Amsterdam Medical Student journal - amsj.nl...AMSj guidelines and submit their manuscript to AMSj. This could be a case report, original arti-cle, experimental study, bachelor- or

CHANGING PERSPECTIVES | INITIATIVES WITH IMPACT | NEWS | SOLVING STATISTICS | RESEARCH ABROADSPOTLIGHT | CLINICAL IMAGE | GUIDELINE UPDATE | RADIOLOGY IMAGE | INTERVIEW | I RAN INTO | MEDICAL BUSINESS

EDITION 22 | MARCH 2021

Amsterdam

Medical

Student

journal

ARTICLE |THE ROLE OF

ENDOTHELIOPATHY IN THE PATHOGENESIS OF

COVID-19

MEDICAL BUSINESS |THE DUTCH EHR-SYSTEM:

CURRENT PROBLEMS AND IMPLICATIONS OF

BLOCKCHAIN

21

AMSj Vol. 22 | March 2021 March 2021 | AMSj Vol. 22

On behalf of the editorial board, I am delighted to

welcome you to the fi rst AMSj edition of 2021! I am proud to tell you that the authors and reviewers once again managed to produce a beautiful edition.

Thank you all!

This edition is quite varied and contains something intriguing for all people. Three interesting manu-scripts have been written by ambitious authors, with subjects varying from the role of endotheliop-athy in COVID-19 to dissociative identity disorder and improving health data sharing between health-care professionals. Do conducting research abroad and Africa make your heart beat faster? Read all about it on page 11. Furthermore, would you like

to learn more about becoming a PhD candidate and

hear the experience of someone who recently fi n-ished her PhD? Read more on page 19.

We are also introducing a new column named ‘Initiatives with impact’. This column highlights initiatives with impact within the educational, management and/or research sector which in some way have (had) impact on society. Exactly how did an initiative emerge, what is the scientifi c back-ground, what diffi culties did the author(s) encoun-ter during the process, and what steps have been taken to achieve the goals and create impact? Who kicks off this column… Dr. Koster! He is a pioneer who was part of an initiative with an enormous impact; introducing AEDs to allow non-medical persons to defi brillate before ambulance arrival. Curious? Read all about it in this edition!

Last but not least; allow us to enthuse you! We encourage medical students to take a look at the AMSj guidelines and submit their manuscript to AMSj. This could be a case report, original arti-cle, experimental study, bachelor- or master the-

sis, systematic or narrative review, meta-analysis, and so forth! We will guide you through the re-view process and perhaps your manuscript will be announced as ‘Best manuscript of AMSj 2021!’. You could also choose to give substance to the col-umn ‘Initiatives with impact’, ‘Research abroad’ or ‘Teachable moments’. And, keep a close eye on the vacancies on our website or on social media!

More information can be found on www.amsj.nl. Do not hesitate to contact [email protected] if you have any questions.

Take a moment and enjoy the 22th edition of AMSj.

Yours sincerely,

Elise Beijer

Editor-in-Chief

Amsterdam UMC, location VUmc

Editorial

2 Editorial

3 News

5 Medical Business | The Dutch EHR-system: current problems and implications of blockchain

7 The role of endotheliopathy in the pathogenesis of Covid-19: A narrative review | M.C.H.

Cheng, K.K.H. Cheng, A.V. Noordegraaf, L. Botros

11 Research abroad | Research project: Operation Hernia 2020 in Ghana

13 Schema Therapy for Dissociative Identity Disorder: A Literature Review | M.L. Adnan

17 Interview | Prof. H.E. van der Horst, MD

19 Spotlight | A PhD without a Master’s Degree

21 Medical Business | Dependence on Foreign Medical Supplies in the Netherlands was a

Contributing Factor in Early Failure of COVID-19 Pandemic Control

23 In the Van Weel-Bethesda Hospital in Dirksland, I ran into… | Jolanda Tessers -

van Gorsel, wound care nurse

25 Sharing is caring - A narrative review and recommendation: Improving health data sharing between healthcare professionals in the Netherlands utilizing electronic patient records | L.J. van den Oord, A. Knegt, E. Heeling, A. Leliveld, T.J. van der Meer

28 Clinical image | A young man with a distinctive trauma sign

29 Interview | Prof. Dr. Irene E. van der Horst-Bruinsma

31 Changing perspectives | Primum non nocere

32 Radiology image | Knee complaints after surgery

33 Initiatives with impact | Early defi brillation in the community

35 Solving statistics | Regression Analysis: the key method to analyse medical data

37 Answers | Radiology image

38 Colophon

Index The Amsterdam Medical Student journal (AMSj) is a scientifi c journal created and published by Amsterdam UMC staff members and students to promote research and to encourage other medical students to publish their clinical observations, research articles and case reports. Go to www.amsj.nl for publication options and to fi nd out how you can contribute to AMSj as reviewer or member of the editorial board.

