group and the group at
baseline. In our study, 58% continued pessary treatment after one year. 91% of them
were satisfied about their treatment. Continuing pessary treatment was not related to
the POP-stage: stage IV-patients had the same success rates as women with milder
prolapses. Of all women operated one year before, 88% said to be satisfied. The burden
of daily activities was equal (56%) or less (42%) than one year before (not more). Topics
returning in the in-depth interviews were the sudden start of the symptoms of POP,
shame and anxiety caused by ignorance about the ailment. POP has serious
consequences, like depression, urinary problems and avoidance of social activities. These
results underline the importance of suitable medical care for this bunch of women.
This study shows, despite of its limited size, that pessary treatment is very suitable for
Nepalese women with POP, provided that continuity of medical care is guaranteed.
These results underline the importance of appropriate medical care for women who
suffer from POP. Success rate of pessaries could be improved by well-trained health
workers at the health post. Surgery should be restricted to the most serious cases.

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Het selectief opladen van geactiveerde T-cellen met TRAIL resulteert in sterk verhoogde anti-tumor activiteit.

Introduction
Adaptive T-cell therapy is the use of own T-cells for the treatment of cancer. Promising
results were accomplished with adaptive T-cell therapy. However, there is allot of room for
improvement. Possibly by arming T-cells with tumor necrosis factor-related apoptosis
inducing ligand (TRAIL), T-cells could be made more effective. TRAIL is a membrane bound
molecule that only induces apoptosis in tumor cells and not in healthy cells. Herefor soluble
TRAIL (sTRAIL) is fused with K12 to form K12:sTRAIL. K12 is the natural ligand of CD7, which
only can be found on T-cells and NK-cells.
Hypothesis: K12:sTRAIL binds toT-cells, which allows T-cells to increase their amount of
TRAIL on their surface and to kill tumor cells more effectively
Materials and methods
With use of recombinant DNA-technology, sTRAIL is genetically fused to K12 and produced
by Chinese hamster ovary (CHO) Kl cells.
T-cells were obtained from healthy volunteers and activated and proliferated in vitro with
anti-CD3 mAb and IL2. First was verified by flowcytometry that K12:sTRAIL binds CD7-specific
toT-cells. Next antitumor activity was investigated by adding activated T-cells, incubated
with K12:sTRAIL, in different E:T ratios to tumor cell lines and primary colon and ovary tumor
cells. Cell death, or apoptosis, was analyzed in tumor cells by flowcytometry by loss of
mitochondrial membrane potential.
Results
T-cells loaded with K12:sTRAIL (loaded T-cells) bind specifically to CD7, which strongly
increased the amount of TRAIL on the surface of the T-cells. In leukemic tumor cell lines and
in solid tumor cell lines, loaded T-cells induced strongly elevated apoptosis in comparison to
T-cells loaded with scFvC54:sTRAIL. Also in primary tumor cells obtained from patients, the
loaded T-cells induced an increase in apoptosis. The loaded T-cells were not toxic for healthy
T -cells or fibroblasts.
Conclusion
Binding of K12:sTRAIL toT-cells is a appropriate manner to arm T-cells with extra TRAIL
K12:sTRAIL binds specifically to CD7. Loaded T-cells are very well capable of inducing
apoptosis in as well tumor cell lines as in primary tumor cells from patients. T-cells loaded
with K12:sTRAIL offers promising therapeutic possibilities for the future in adaptive T-cell
therapy.

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Measuring effects of drug intervention on estrogen receptor expression in breast cancer.

Breast cancer is the most common cancer among women worldwide. Approximately 70% of
all breast cancers tumours express the estrogen receptor (ER), and for these patients antihormonal
therapy is the treatment of choice. Eventually, however, all patients will become
resistant to anti-hormonal therapy, either with lost ( …… 20%), preserved ( ….. 55%) or enhanced
( …… 25%) ER-expression. Literature suggests that these different ER-phenotypes in resistant
tumours demand a different treatment strategy. ER-expression can not only be altered by antihormonal
medication, but also by non-hormonal drugs like trastuzumab (Her2-antagonist),
heat shock protein 90 (Hsp90) inhibitors or histone deacetylase (HDAC) inhibitors.
In tumours that have lost ER-expression, epigenetic silencing plays an important role. Studies
have shown that re-expression of the ER can restore response to anti-hormonal therapy. For
tumours that have preserved ER-expression, the ER could be targeted by non-hormonal drugs
that down regulate ER-expression, and thereby impede tumour growth. In tumours with
increased ER-expression, estrogen paradoxically induces apoptosis. Thus, also in resistant
breast cancer tumours the ER plays a key role.
The purpose of our study was to determine the effects of Hsp90-inhibition and HDACinhibition
on ER-expression in both intrinsically ER-negative and ER-positive tumours.
We’ve shown that HDAC-inhibition can increase ER-expression in ER-negative tumours,
while down-regulating ER-expression in ER-positive tumours. Furthermore the effects of
HDAC-inhibition were dependent upon culture conditions, as in the ER-positive MCF-7 cells
we observed a down-regulation of ER-expression in hormone-deprived medium, while an upregulation
was observed in normal culture medium. Combination therapy of the HDACinhibitor
vorinostat with the ER-antagonist fulvestrant showed to have additive effects.
From our results we can conclude that HDAC-inhibition seems a promising epigenetic
therapy that is able to restore ER-expression in ER-negative tumours. In ER-positive tumours
HDAC-inhibition can lower ER-expression in certain conditions and could therefore provide a
way to target the ER with a non-hormonal drug. Combination therapy of HDAC-inhibitors
with anti-hormonal medications showed additive effects and further studies should thus be
executed to determine possibilities for application in clinical practise. In our study, the role of
Hsp90-inhibition on ER-expression was insignificant, however because of the observed
apoptotic effects in Her-2-positive cells and the ability to down-regulate Her2-expression,
Hsp90-inhibitors remain an interesting therapy option for future research.

