[Increased menstrual bleeding among direct oral anticoagulant users]. / Toegenomen menstrueel bloedverlies bij DOAC-gebruik.

BACKGROUND: Two-thirds of users of oral anticoagulants use direct oral anticoagulants, among which increasingly women in their reproductive age. The risk of severe or abnormal menstrual bleeding doubles to 70% when using anticoagulants. With rivaroxaban especially the risk seems higher than with vitamin K antagonists; with dabigatran possibly lower. CASE DESCRIPTION: We saw a 49-year-old woman who started the oral contraceptive pill because of heavy menstrual bleeding. After getting deep vein thrombosis we stopped the pill and started rivaroxaban. Despite leuproreline the heavy bleeding persisted and 6 blood transfusions were necessary, after which the type of anticoagulant was changed. Eventually, we performed a hysterectomy. CONCLUSION: Anticoagulants can cause severe menstrual bleeding, especially in women with a history of heavy menstrual periods. The type of anticoagulant can be changed and the bleeding can be treated by both hormonal and non-hormonal therapies.

Role of male partners in the long-term well-being of women who have experienced severe pre-eclampsia and eclampsia in rural Tanzania: a qualitative study.

Men can be essential sources of support in maternal health, even more so in case of severe acute maternal morbidity (SAMM), affecting 1-2% of childbearing women in low-resource settings. In a qualitative study using semi-structured interviews, we explored the perspectives of nine male partners of women who suffered from (pre-)eclampsia six to seven years earlier in rural Tanzania. Male partners considered their role to be pivotal regarding finances, decision-making in healthcare-seeking and family planning and provided physical and emotional support. After SAMM, households may be affected in the long run. Some men took over their female partner's household duties until up to two years after birth. Providing men with more information on complication readiness and birth preparedness would enable them to extend their role in maternal morbidity prevention.IMPACT STATEMENTWhat is already known on this subject? The essential role of male partners in maternal health in low- and middle-income countries is well-studied in relation to its impact on care-seeking behaviour. After childbirth, the long-term role of male partners has not yet been studied.What do the results of this study add? We demonstrated the important role of men during, but also after SAMM. Households may be affected years after women suffered from SAMM. For women with the most urgent support needs, this study suggest that at least some men feel responsible for their partner and have different pivotal roles.What are the implications of these findings for clinical practice and/or further research? Because of their motivation to support their female partner, strategies to reduce recurring complications in subsequent pregnancies should include targeting male partners, for example, by increasing birth preparedness and complication readiness. Further studies should confirm the results from our innovative but small-scale study, as well as investigate the long-term role of male partners after uncomplicated births. Other studies could investigate the separation of couples after SAMM, family planning decisions after SAMM and strategies for involving men and increasing complication readiness and birth preparedness.

[Complications related to pessary use in the treatment of female pelvic organ prolapse]. / Complicaties van conservatieve prolapsbehandeling.

Pelvic organ prolapse affects 40% of women over 40 years. Pessaries are often used as a first-line treatment and give high patient satisfaction. Complications of pessaries are rare, but vaginal erosions can lead to adhesions, haemorrhage, impaction and migration. This year we have seen an increase in pessary complications in our hospital after check-ups were postponed. In this article, we present a case of a complication of a vaginal pessary after the postponement of a follow-up visit in the COVID-19 era. An 85-year old woman had a pessary which had migrated into the bladder, 8 months after her last check-up. The fistula was repaired and a new pessary could be fitted after 6 weeks. Vaginal erosions can be prevented by good fitting, local estrogens and self-management. Early detection can be achieved with careful follow-up and patient education. Erosions can be treated with local estrogens and temporary removal of the pessary.

The contribution of Dutch doctors in Global Health and Tropical Medicine to research in global health in low- and middle-income countries: an exploration of the evidence.

Results from medical research from high-income countries may not apply to low- and middle-income countries. Some expatriate physicians combine clinical duties with research. We present global health research conducted by Dutch medical doctors in Global Health and Tropical Medicine in low- and middle-income countries and explore the value of their research. We included all research conducted in the last 30 years by medical doctors in Global Health and Tropical Medicine in a low- and middle-income country, resulting in a PhD thesis. Articles and co-authors were found through Medline. More than half of the 18 identified PhD theses concerned maternal health and obstetrics, and the majority of the research was conducted in low-income countries, mostly in rural hospitals. Over 70 local co-authors were involved. Different aspects of these studies are discussed.

Intracranial control after Cyberknife radiosurgery to the resection bed for large brain metastases.