NEWS NEWS

3 4


Big progress in kidney tissue regeneration

ARMEL BOES1 AND LIFFERT VOGT

2

1. FACULTY OF MEDICINE, AMSTERDAM UMC, LOCATION VUMC

2. DEPARTMENT OF INTERNAL MEDICINE, SECTION NEPHROLOGY,

AMSTERDAM UMC, LOCATION AMC

Chronic Kidney Disease (CKD) is a global issue and poses patients at high risk of development of end-stage kidney disease. Currently, the two main therapies to replace kidney function are kidney transplantation or dialysis. However, both life-sav-ing options have an important negative impact on patient’s quality of life. Regeneration of lost func-tioning kidney tissue may serve as a future alterna-tive option in CKD. However, before implemen-tation can be successful, many hurdles need to be overcome. In vivo generation of adequate vascular supply within the regenerated kidney parenchyma represents a crucial challenge. Pleniceanu et al.1

recently reported on their mice studies in which they introduced human renal tubule-forming cells (RTFCs), mesenchymal cells (MSCs) and endo-thelial colony-forming cells (ECFCs) into mice. Injection of MSCs with ECFCs resulted in do-nor-derived vascularized grafts, without tubular structures. Injection of MSCs in combination with ECFCs and RTFCs, resulted in grafts containing donor-derived tubular structures with tubular ep-ithelia from different nephron segments. Striking-ly, these grafts made out of human cells not only contained a network of donor-derived vessels, but were also successfully integrated in the host vascu-lature. These results set a promising basis for kid-ney regenerative therapies, and provide a big step in a potential future way to help CKD patients.

1. Pleniceanu O, Harari-Steinberg O, Omer D, et al. Suc-cessful Introduction of Human Renovascular Units into the Mammalian Kidney. Journal of the American Society of Nephrology: JASN 2020;31(12):2757-72.

Perinatal mortality in the Netherlands

CHARLOTTE LESEMAN1 AND JAN MOLKENBOER21. FACULTY OF MEDICINE, AMSTERDAM UMC, AMSTERDAM MEDICAL

CENTRE

2. DEPARTMENT OF GYNAECOLOGY & OBSTETRICS, SPAARNE

GASTHUIS, HAARLEM

In 2019 161.720 women gave birth to a total of 164.225 children after a pregnancy duration of at least 22 weeks.1 Perinatal mortality, defined as decease of the child between 22 weeks of pregnancy until 28 days postpartum, occurred in 7.8%. Over the past 15 years the perinatal mor-tality rate has significantly decreased. However, in the last 6 years this decrease has stagnated.2

There are numerous factors that contribute to peri-natal mortality such as prematurity, being small for gestational age, low APGAR-score and congenital defects (known as the Big 4). But unhealthy lifestyle of the mother and poor socioeconomic skills are

also associated with increased perinatal mortality.

A news report from Perined states that the cur-rent stagnation seems mainly to be caused by these unhealthy lifestyle and socioeconomic risk factors. This is confirmed by higher rates of peri-natal mortality in areas with poor socioeconomic skills.3 For example, for future mothers with a mi-gration background it is even estimated that they attribute up to 25% of the total perinatal mortality.

In conclusion, the report advises that maternal and perinatal healthcare should respond more to life-style and social risk factors in order to prevent fur-ther stagnation or even increase in perinatal mor-tality rates in the Netherlands.

1. Perined, Perinatale zorg in Nederland anno 2019: landeli-jke perinatale cijfers en duiding, Utrecht 2020

2. Rijksinstituut voor Volksgezondheid en Milieu (RIVM), Beter weten: een beter begin; samen sneller naar een betere zorg rondom de zwangerschap, 2020

3. Bertens, L.C.M, Burgos Ochoa, L., van Ourti, T., et al. 2020, Persisting inequalities in birth outcomes related to neighbourhood deprivation. Journal of Epidemiology and Community Health, 73, 232-239.