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De rol van serotonine afkomstig uit bloedplaatjes in leverchirurgie.

Background:
A substantial portion of patients undergoing a liver transplantation or partial
liver resection still experiences post-surgical complications such as thrombosis, bile duct
complications, and liver failure. Different studies have shown that blood platelets play a
crucial role in these complications by various mechanisms. Furthermore, platelets are crucial
in the process of liver regeneration, at least in animal models. These effects appear mediated
(in part) by serotonin, which is present within platelet storage granules. Better understanding
of the serotonin metabolism and the effects on hepatocytes, cholangiocytes, and platelets is of
great clinical relevance and will contribute to the development of strategies to influence the
serotonin metabolism and in that way the outcome after liver surgery.
Aims and hypotheses:
Two sub-projects were performed. The first part of the study aimed to
investigate potential alterations in serotonin metabolism during a partial liver resection and
the effects of these alterations on platelet function. The hypothesis was that the serotonin
content of the platelets would decrease and that this would diminish the function of the
platelets, since serotonin is a potent platelet activator. The second project investigated the
contribution of a polymorphism of the SERT-gene and the 5-HT2A-receptor-gene in relation
to post-operative complications following liver transplantation. The hypothesis was that
allelic variants associated with a decrease in serotonin levels in the platelets or a diminished
response to serotonin would increase the risk of liver failure but would decrease the risk of
bile duct complications and thrombosis.
Methods:
In the first sub-project, which was a pilot study, five adult patients undergoing a
major liver resection were included. Primary endpoints were serotonin content of platelets
and platelet function at different stages of the resection. The secondary endpoint was the level
of tryptophan, the precursor of serotonin, in blood plasma. For the sub-project of the
polymorphisms a database containing 735 transplantations performed at the University
Medical Center Groningen in the period 1989-2006 was available. Children,
retransplantations, and split liver transplantations were excluded which resulted in a research
population of 428 patients. Polymerase chain reaction and gelelectrophoresis were used to
determine the SERT-polymorphism. The 5-HT2A-polymorphism was already determined in
previous studies.
Results:
In the pilot-study no significant decrease of serotonin content of the platelets and
platelet function during liver resection was observed. Furthermore, no clinical consequences
of genetic variations of the SERT-gene and 5-HT2A-receptor-gene could be demonstrated.
Conclusion:
These studies did not provide evidence for a significant role of serotonin in liver
regeneration and in complications of liver surgery in humans. However, as these
complications are multifactorial, a contributory role of serotonin cannot be fully excluded at
present.

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Kwaliteit van leven bij patiënten met cystic fibrosis.

Background.
The aim of this study was to investigate the influence of disease severity on the
health-related quality of life (QOL) of patients with cystic fibrosis (CF). The second aim of
this study was to investigate if changes in the disease severity over time result in a change in
the QOL. Previous research showed a weak to moderate correlations between the QOL and
the clinical variables.
Design.
Cross-sectional and longitudinal analysis.
Methods.
The health-related QOL was measured with the Cystic Fibrosis Questionnaire
(CFQ), which contains thirteen different domains. For cross-sectional analysis 67 patients
with CF answered the CFQ in 2008. Demographic and clinical variables were collected at the
same time patients answered the CFQ. The contribution of demographic and clinical variables
on the QOL was determined by multiple regression analysis. For longitudinal analysis patients
answered each year a CFQ during three years. At the same time lung function, BMI and the
number of exacerbations were collected. Analysis was performed with linear mixed effect
models.
Results.
Cross-sectional analysis showed that demographic and clinical variables could
explain a moderate part of the variance on ten domains (15 to 3 7.4% ). At the domain health
perception the variance was best explained by the age, lung function and the diabetes status
(R2 = 33.5%). At the domain weight the variance was best explained by the BMI (R2 =
37.4%).
Longitudinal analysis showed that in four domains of QOL, changes in a clinical variable over
time, were significantly associated with QOL. In the domains ‘physical functioning’ and
‘vitality’ this variable was lung function. In the domain ‘social’ it was the number of
exacerbations, and in the domain ‘weight’ it was the BMI.
Conclusions.
The disease severity negatively influences the health related QOL on most of the
domains and the effect on the quality of life is stronger then was concluded from previous
research. Increase of the disease severity in time predicts a decline of the QOL in four out of
thirteen domains. However most of the domains show a stability in the QOL despite of
increase of the disease severity.