BACKGROUND: Stereotactic radiosurgery (SRS) is an alternative to post-operative whole brain radiation therapy (WBRT) following resection of brain metastases. At our institution, CyberKnife (CK) is considered for local treatment of large cavities ≥2 cm. In this study, we aimed to evaluate patterns of failure and characterize patients best suited to treatment with this approach. METHODS: We retrospectively reviewed 30 patients treated with CK to 33 resection cavities ≥2 cm between 2011 and 2014. Patterns of intracranial failure were analyzed in 26 patients with post-treatment imaging. Survival was estimated by the Kaplan-Meier method and prognostic factors examined with log-rank test and Cox proportional hazards model. RESULTS: The most frequent histologies were lung (43 %) and breast (20 %). Median treatment volume was 25.1 cm(3) (range 4.7-90.9 cm(3)) and median maximal postoperative cavity diameter was 3.8 cm (range 2.8-6.7). The most common treatment was 30 Gy in 5 fractions prescribed to the 75 % isodose line. Median follow up for the entire cohort was 9.5 months (range 1.0-34.3). Local failure developed in 7 treated cavities (24 %). Neither cavity volume nor CK treatment volume was associated with local failure. Distant brain failure occurred in 20 cases (62 %) at a median of 4.2 months. There were increased rates of distant failure in patients who initially presented with synchronous metastases (p = 0.02). Leptomeningeal carcinomatosis (LMC) developed in 9 cases, (34 %). Salvage WBRT was performed in 5 cases (17 %) at a median of 5.2 months from CK. Median overall survival was 10.1 months from treatment. CONCLUSIONS: This study suggests that adjuvant CK is a reasonable strategy to achieve local control in large resection cavities. Patients with synchronous metastases at the time of CK may be at higher risk for distant brain failure. The majority of cases were spared or delayed WBRT with the use of local CK therapy.

Characteristics and outcomes of patients with eclampsia and severe pre-eclampsia in a rural hospital in Western Tanzania: a retrospective medical record study.

BACKGROUND: Eclampsia and pre-eclampsia are well-recognized causes of maternal and neonatal mortality in low income countries, but are never studied in a district hospital. In order to get reliable data to facilitate the hospital's obstetric audit a retrospective medical record study was performed in Ndala Hospital, Tanzania. METHODS: All patients diagnosed with severe pre-eclampsia or eclampsia between July 2011 and December 2012 were included. Medical records were searched immediately following discharge or death. General patient characteristics, medical history, obstetrical history, possible risk factors, information about the current pregnancy, antenatal clinic attendance and prescribed therapy before admission were recorded. Symptoms and complications were noted. Statistical analysis was done with Epi Info®. RESULTS: Of the 3398 women who gave birth in the hospital 26 cases of severe pre-eclampsia and 55 cases of eclampsia were diagnosed (0.8 and 1.6%). Six women with eclampsia died (case fatality rate 11%). Convulsions in patients with eclampsia were classified as antepartum (44%), intrapartum (42%) and postpartum (15%). Magnesium was given in 100% of patients with eclampsia and was effective in controlling convulsions. Intravenous antihypertensive treatment was only started in 5% of patients. Induction of labour was done in 29 patients (78% of women who were not yet in labour). Delivery was spontaneous in 67%, assisted vaginal (ventouse) in 14% and by Caesarean section in 19% of women. Perinatal deaths occurred in 30% of women with eclampsia and 27% of women with severe pre-eclampsia and were associated with low birth weight and prolonged time between admission and birth. CONCLUSIONS: 2.4% of women were diagnosed with severe pre-eclampsia or eclampsia. The case fatality rate and overall perinatal mortality were comparable to other reports. Better outcomes could be achieved by better treatment of hypertension and starting induction of labour as soon as possible.

[Ectopic pregnancy]. / Extra-uteriene graviditeit.

An ectopic pregnancy is a pregnancy outside of the uterine cavity. An ectopic pregnancy can rupture and lead to hypovolaemic shock due to intraperitoneal bleeding. We describe 3 cases of women with ectopic pregnancy and discuss the diagnostic and therapeutic options. All women of fertile age with abdominal pain or abnormal vaginal bleeding should get a pregnancy test. Vaginal ultrasound and human chorionic gonadotrophin levels are the most important diagnostic tools. Depending on the findings, management can may be either conservative with repeated follow-up, intramuscular methotrexate or surgical, depending on the findings. After an ectopic pregnancy there is a higher risk of subfertility and another ectopic pregnancy, but more than half of the women will have a subsequent ongoing intra uterine pregnancy.

[A young woman with acute abdominal pain]. / Een jonge vrouw met acute buikpijn.

A 17-year-old woman was operated in a Tanzanian hospital because of a suspected ruptured ectopic pregnancy. During laparatomy an interstitial ectopic pregnancy with an intact gestational sac was found. The ectopic pregnancy had ruptured into the abdominal cavity.