Telemedicine andpersonal protective equipment

CAROLIJN KAPOEN1 AND MINA ZAMARAY

2


2. EMERGENCY DEPARTMENT, AMSTERDAM UMC, LOCATION VUMC

In the COVID-19 pandemic, patients with a con-firmed infection are treated in contact isolation to prevent transmission from patients to healthcare workers. Personal protective equipment (PPE) is used by healthcare workers and must be changed every patient contact. The World Health Organiza-tion has advised to limit the use of PPE, to prevent an international shortage.1 Telemedicine has been suggested to reduce PPE use.2 In current literature,

however, it remains unclear if the introduction of telemedicine reduces PPE use in the treatment of patients with COVID-19. A study by Candel et al. aimed to investigate whether telemedicine (using iPads) reduces the use of PPE in the emergency department (ED). The study shows that the use of telemedicine significantly decreases the total PPE use per patient contact for ED physicians. Howev-er, the time physicians spend on patients in con-tact isolation also considerably decreases, having a negative impact on the contentment of hospital-ized patients. No significant differences were ob-served for anxiety levels and satisfaction scores among patient groups.3 Telemedicine in the ED could successfully reduce the use of PPE, without increasing anxiety levels or dissatisfaction among patients. Limiting the use of PPE contributes to saving costs, reducing medical waste and prevent-ing shortages.

1. World Health Organization. Rational use of personal pro-tective equipment for coronavirus disease (COVID-19) and considerations during severe shortages: interim guid-ance.

2. Chou E, Hsieh YL, et al. Onsite telemedicine strategy for coronavirus (COVID-19) screening to limit exposure in ED. Emerg Med J. 2020 Jun 1;37(6):335–7.

3. Candel BGJ, Vaes SMM, et al. Telemedicine in the emer-gency department to decrease personal protective equip-ment use: A before-and-after study. Emerg Med J. 2020.

A new type of anti-cancer drug with a Dutch origin

SANNE ROOS1, REMCO J. MOLENAAR

2


2. DEPARTMENT OF ONCOLOGY, AMSTERDAM UMC, LOCATION

AMC, AMSTERDAM

Metastatic cervical cancer has a poor prognosis, with a 5-year survival rate of 17,2%.1 A potential new drug for this disease is tisotumab vedotin, an antibody-drug conjugate (ADC) in which highly toxic chemotherapeutic agents are linked, or con-jugated, to an antibody. Via this mechanism, che-motherapeutic agents that would be too toxic for conventional intravenous administration are deliv-ered to the tumor with higher specificity. In tiso-tumab vedotin, the antibody tisotumab has affinity for tissue factor (TF), which is highly expressed in solid tumors including cervical cancer and is associated with worse outcomes.2 The preclinical

development of tisotumab vedotin was primarily

performed in the Netherlands, at Genmab BV.The innovaTV201 (phase I/II) study2 investigated tisotumab vedotin in previously treated patients with advanced and metastatic tumors, with un-known levels of expression of TF. Results showed an objective response rate of 24% compared to ap-proximately 15% in previous therapies.3 The side effects seem manageable, although reported ocu-lar adverse events need further investigation into their mechanism. In conclusion, tisotumab vedotin could improve survival in metastatic cervical can-cer. Further research is required to establish clini-cal efficacy in patients with varying expression of TF.

1. 2018 SEER cancer statistics review 1975-2015: cancer of the cervix uteri. Available from: https://seer.cancer.govre-sults_single/sect_05_table.08.pdf

2. Hong, D.S. Tisotumab Vedotin in Previously Treated Re-current or Metastatic Cervical Cancer. Clin Cancer Res. 2020 March; 26: 1220-8.

3. Genmab and Seattle Genetics Present Data from Tisotum-ab Vedotin innovaTV 204 Pivotal Trial in Recurrent or Metastatic Cervical Cancer at ESMO Virtual Congress 2020.