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Salbutamol as inhalation therapy for preterm infants with (developing) bronchopulmonary dysplasia.

Introduction:
Bronchopulmonary dysplasia (BPD) is an important cause of respiratory
disease in preterm infants. Salbutamol is often prescribed to infants with (developing) BPD.
Although no long term benefits could be demonstrated, on short term it leads to
improvements in lung function. It is still unknown which dose of salbutamol as inhalation
therapy for preterm infants should be prescribed. Lung deposition of aerosolised salbutamol
is low in preterm infants. Optimising nebuliser efficiency might offer more therapeutic options.
Methods:
Sub-question A: To get insight in which dosage of inhaled salbutamol is
prescribed, how salbutamol is administered, when the treatment is started and stopped and
what the opinion is of neonatologists about the use of salbutamol as inhalation therapy a
survey was conducted among neonatology departments in the Netherlands, Belgium,
Germany, Austria, Switzerland, Australia and New Zealand. Sub-question B: Comparisons of
lung deposition in an upper airway model of a preterm infant (PriNT) were made applying a
standard jet nebuliser, three types of vibrating membrane nebulisers and a standard MDI
with spacer. Sub-question C: In mechanically ventilated patients clinical effects of salbutamol
(decreasing serum potassium and increasing heart rate) were measured to estimate the
therapeutic effect of two doses (0.1 and 0.5 mg/kg). These doses were compared in a
double-blind randomised cross-over pilot study.
Results:
Sub-question A: Thirty-nine percent of respondents does not prescribe salbutamol,
most of these neonatologists are from Oceania. Sixty-nine percent starts salbutamol in doses
between 0.1 and 0.2 mg/kg 2-4 times a day. Unless better evidence is reported on the
effectiveness, nobody wants to add salbutamol more often to the treatment of infants with
BPD. Sub-question B: Lung deposition in the PriNT-Model was 1.5%[0.1] for a standard jet
nebuliser, 18.0%[1.5] for a vibrating mesh device and for a MOl-spacer combination
6.8%[0.9]. Inserting an elbow significantly reduces lung deposition. Inhaled mass was
significantly lower applying a high breathing pattern. Sub-question C: Administration of 0.5
mg/kg did not lead to a significant change in serum potassium, heart rate, breathing
frequency and saturation compared to 0.1 mg/kg per nebulisation.
Discussion:
The results from our survey show there is currently no worldwide uniformity in
the prescription of salbutamol as inhalation therapy for preterm infants with (developing)
BPD. Average dose prescribed by European neonatologists still rarely exceeds 0.5 mg/kg.
Jet nebulisers are inefficient in aerosol delivery compared to newer vibrating membrane
devices, therefore these low dosages might not be sufficient. We could not demonstrate a
beneficial effect of a slightly higher dose salbutamol due to low number of subjects, but future
clinical studies evaluating higher dosages are needed.

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Hyaluronan en zijn receptoren dragen bij aan het ontstaan van nierschade tijdens behandeling met ACE-remmers en zoutbeperking.

The standard treatment for kidney failure is treatment with angiotensin-converting enzyme
inhibitors (ACEi), this has a positive effect on the decline of the kidney function. This effect can
be enhanced by sodium restriction. However, several animalstudies demonstrated an adverse
effect of this treatment, ACEi and sodium restriction, in the development of structural
histological abnormalities. One of these studies, performed in Groningen by Hamming in 2006,
found interstitial abnormalities in kidneys of healthy rats and adriamycin nephrotic rats who
were treated with ACEi en low sodium diet, despite a reduction of proteinuria. Hyaluronan may
contribute to these findings. Hyaluronan is a negatively charged glycosaminoglycan with a
unique water binding capacity. Renal interstitial cells produce more hyaluronan in a low
osmolality. Sodium restriction may cause a low osmolality. Hyaluronan interacts with L YVE-1, an
important marker for lymph vessels and endothelium, and a receptor for hyaluronan. We
hypothesize that hyaluronan and its receptors contribute to the development of damage to the
kidney during treatment with ACEi and sodium restriction.
The effects of ACEi in combination with high or low sodium on hyaluronan and its receptors
was investigated in healthy rats and in adriamycin nephrotic rats. After three weeks of
treatment, the rats were sacrificed. Representative sections of the kidneys (three kidneys for
each group) were stained for hyaluronan and LYVE-1. A quantative analysis was performed on
these slides. The groups of rats with ACEi and low sodium showed no significant increase in
quantity of hyaluronan staining compared to the group with high sodium and placebo. A
remarkable decrease of LYVE-1 quantity was observed in healthy rats, who were treated with
ACEi and low sodium (p These results show no contribution of hyaluronan to the development of kidneyfailure during
treatment wicht ACEi and sodium restriction. There may be an important role for a decline in
quantity of lymphvessels, further studies in regards to these observations should be performed.

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The prognostic influence of natural killer cells & HLA-E in epithelian ovarian cancer.