Validity of the Dutch version of the Amyotrophic Lateral Sclerosis Assessment Questionnaire, ALSAQ-40, ALSAQ-5.

The objective was to validate the Dutch translation of the 40-item and 5-item Amyotrophic Lateral Sclerosis Assessment Questionnaire (ALSAQ-40, ALSAQ-5). Eighty-one ALS patients participated in this cross-sectional study. The measures used were the ALSAQ-40, the ALSAQ-5, MOS Short-Form-36 (SF-36) and Revised ALS Functional Rating Scale (ALSFRS-R). The Dutch ALSAQ-40 was sensitive to differences in disease severity (all scales Kruskal-Wallis, p<0.05), had no floor and few ceiling effects (Communication, Eating and Drinking scales), had excellent internal consistency reliability (all scales Cronbach's alpha >0.90, all item to subscale correlations above 0.40) and showed good construct validity as it correlated as expected with SF-36 and ALSFRS-R scores. The total and item scores of the ALSAQ-5 were strongly correlated with the corresponding total and subscale scores of the ALSAQ-40 (Spearman's rho >0.80). The ALSAQ-5 and ALSAQ-40 showed comparable correlations with the subscales of the SF-36 and the ALSFRS-R, except for Activities Daily Living and Independence (ADL). All other results of the Dutch ALSAQ-40 and ALSAQ-5 were comparable to those of the original UK questionnaires. It is concluded that the psychometric properties of the Dutch version of the ALSAQ-40 and the ALSAQ-5 are good and similar to those of the original English version.

Evaluation of dose delivery accuracy of Gamma Knife by polymer gel dosimetry.

The BANG polymer gel dosimeter was used to evaluate 3D absorbed dose distributions in tissue delivered with Gamma Knife stereotactic radiosurgery systems. We compared dose distributions calculated with Leksell GammaPlan (LGP) treatment-planning software with dose distributions measured with the polymer gel dosimeter for single-shot irradiations. Head-sized spherical glass vessels filled with the polymer gel were irradiated with Gamma Knife. The phantoms were scanned with a 1.0T MRI scanner. The Hahn spin-echo sequence with two echoes was used for the MRI scans. Calibration relations between the spin-spin relaxation rate and the absorbed dose were obtained by using small cylindrical vials, which were filled with the polymer gel from the same batch as for the spherical phantom. We made voxel-by-voxel comparisons of measured and calculated dose distributions for 31 x 31 x 31 dose matrix elements. With the 3D dose data we calculated the tumor control probability (TCP) and normal tissue complication probability (NTCP) for a simple model. For the maximum dose of 100 Gy, the mean and one standard deviation of differences between the measured and the calculated doses were the following: -0.38+/-4.63 Gy, 1.49+/-2.77 Gy, and -1.03+/-4.18 Gy for 8-mm, 14-mm, and 18-mm collimators, respectively. Tumor control probability values for measurements were smaller than the calculations by 0% to 7%, whereas NTCP values were larger by 7% to 24% for four of six experiments.

Heterogeneity phantoms for visualization of 3D dose distributions by MRI-based polymer gel dosimetry.

Heterogeneity corrections in dose calculations are necessary for radiation therapy treatment plans. Dosimetric measurements of the heterogeneity effects are hampered if the detectors are large and their radiological characteristics are not equivalent to water. Gel dosimetry can solve these problems. Furthermore, it provides three-dimensional (3D) dose distributions. We used a cylindrical phantom filled with BANG-3 polymer gel to measure 3D dose distributions in heterogeneous media. The phantom has a cavity, in which water-equivalent or bone-like solid blocks can be inserted. The irradiated phantom was scanned with an magnetic resonance imaging (MRI) scanner. Dose distributions were obtained by calibrating the polymer gel for a relationship between the absorbed dose and the spin-spin relaxation rate of the magnetic resistance (MR) signal. To study dose distributions we had to analyze MR imaging artifacts. This was done in three ways: comparison of a measured dose distribution in a simulated homogeneous phantom with a reference dose distribution, comparison of a sagittally scanned image with a sagittal image reconstructed from axially scanned data, and coregistration of MR and computed-tomography images. We found that the MRI artifacts cause a geometrical distortion of less than 2 mm and less than 10% change in the dose around solid inserts. With these limitations in mind we could make some qualitative measurements. Particularly we observed clear differences between the measured dose distributions around an air-gap and around bone-like material for a 6 MV photon beam. In conclusion, the gel dosimetry has the potential to qualitatively characterize the dose distributions near heterogeneities in 3D.