N E W S N E W S N E W S

MEDICAL BUSINESS

5 6MEDICAL BUSINESS


The Dutch EHR-system: current problems and implications of blockchain

Dewi Mulyadi11. FACULTY OF MEDICINE, AMSTERDAM UMC, LOCATION VUMC,

VU UNIVERSITY, AMSTERDAM

Large scale digitization of data has been crucial for

many sectors as it improves important factors such

as time management, efficiency and wage costs. Digital records are more developed in some sec-

tors - such as accountancy, business and finance - than others. Hospitals, general practices and pharmacies all have individual health record sys-

tems, though a national system still has not been

realized. However, rapid exchange of information is essential to ensure the continuity of the provided

healthcare. A bill that pleaded for the implemen-

tation of a national health record system in the

Netherlands has unfortunately failed numerous

times due to safety and privacy concerns.1,2,3 Re-

cent studies have suggested that these hazards can

be eradicated by using novel technologies, such

as blockchain. The implementation of a national health record system needs to be realized in order

to maintain and improve the quality of the Dutch

healthcare system.

The current electronic health record system (EHR-system) is regional, meaning that when a healthcare provider needs access to information

from another healthcare worker (in the same re-

gion), they need to make use of the so-called ‘Landelijk Schakelpunt’ (LSP). This is a platform in which healthcare providers can request patient records, only after the patient has given explicit permission.4 According to a survey study conduct-ed by Statistics Netherlands (CBS)5, only sixty percent of the respondents that were familiar with the LSP had given permission for the use of the

platform. The respondents that actively declined permission mainly did so because of privacy con-

cerns and the fear that information would be mis-

used by third parties. The survey study suggests that a substantial number of Dutch residents has

declined permission for the use of the LSP. This in turn leads to inefficient communication between

different healthcare workers (e.g. via e-mail and telephone), subsequently causing fragmented de-

livery of health services. This results in a subopti-mal healthcare system and opposes the concept of

‘integrated care’. Integrated care, according to the World Health Organization (WHO) Regional Of-fice of Europe, is “delivered by a coordinated mul-

tidisciplinary team of providers working across

settings and levels of care.”6 This ‘coordinated team of providers’ can in many cases not be real-

ized due to the absence of a national EHR-system.

The inefficient communication between health-

care providers that the current system precipitates,

does not only result in fragmented health services,

but also in more errors. A report published by the Health and Youth Care Inspectorate (IGJ) in 2011 elucidated that hospital information systems were often not linked to the system of their associated

pharmacy.7 Medical specialists therefore had no

access to updated medication lists, and pharma-

cists were not able to view important patient char-acteristics (e.g. age, weight, relevant lab results), which made the system prone to medication-re-

lated errors. The implementation of a national EHR-system could avoid these errors, as it would enable the linkage of different health record sys-

tems and would give access to essential and updat-ed information to all the healthcare workers that are involved in a patient’s treatment.

Opponents argue that a national EHR-system would not be safe enough and may lead to priva-

cy violations. However, recent studies elucidate that the usage of novel blockchain technology for

health record systems can eliminate safety and pri-

vacy hazards. Blockchain is essentially a system for data storage, originally made for Bitcoin cryp-

tocurrency. It has three key features which ensure the safety of the information stored on the block-

chain: (1) decentralized storage of data, (2) shared data ownership and (3) cryptographic security.8 A systematic review on blockchain-based EHR-sys-

tems pointed out that the use of blockchain has the

potential to tackle common problems in health-

care, such as EHR interoperability, privacy, and es-

tablishing sharing trust between healthcare provid-

ers.9 Blockchain in national health infrastructures

has already been tested in various pilots.10 Estonia,

for example, is the first country to successfully apply blockchain technology in its EHR-system. The country started using blockchain developed by Guardtime in 2011 and has been using this technology since, proving the efficacy and safety of blockchain in the context of EHR. 11 Block-

chain technology therefore shows great potential in the development of secure EHR-systems, which makes it promising technology for the long-await-ed Dutch national health record system.

In conclusion, the implementation of a nation-

al electronic health record system in the Nether-

lands can tackle important problems caused by

the current EHR-system and improve the overall quality of the Dutch healthcare system. A national EHR-system would enable healthcare providers to easily access patient information of other provid-

ers, which would increase coordination between providers and improve continuity of the provided

care. A national EHR-system would additionally result in fewer medication-related errors and de-

crease the chances of miscommunication. Lastly, safety concerns of a national system can be elim-

inated by the use of blockchain technology, mak-

ing this a potential infrastructure for a national

EHR-system in the Netherlands.