Introduction:
Despite cytoreductive surgery and chemotherapeutic treatment, ovarian cancer
is the most frequent cause of death from gynecological malignancies. Immunotherapeutic
strategies for treatment of ovarian cancer are being developed and results are promising.
However, the immune system can develop strategies to evade anti-tumor responses, which
decreases the effects of immunotherapy. In this report we focus on the presence of intratumoral
natural killer (NK) cells and mechanisms by which epithelial ovarian tumors can
escape NK cell mediated lysis, e.g. expression of human leukocyte antigen-E (HLA-E).
Patients and methods: Immunohistochemistry with anti-CD56 and anti-HLA-E antibodies
was performed on tissue micro arrays from 3 06 patients, that contained primary ovarian
cancer tissue and/or metastatic omental tissue. Presence of CD 56+ intra-tumoral NK cells,
HLA-E expression and their mutual relationship were evaluated. Immunohistochemistry data
were also correlated to established prognostic parameters and survival data.
Results:
Neither intra-tumoral NK cells nor HLA-E expression were correlated to survival.
No relation was found between immunohistochemical staining patterns. Although intratumoral
NK cells were not correlated to established prognostic factors, up-regulated
expression ofHLA-E was associated with unfavorable prognostic parameters e.g. advanced
stage disease, serous tumor type, poorly differentiated tumors and amount of residual disease.
Conclusion:
To our knowledge, this is the first study where the spontaneous, in vivo
expression ofHLA-E in epithelial ovarian cancer has been demonstrated. HLA-E upregulation
is not the main strategy by which NK cell mediated lysis can be escaped.

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Decreasing ischemia reperfusion injury in liver surgery with heme oxygenase-1 induced by Rapamycin.

Introduction
Limitation of ischemia reperfusion (IR) injury seems to be the key to improve
survival and organ function after liver surgery. One strategy to protect the liver against this
type of injury, is to precondition the liver. A target for this preconditioning might be Heme
Oxygenase-1 (H0-1 ), which has found to protect the liver against IR injury. H0-1 can be up
regulated in the liver by cobalt protoporphyrin (CoPP), but this has potential toxic effects in
human and it can be up regulated by clamping of the main blood supplying vessels of the
liver. In previous studies, the immunosuppressive drug Rapamycin has shown to up regulate
H0-1.
The aims of this study are to determine the effect of the duration of the surgical
procedure on H0-1 expression and to test whether Rapamycin can induce H0-1 expression.
Materials and Methods
Rapamycin (n=8) or a vehicle solution (n=8) was injected intra
peritoneally in male Spraque Dawley rats, 24 hours before the surgery. 4 rats of each group
underwent rapid extraction surgery, the other 8 rats underwent a sham operation. The
concentration of Rapamycin in the blood was measured by HPLC and the relative H0-1
expression in mRNA from liver cells was measured with Q-RT-PCR. H0-1 expression in
protein of liver cells was assessed by Western blotting.
Results
The blood Rapamycin concentration was variable in the Rapamycin injected rats.
Rapamycin has not up regulated H0-1 in mRNA, since the fold induction in the Rapamycin
injected and vehicle injected groups was almost the same. The duration of the procedure did
make a difference. In the vehicle injected groups, the sham operation gave an 8-fold increase
in H0-1 expression compared to the rapid extraction surgery. In the Rapamycin injected
groups, the sham operation even gave a 1 0-fold increase in H0-1 expression compared to
the rapid extraction surgery. There was found a correlation between blood Rapamycin
concentration and H0-1 fold induction in the rapid extraction group where R = 0.860 and in
the sham operated group were R = 0.958. H0-1 protein expression had been detected with
the Western blotting, however this experiment needs to be optimized further before it’s
possible to compare between the groups.
Conclusion
Preconditioning of the liver with Rapamycin 24 hours before the surgery does not
up regulate H0-1 in mRNA, but there is a correlation between blood Rapamycin
concentration and H0-1 fold induction, therefore more research needs to be conducted. The
sort of surgical procedure influences H0-1 expression, this is an interesting finding which
needs to be looked at. H0-1 protein expression can be detected with Western blotting, so this
technique needs to be optimized more.

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Alternatieve Preservatievloeistoffen en luminaal contact tijdens dunne darm preservatie.

Introduction:
Universtiy of Wisconsin solution (UW) is the standard preservation solution
used in the clinic for the preservation of organs during transplantation, also for small
intestines. UW is not a good preservation solution for the intestine. Institute of Georges Lopez
(IGL) and IGL +glutamine (GIGL) might be good alternatives. Luminal contact with a
preservation solution results in better transplantation outcomes. In this study we investigated
new preservation solutions and the influence of luminal contact.
Methods:
The influence of cold and warm ischemia was evaluated in 2 experiments with 4
Lewis rats. In experiment 1 UW was compared with IGL and GIGL, in experiment 2 UW was
compared with GIGL only. Intestine was immediately, after 4 hours and after 20 hours cold
storage investigated for histology, Trans Epithelial Electrical Resistance (TEER) glucose,
lactate, LDH and ATP. TEER is not a standard method to investigate quality of the intestine,
so we compared the TEER results with the other outcome parameters. Intestine was stored
luminal and closed to investigate the influence of luminal contact.
Results:
UW closed has high Park scores and low TEER in both experiments. UW closed
Park score was significant lower than GIGL closed. Furthermore UW closed had the highest
lactate and glucose values. After 4 hours of hypothermia GIGL closed had lower Park scores
and higher TEER then the other alternatives. No significant differences we found between
open and closed preservation, although after 20 hours preservation there was a slight positive
effect of luminal preservation. The Correlation between TEER and Parkscore was in the first
experiment -0.6 (significant 0.001). In the second experiment no significant differences were
found.
Conclusion:
We showed that the standard UW closed is not a good method for preservation
of the intestine. We did not found a good alternative. Adding glutamine to the preservation
solution has maybe an protective effect during clinical relevant periods of hypothermia.
Luminal contact did show a positive influence on the quality of intestine, especially after 20
hours of cold storage. With some adjustments the influence could be bigger and better.
Measuring the TEER could be in the future a good additive or even an alternative for the
standard Park score.