REFERENCES1. Eerste Kamer der Staten-Generaal - Eerste Kamer wil

aangepaste wet elektronisch patiëntendossier. Accessed November 1, 2020. https://www.eerstekamer.nl/nieu-

ws/20100601/eerste_kamer_wil_aangepaste_wet2. Eerste Kamer der Staten-Generaal - Eerste Kamer zet rem

op elektronisch patiëntendossier. Accessed November 1, 2020. https://www.eerstekamer.nl/nieuws/20100706/eerste_kamer_zet_rem_op

3. Eerste Kamer der Staten-Generaal - Eerste Kamer verw-

erpt unaniem voorstel landelijk EPD. Accessed November 1, 2020. https://www.eerstekamer.nl/nieuws/20110405/eerste_kamer_verwerpt_unaniem

4. Landelijk Schakelpunt (LSP). Accessed May 11, 2020. https://kennisbank.patientenfederatie.nl/app/answers/de-

tail/a_id/471/~/landelijk-schakelpunt-%28lsp%295. CB voor de Statistiek. Helft zegt toestemming te geven

voor delen medische gegevens. Centraal Bureau voor de Statistiek. Accessed May 11, 2020. https://www.cbs.nl/nl-nl/nieuws/2019/20/helft-zegt-toestemming-te-geven-voor-delen-medische-gegevens

6. Zonneveld N, Driessen N, Stüssgen RAJ, et al. Values of Integrated Care: A Systematic Review. Int J Integr Care. 2018;18(4):9. doi:10.5334/ijic.4172

7. Ministerie van Volksgezondheid W en S. Staat van de Gezondheidszorg 2011 - Rapport - Inspectie Gezondhe-

idszorg en Jeugd. doi:https://www.igj.nl/documenten/rap-

porten/2011/10/15/staat-van-de-gezondheidszorg-20118. Shahnaz A, Qamar U, Khalid D. Using Blockchain for

Electronic Health Records. IEEE Access. 2019;PP:1-1. doi:10.1109/ACCESS.2019.2946373

9. Mayer AH, da Costa CA, Righi R da R. Elec-

tronic health records in a Blockchain: A system-

atic review. Health Informatics J. Published on-

line September 30, 2019:1460458219866350. doi:10.1177/1460458219866350

10. Li K-C, Chen X, Jiang H, et al. Essentials of Blockchain Technology. CRC Press; 2019.

11. Mettler M. Blockchain technology in healthcare: The revolution starts here. In: 2016 IEEE 18th International Conference on E-Health Networking, Applications and Services (Healthcom). ; 2016:1-3. doi:10.1109/Health-

Com.2016.7749510

‘‘Blockchain is essentially a system for data storage, originally made for Bitcoin cryptocurrency.’’

ARTICLE ARTICLE

7 8


proper gas exchange. This endothelial injury with pulmonary thrombosis formation (discussed be-low) can cause an acute respiratory distress syn-drome (ARDS).5 Remarkably, the clinical features of Covid-19-associated ARDS are similar to that of those with ARDS unrelated to Covid-19.5

Covid-19-associated coagulopathyA second concerning feature of patients with Covid-19 is a high incidence of thrombotic com-plications, including deep vein thrombosis, pul-monary embolism and arterial thrombotic events.6

This may again be related to endothelial dysfunc-tion. The disruption of vascular integrity leads to exposure of the thrombogenic basement mem-brane which results in activation of the clotting cascade.7 Furthermore, cytokines, such as inter-leukin-1β (IL-1β) and tumor necrosis factor (TNF) activate endothelial cells to initiate coagulopathy by expression of P-selectin, von Willebrand Fac-tor (vWf) and fibrinogen, to which platelets bind.8