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Allergische rhinitis bij kinderen met astma.

Background
Asthma is a chronic inflammatory disease of the airways with intermittent symptoms of wheezing,
coughing and breathlessness. Worldwide, the prevalence is high and has increased in the last two
decades. Many children also have an allergic rhinitis. Asthma and allergic rhinitis frequently coexist
because of their pathogenesis and physiological pattern, but this has rarely been evaluated in children.
Prevalence of allergic diseases in children is increasing. However, the reported prevalence of allergic
rhinitis in children with asthma ranges from 60-80%. Allergic rhinitis was clinically defined as a
symptomatic disorder of the nose induced by a lgE-mediated inflammation. Symptoms include
rhinorrhoea, nasal obstruction, nasal itching and sneezing.
Allergic rhinitis in children with asthma is often not well recognized or treated. It appears in adults that
good treatment of the allergic rhinitis can improve the asthma control. Probably this is also true for
children. For that reason it is important to know the prevalence of allergic rhinitis and what its treatment
has been until now. This could lead to further improvements and thus better asthma control.
Objectives
To determine the prevalence of allergic rhinitis in children with asthma and their current treatment.
I also would like to know their serum specific lgE and fractional exhaled nitric oxide and its relationship
with allergic rhinitis complaints and asthma score.
Methods
A cross-sectional questionnaire survey in 200 children with asthma, aged 5-19 years who visit the
hospital for their asthma control. The questionnaire is based upon the ISAAC Rhinitis questionnaire and
the Juniper Asthma Control Questionnaire (ACQ). Also fractional exhaled nitric oxide (FeNO), and
serum specific lgE was determined.
Results
It appears that 70.7% of the children in the last year have had complaints of allergic rhinitis in the last
year, most commonly between March and July. Only 56.4% of the parents of these children think that
their child has hay fever and only 62.4% of the children with allergic rhinitis receive rhinitis therapy.
Children with allergic rhinitis have a significant higher ACQ score (mean 0.85; SD=0.07) than children
without allergic rhinitis (mean 0.65; SD=0.09) (P =0.007).
Children with rhinitis complaints have a significant higher FeNO (P=0.013) and a higher serum specific
lgE (P=0.033).
Conclusion
Allergic rhinitis is common in children with asthma, but is frequently unrecognized or untreated. Because
asthma control is poorer in children with asthma with concurrent rhinitis, efforts should be made to
improve recognizing and treating allergic rhinitis in children with asthma.

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Pulmonale complicaties na transthoracale, transhiatale en minimaal invasieve oesofagectomie.

Introduction.
Carcinoma of the oesophagus is a disease with a dismal
prognosis. The curative treatment consists of a surgical resection of the
oesophagus including a regional lymph node dissection, aiming to remove all
cancerous tissue. There are three main surgical approaches, transthoracal,
transhiatal and minimally invasive oesophagectomy (MIO). MIO has a number
of intraoperative benefits compared to transthoracal surgery, such as a
reduced number of pulmonary complications. Successful epidural analgesia
is expected to effectively reduce postoperative pain and consequently the
number of pulmonary complications, making it as safe as MIO. However,
iatrogenous trauma of the mediastinum is supposed to be responsible for a
large proportion postoperative pulmonary complications, independent of the
factor pain. This research therefore aims to determine if there are differences
between the three treatments with respect to these complications, and what
the influence of the extent of mediastinal trauma and the role of epidural
analgesia would be.
Material and methods.
For the epidemiological characteristics and
comparison of pulmonary complications, several publications are used. Data
concerning pulmonary complications and the extent of mediastinal dissection
is extracted from available patient resources treated with transthoracal
surgery in our hospital between 1991 and 2005; the latter by counting the
number of retrieved lymph nodes. Confounding variables have been corrected
for. The relationships between pulmonary complications and epidural
analgesia, and the number of harvested lymph nodes have been statistically
analysed.
Results.
There is no statistically significant association between epidural
analgesia and pulmonary complications within our population. In addition,
there is no correlation between the number of harvested lymph nodes and
pulmonary complications. A crude comparison with literature data yields a
lower rate of pulmonary complications and a higher number of harvested
lymph nodes in MIO compared to the transthorically treated patients in our
hospital, and with transhiatal and transthoracal esophagectomy combined in
literature.
Conclusion.
The non-significant effect of epidural analgesia could be rejected
by choosing another end parameter within the same population. The lack of
association between the number of harvested lymph nodes and pulmonary
complications is probably caused by the effective epidural analgesia. MIO
seems to be safe and effective and the pulmonary complication rate seems to
be lower than in transthoracal esophagectomy. However, these results should
be considered flawed by some selection bias. The long term oncological
effectivity of MIO and its probably lower pulmonary complication rate has yet
to be proven by conducting a multi centered randomised controlled study.