After platelet binding, endothelial cells release tro-phic cytokines that stimulate additional production of platelets and activate tissue factor, which is a strong activator of the coagulation cascade. Final-ly, thrombosis may also be induced by neutrophils that release extracellular traps resulting in neutro-phil extracellular traps (NETs).9 These NETs can act as a foundation for binding of platelets that ac-tivate coagulation factor XI to generate thrombin and consequently, fibrin production causing throm-bosis. As evidence that endotheliopathy evokes the Covid-19-associated coagulopathy, a biochemical study demonstrated that endothelium-specific bio-markers10 and platelet activation, including vWf, P-selectin and soluble thrombomodulin were el-evated in Covid-19 patients.10,11 Importantly, the

mortality rate was positively associated with the levels of these markers (r=0.38; p=0.0022).11 The

clinical relevance of these biochemical findings was emphasized by autopsy series in which endo-thelialitis, NETs and thrombi were present in mul-tiple organs, particularly in the lungs, heart and brain.2,4 However, a remarkable finding was that thrombi were also observed in organs with normal blood vessels.2 This implies that virus-induced en-dothelialitis is not essential for the development of Covid-19-associated coagulopathy.

Hyperinflammation and cytokine stormA hyperinflammatory syndrome is characterized by a fulminant and life-threatening hypercytokin-

emia with multi-organ failure. In patients with se-

vere Covid-19, a profound increase in circulating

cytokines was observed, including interleukins, TNF-α12,13 and vascular endothelial growth factor (VEGF).14,15 The cytokine profile of these patients, the so-called cytokine storm, resembles hyper-

inflammatory syndrome.16 Of note, the levels of some cytokines, such as IL-6 and VEGF-D (one of the five members of the VEGF family) positively-

correlated with the severity of the illness (r=0.47; p=0.0021).14 This suggests that the mortality may

be caused by virus-driven hyperinflammation.13,16

Although some studies debate the contribution of excessive inflammation in the development of Covid-1917,18, malfunction of endothelial cells is

again essential in the development and progres-

The role of endotheliopathy in the pathogenesis of Covid-19: A narrative review

MAXIMILIAAN C.H. CHENG1*, KEVIN K.H. CHENG

1*, ANTON VONK NOORDEGRAAF2,

MD PHD AND LIZA BOTROS2, MD

* BOTH AUTHORS CONTRIBUTED EQUALLY

1. FINAL YEAR STUDENTS OF HYPERION LYCEUM AND HERVORMD LYCEUM ZUID,

AMSTERDAM

2. DEPARTMENT OF PULMONARY DISEASES, AMSTERDAM UMC, LOCATION VUMC

AMSTERDAM CARDIOVASCULAR SCIENCES

INTRODUCTIONThe coronavirus disease 2019 (Covid-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) threatens global health and in-duces an unprecedented recession in the economy. As there are currently no optimal treatments avail-able, understanding of its pathophysiology is most important for development of targeted therapies.

PATHOPHYSIOLOGYSARS-CoV-2 is an RNA virus1 that infects nearly all organs, but mainly the lungs.2 Histopathological and biochemical studies suggest that the entry of SARS-CoV-2 into the pulmonary endothelial cells and the following inflammatory processes within these cells, play a central role in the pathogene-sis underpinning Covid-19.3 After viral invasion of endothelial cells, three main pathological path-ways simultaneously develop: endothelial barrier dysfunction, coagulopathy and hyperinflammation leading to a cytokine storm (see FIGURE 1).3

Covid-19-induced vascular leakageThe primary cause of mortality in patients with Covid-19 is acute hypoxic respiratory failure from vascular leakage and pulmonary oedema.2 The

loss of vascular integrity is thought to be caused by both a direct and an indirect effect of the virus on the endothelium. First, SARS-CoV-2 can enter and infect endothelial cells through binding to the surface angiotensin-converting enzyme 2 receptor. An autopsy study with patients who died due to Covid-19 showed pulmonary vascular endotheli-alitis with the presence of intracellular virus and endothelial cell destruction.4 Second, activated neutrophils and lymphocytes triggered by the in-fected endothelial pulmonary cells produce an excessive amount of inflammatory cytokines lead-ing to enhanced inter-endothelial gaps.2,3 Both the direct cytotoxicity of the virus and production of these cytokines induce loosening of inter-endo-thelial junctions, resulting in increased vascular permeability and alveolar oedema which hampers

ABSTRACTCoronavirus disease (Covid-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has induced an immense crisis in health-care systems and in the economy worldwide. So far, no optimal treatment for Covid-19 has been established. As knowledge about SARS-CoV-2’s disease mechanism is essential for drug development, this review summarizes the presumed pathological processes that underly Covid-19. These include endothelial barrier dysfunction, coagulopathy and hyperinflammation. Because SARS-CoV-2 infects al-most all organs, Covid-19 is recognized as a systemic disease. Further evidence shows that an overreacting im-mune-mediated response leads to excessive cytokine production, causing hyperinflammation and extensive tissue damage, resulting in multi-organ failure. These findings provide the rationale to explore immunomodulation and anti-cytokine agents as potential therapeutic options for the treatment of Covid-19. Clinical trials with cytokine inhibitors are warranted.

FIGURE 1 After viral invasion of endothelial cells, three main pathological pathways simultaneously develop: endothelial barriar dysfunction leading to vascular leakage and alveolar edema, coagulopathy and hyperinflammation with cytokine storm

ARTICLE

9

AMSj Vol. 22 | March 2021

sion of Covid-19-related cytokine storm. Infected endothelial cells express leukocyte adhesion mol-ecules and also activate the complement system,

promoting recruitment of leukocytes, including

neutrophils and inflammatory cells.3,8 Profuse tox-

ic mediators from neutrophils, together with the uncontrolled excessive cytokines produced by the inflammatory cells, lead to apoptosis of the endo-

thelial cells and extensive collateral tissue damage. This mechanism was confirmed by immunohisto-

chemical studies, in which extensive immune-me-

diated responses in many organs of patients with fatal Covid-19 were detected.2,4 Notably, the viral

load of SARS-CoV-2 significantly decreased with increased disease course, while an exorbitant sys-

temic inflammatory response was noted in the late phase of Covid-19. The disproportionate presence of neutrophils and NETs in relation to occasion-

al presence of virus suggests a maladaptive im-

mune-mediated response.2 This finding provides rationale for immunomodulation as a therapeutic

option for the treatment of this disorder.

Therapeutic optionsSeveral potential anti-SARS-CoV-2 drugs have been tested in clinical randomized trials world-

wide, in which thousands of patients with Covid-19 were included. Thus far, remdesivir, hydroxychlo-

roquine, lopinavir with ritonavir, interferon- β1a19

and azithromycin alone20 or in combination with hydroxychloroquine21 appeared to have little or no

effect on patients with Covid-19. Up to now, cor-ticosteroids have shown beneficial effects.22,23 The use of dexamethasone and hydrocortisone resulted in lower 28-day mortality22 and 93% probability of benefits respectively.23 Considering the autop-

sy-based findings that multiple organs are princi-pally affected by severe inflammatory processes2,

the beneficial effects of corticosteroids emphasize the importance of downregulating the immune re-

sponse in these patients. Until effective antiviral agents are available, the best remedy for Covid-19

might be administration of inhibitors of cytokines

such as tocilizumab,24,25 in addition to corticoste-

roids with thromboprophylaxis. Although vacci-nations against SARS-CoV-2 have been initiated in wealthy countries recently, three new and more contagious variants of coronavirus have been

identified. These mutants might pose a new threat because the extent of the protection of the current

vaccines against these new strains is yet unclear.26

Pending the outcomes of the immunizations, clin-

ical trials with antibodies against cytokines are ur-gently needed.

CONCLUSIONThe global health and socio-economic impacts of Covid-19 are enormous. Currently, the search for an effective treatment is the greatest challenge. The pathophysiological mechanisms of Covid-19 are

endothelial barrier dysfunction, coagulopathy and

hyperinflammation, which affects multiple organ systems. Clinical trials with immunosuppressive agents including selective cytokine blockers to mit-

igate the excessive inflammatory state are required.

ACKNOWLEDGEMENTWe are grateful to Dr. Botros and Professor Vonk-Noordegraaf for the opportunity offered to write this article and thank them for their assis-

tance in writing the manuscript.

REFERENCES1. Becker, R. C. 2019. Toward understanding the 2019

Coronavirus and its impact on the heart. J. Thrombosis and Thrombolysis. 50(1), 33–42.

2. Schurink, B., Roos, E., Radonic, T., et al. 2020. Viral presence and immunopathology in patients with lethal COVID-19: a prospective autopsy cohort study. Lancet Microbe. 1(7) E290-E299

3. Teuwen, L.-A., Geldhof, V., Pasut, A., et al. 2020. COVID-19: the vasculature unleashed. Nature Reviews Immunology. 20(7), 389–391.