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Potential neuroprotective agents in acute ischemic stroke in combination with tPA treatment.

Stroke is the second most common cause of death worldwide and it is a major cause of longterm
disability. In future years, an increase in the prevalence and the burden of stroke is to be
expected. Therefore, it is important to look for strategies to reduce disability after stroke in
addition to attention for primary prevention. Revascularisation therapy has shown to be of
great benefit in treatment of ischemic stroke, but unfortunately few patients can benefit from
this therapy. In addition, several neuroprotective agents are studied. These agents are thought
to protect and save neurons in the ischemic penumbra. Preclinical studies have shown
promising results, but clinical trials with these neuroprotective agents have been
disappointing.
In this research project the combination of revascularisation therapy with tissue plasminogen
activator (tPA) and two possible neuroprotective agents, namely selective serotonin re-uptake
inhibitors (SSRis) and benzodiazepines, will be evaluated in patients with acute ischemic
stroke. Both agents act in different ways on neural level in the acute phase of ischemic stroke.
Furthermore, SSRis might also have an additional effect on neurorestoration after the acute
phase. The hypothesis of improved functional outcome at 3 months after ischemic stroke in
patients treated with tPA in combination with prior SSRI or benzodiazepine use is tested.
In a prospective observational cohort study of 461 patients the relationship between prior use
of SSRis or benzodiazepines and functional outcome at 3 months, the occurrence of
symptomatic intracerebral haemorrhage (SICH) and early in-hospital mortality is investigated.
Favourable outcome is defined as a modified Rankin Scale score :S2.
The number of patients with favourable outcome was not significantly different between
patients using SSRis or benzodiazepines and the control group (for SSRI: 31% vs 46%, p
0.26; for benzodiazepines: 38% vs 46%, p 0.32). In the multivariable analysis SSRI use was
significantly associated with a non favourable outcome (OR 0.25, 95% C.I. 0.07-0.86, p 0.03).
Benzodiazepine use was not associated with functional outcome (OR 0.97, 95% C.I. 0.46-
2.02, p 0.93). For both drugs no difference in the occurrence of SICH and early in-hospital
mortality was found.
In this research project, in contrast to the hypothesis, prior SSRI treatment was significantly
associated with a non favourable outcome. Prior benzodiazepine use showed no beneficial or
detrimental effect on functional outcome.

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De zoektocht naar hoogrisico haplotypen voor het identificeren van onbekende BRCA 112 mutaties.

Introduction
Breast cancer is the most frequent type of cancer among women
worldwide. About 5°/o of breast cancer is part of a hereditary tumor syndrome, in
which women are also at risk for ovarian cancer. People with this syndrome have a
mutation in the BRCA 1 or BRCA2 gene and the life-time risk on developing breast
and ovarian cancer is much higher compared with the normal population. Families
with characteristics on carrying a BRCA 1 or BRCA2 mutation were sent for genetic
analysis to the genetic department, but in only 12% a BRCA 1 or BRCA2 mutation
was found. Because of the heterogeneity of the mutational spectrum it is possible
that there are unknown mutations in BRCA 1 or BRCA2 which are undetectable with
the present scanning techniques. The aim of this project is to select from the large
group of families in which no BRCA 112 was found, a small patient group for more
comprehensive mutation screening of the BRCA 1 and 2 genes. We have tried to
make a selection based on high-risk haplotypes.
Method
Haplotypes were constructed for the patients and a control group using 23
BRCA 1 SNPs and 39 BRCA2 SNPs. From the BRCA 1 haplotypes which were
exclusively present in the patient group, the two most frequent were selected for
pedigree analysis. The pedigree analysis assesses the risk for having hereditary
breast and ovarian cancer, using two score systems.
Results
The BRCA 1 haplotype construction resulted in 26 different haplotypes, from
which 18 were exclusively present in the patient group. For BRCA2 it was not
possible to construct consistent haplotypes. The two selected BRCA 1 haplotypes for
the pedigree analyses had similar risk-scores as the patients with the most regular
haplotypes and much lower scores than families with a known BRCA 1 mutation.
Conclusion
No haplotypes were found with a high risk on carrying a BRCA 1 or
BRCA2 mutation. Therefore it was not possible to select patients with high-risk
haplotypes for a more comprehensive mutation screening of the BRCA 1 and BRCA2
genes.

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Leefstijladvisering door een praktijkondersteuner: het effect op het gewicht en de relatie met de mate van beweging en fitheid, na 1 en 3 jaar.

Context
Overweight and obesity are a global problem and are associated with many serious health
effects. To combat obesity, decreasing the calorie intake plays a large role. Today, however,
increasingly recognized are the benefits of encouraging more physical activity together with
calorie- reduction, to achieve weight loss and maintain the loss over the long term. The
identification of overweight and obesity is mainly done by the General Practitioner (GP). But,
there is often insufficient time and knowledge for advice on lifestyle changes. A nurse
practitioner could take this task of the GP and could provide lifestyle counseling.
Objective
The purpose of this study is to examine how effective lifestyle counseling is provided by a
nurse practitioner, in achieving weight loss in people with overweight and obesity, and then
also maintain the loss. There will also be examined whether a relationship exists between the
amount of physical activity and fitness.
Method
The patient population consists of 303 participants (from de GOAL (Groningen/ Friesland
Overweight And Lifestyle-) study) aged between 40 and 70 years with a Body Mass Index of
25 to 40 kg/m2 and have hypertension and I or dyslipidemia. This is a randomized controlled
trial, conducted from January 2006 to June 2009. The intervention group received structured
lifestyle advice by a nurse practitioner. The control group received usual care from their GP.
Results
After 1 year the intervention group lost significantly more weight than the control group (-
2.4% vs -0.8%) (P = 0.003). For men lifestyle counseling by nurse practitioners is more
effective on weight loss (P= 0.001) and waist circumference (P = 0.010) after 1 year than
usual care. After 3 years, the results show that there is no difference between intervention and
control group regarding weight loss and change in waist circumference. There is a significant
difference in the group with a weight loss > 5%, in the Borgscore after 2 minutes, between
intervention and control group.
Conclusion
Lifestyle counseling provided by a nurse practitioner in general practice setting, is effective
for weight loss in 1 year to achieve, especially for the male sex. To maintain weight loss and
loss of waist circumference during follow- up, and retain people to increase physical activity,
more contact- moment are required.

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Predictive value of placental pathology on motor, cognitive and behavioural outcome of preterm born children at toddling age.

Introduction:
Placental factors (thrombosis, chorioamnionitis, multiple lesions) are
associated with neurological impairment with term born children. Placental pathology can
lead to ischemia and hypoxia and may cause respiratory and circulatory difficulties in the preand
early postnatal period. The question is whether particular forms of placental pathology (in
particular thrombosis, edema, chorioamnionitis, multiple lesions) are related to neurological
morbidity in preterm infants and whether or not that relation can still be seen at toddling age.
Aim:
To determine whether placental pathology forms a risk factors for motor, cognitive and
behavioural developmental difficulties in preterm born children at toddling age.
Methods:
We examined a patient group of 31 preterm born children, all born in 2005.
Preterm born children ( <34 weeks) were included at postnatal day 1. All children received
treatment at the Neonatal Intensive Care Unit (NICU) of the Univeristairy Medical Center
Groningen (UMCG). Placentas were re-examined and sorted within various pathological
groups, using a list of pathological abnormalities. For motor outcome the neurological
examination by Hempel was used. Cognitive outcome was determined by the Snijders-Oomen
Non-Verbal Intelligence Test (SON-R, 2.5-7) and the Developmental Test for Visuomotor
Integration (VMI). For behavioural outcome, we asked the parents to fill in the Child
Behaviour Checklist (CBCL).
Results:
Of 31 children, 4 (13%) died. At follow-up, we were able to include 19 children,
with a mean age of 3.9 years (range 3.8-4.2); 8 children declined or were as yet untraceable.
Placental pathology was found in 16 (84%) placentas. In 6 placentas(32%), an ascending
intra-uterine infection was found. In 2 placentas (11%) chronic villi tis was found. In 4
placentas (21 %) fetal thrombotic vasculopathy (FTV) was found. At follow-up 4 children
(21%) were diagnosed with subclinical and 2 children (11%) with clinical motor
developmental impairments. The mean non-verbal intelligence score was 99 (range 84-124).
Two children(11%) attended special education and one child (5%) attended normal education
with a grant for a special needs program. The mean VMI-score was 3.8 (range 1-7). Three
children(16%) had subclinical and another 3 (16%) had clinical visual-motor integration
impairments. Six children(32%) were diagnosed with subclinical behavioural difficulties and
2 (11%) had clinical behavioural impairment. Certain forms of placental pathology correlated
with neurological development. The presence of fetal thrombotic vasculopathy was associated
with motor developmental difficulties(p=0.035). A trend was found for ascending intrauterine
infection (p=0.06). Behavioural development was also correlated with placental
pathology. Presence of an ascending intra-uterine infection was associated with behavioural
developmental difficulties(p=0.033). Trends were found for cognitive (p=0.099) and visualmotor
(p=0.083) development and presence of chronic villitis. Placental bed pathology and
chronic deciduitis did not correlate with neurological developmental impairment.
Conclusion:
Certain forms of placental pathology factors are associated with developmental
impairments of preterm born children at toddling age. This is especially the case with fetal
thrombotic vasculopathy (FTV) and ascending intra-uterine infection.

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Cerebrale zuurstofextractie en bloeddruk bij preterme pasgeborenen.

Introduction:
Preterm newborns are at risk of developing intraventricular haemorrhage
(IVH) or peri ventricular leukomalacia (PVL ). The pathogenesis of these disorders are not
completely known. Presumable cerebral ischemia en reperfusion are involved. Hypotension
and blood pressure variability are possible causes of diminished cerebral blood flow, in case
of disturbed cerebral autoregulation.
A way to continuously and non-invasively monitor cerebral blood flow in the neonatal period
is by Near Infrared Spectography (NIRS). NIRS measures the regional cerebral tissue
oxygenation (rcS02). By combining rcS02 with the arterial oxygenation (Sa02) the Fractional
Tissue Oxygen Extraction (FTOE) can be calculated. FTOE represents the balance between
oxygen delivery and oxygen consumption.
The aim of my study was to investigate the relationship between Mean Arterial Pressure
(MAP) and FTOE in preterm newborns. I hypothesized the relation is not present in most
infants, reflecting an intact cerebral autoregulation. Because extraction of oxygen will be
higher in case of diminished blood flow, I expect a negative correlation between MAP en
FTOE in absence of autoregulation. My Secondary aim was to analyze influencing factors on
the presence of cerebral autoregulation and the effect of the presence of cerebral
autoregulation on short -term outcome.
Methods:
This was an observational study of preterm infants ( < 32 weeks gestational age)
admitted to the NICU of the University Medical Centre in Groningen, the Netherlands. Infants
were included in their first week after birth, when they had arterial invasive blood pressure
measurements for clinical reasons, and 24 hours of NIRS measurements. Every five minutes
rcS02, Sa02, systolic blood pressure, diastolic blood pressure, MAP, heart rate were
collected. FTOE was calculated as follows: FTOE = (Sa02- rcS02) I Sa02. Clinical data such
as birth weight, gestational age, treatment for hypotension, cerebral ultrasound, were
collected. Correlations were calculated by the Spearman’s Rank Test in SPSS. Regression
analyses were used to assess influencing factors. Mann Whitney-U was used to compare
between groups.
Results:
27 preterm infants (7 female) were included with median birth weigt 1245 gram
(range 560- 1975 gram) en median gestational age 29.1 weeks (range 25.4-31.7 weeks).
The first complete, simultaneous MAP en NIRS measurements after birth were analysed. In 9
(33%) infants a significant correlation between MAP and FTOE was not present over the 24
hours. In 11 ( 41%) infants, a significant negative correlation was present and in 7 (26%)
infants a positive correlation. Hemoglobin (Hb) levels en treatment with dopamine seem to
have an effect on the relationship between MAP and FTOE. The presence of a significant
relationship between MAP and FTOE was not related to the development of brain damage or
mortality.
Conclusion:
In at least some of the studied infants cerebral autoregulation appears to be
present, suggested by absence of a significant correlation between MAP and FTOE. Preterm
infants with a significant correlation between MAP and FTOE may have a disturbed cerebral
autoregulation, or their MAPs are below or above certain limits in which cerebral
autoregulation is intact. In my study Hb and dopamine treatment appear to be influencing
factors on the relation between MAP and FTOE.

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Diagnostiek complete en partiële mola hydatidosa.

Hydatidiform moles are defined based on their genetic composition. A complete
hydatidiform mole (CHM) has a diploid karyotype which is paternally derived. A partial
hydatidiform mole (PHM) has a triploid karyotype consisting of two thirds paternally derived
DNA and one third maternally derived DNA. A hydropic abortion (HA) has a normal
(biparental) diploid karyotype, which can show histologic features of a hydatidiform mole.
CHMs, PHMs and HAs are traditionally being separated based on histologic features. At the
University Medical Centre Groningen (UMCG) a histologic diagnosis is supplemented with
ploidy status using flow-cytometry, which is a costly, time-consuming and sometimes gives
an uncertain diagnosis. FISH (flow in situ hybridization) and p57Kip2 immunohistochemistry
are other ancillary techniques which are possibly cheaper, faster and more accurate than
flow-cytometry. FISH and p57Kip2 immunohistochemistry were compared with the diagnosis
based on histology and flow-cytometry information in 75 cases of hydatidiform moles and
hydropic abortions. The histology and flow-cytometry data were re-evaluated in all cases
and the diagnosis came in agreement with the original diagnosis in 95% (K = 0,92) of cases.
Immunohistochemical staining with p57Kip2 confirmed the diagnosis based on histology and
flow-cytometry in 97% (K = 0,94} of all cases; a negative p57Kip2 staining was always
confirmative for a CHM. The ploidy according to FISH was consistent with the ploidy
according to flow-cytometry in 91% (K = 0,81) of cases. From the other 9% of these cases half
showed an uncertain flow-cytometry result, but FISH was seen as reliable. The other half
showed reliable flow-cytometry and FISH results, however because of the contradicting
results no certain diagnosis could be made. In all these cases there was a differential
diagnosis between a hydropic abortion and partial hydatidiform mole. The conclusion was
drawn that FISH and p57Kip2 immunohistochemistry are faster and more reliable ancillary
techniques than flow-cytometry when there is a histologic suspicion of a hydatidiform mole.

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