4. Ackermann, M., Verleden, S. E., Kuehnel, M., et al. 2020. Pulmonary Vascular Endothelialitis, Thrombosis, and An-giogenesis in Covid-19. New England Journal of Medi-cine. 383(2), 120–128.

5. Grasselli, G., Tonetti, T., Protti, A., et al. 2020. Patho-physiology of COVID-19-associated acute respiratory distress syndrome: a multicentre prospective observation-al study. Lancet Respir Med. 8, 1201-08.

6. Klok, F. S., Kruip, M. J. H. A., van der Meer, N. J. M., et al. 2020. Incidence of thrombotic complications in criti-cally ill ICU patients with COVID-19. Thrombosis Re-search. J.Throm Res. 191, 145–147.

7. Nachman, R. L. and Rafii, S. 2008. Platelets, Petechiae, and Preservation of the Vascular Wall. New England Jour-nal of Medicine. 359(12), 1261–1270.

8. Pober, J. S. and Sessa, W. C. 2007. Evolving functions of endothelial cells in inflammation. Nature Reviews Immu-nology. 7(10), 803–815.

9. Becker, RC. 2020. COVID-19 update: Covid-19-associ-ated coagulopathy. Journal of Thrombosis and Thrombol-ysis. 50(1), 54–67.

10. O’Sullivan, J. M., Gonagle, D. M., Ward, S. E., et al. 2020. Endothelial cells orchestrate COVID-19 coagulop-

athy. Lancet Haematology. 7(8), e553–e555.11. Goshua, G., Pine, A. B., Meizlish, M. L., et al. 2020. En-

dotheliopathy in COVID-19-associated coagulopathy: evidence from a single-centre, cross-sectional study. Lan-cet Haematology. 7(8), e575–e582.

12. Huang, C., Wang, Y., Li, X., et al. 2020. Clinical features of patients infected with 2019 novel coronavirus in Wu-han, China. Lancet. 395: 497-506.

13. Ruan, Q., Yang, K., Wang, W., et al. 2020. Clinical pre-dictors of mortality due to COVID-19 based on an analy-sis of data of 150 patients from Wuhan, China. Intensive Care Med 2020.

14. Kong, Y., Han, J., Wu, X., et al. 2020. VEGF-D: a novel biomarker for detection of COVID-19 progression. Crit-ical Care. 24(1).

15. Meizlish, M., Pine, A., Goshua, G., et al. 2020. Circu-lating Markers of Angiogenesis and Endotheliopathy in COVID-19. MedRxiv Preprent.

16. Mehta, P., McAuley, D. F., Brown, M., et al. 2020. COVID-19: consider cytokine storm syndromes and im-munosuppression. Lancet. 395(10229), 1033–1034.

17. Sinha, P., Matthay, M.A., Calfee, C.S., et al. 2020. Is a “cytokine storm” relevant to COVID-19? JAMA Intern Med. 180(9), 1152-1154.

18. Guillon, A, Hiemstra, P.S., Si-Tahar, M., et al. 2020. Pul-monary immune responses against SARS-CoV-2 infec-tion: harmful or not? Intensive Care Med. 46, 1897-1900

19. Pan, H., Peto, R., Karim, Q.A., et al. 2020. Repurposed antiviral drugs for COVID-19 –interim WHO Solidarity trial results. doi: 10.1056/NEJMoa2023184

20. Furtado, R.H.M., Berwanger, O., Fonseca, H.A., et al. 2020. Azithromycin in addition to standard of care ver-sus standard of care alone in the treatment of patients admitted to the hospital with severe COVID-19 in Bra-zil (COALITION II): a randomised clinical trial. Lancet. 396(10256), P959-967

21. Cavalcanti, A.B., Zampieri, F.G., Rosa, R.G., et al. 2020. Hydroxychloroquine with or without Azithromycin in Mild-to-Moderate Covid-19. New England Journal of Medicine. 383, 2041-2052

22. Horby, P., Lim, W. S., Emberson, J. R., et al. 2020. Dexa-methasone in Hospitalized Patients with Covid-19 – Pre-liminary Report. The RECOVERY Collaborative Group. New England Journal of Medicine. DOI: 10.1056/NEJ-Moa2021436

23. Angus, D. C., Derde, L., Al-Beidh, F., et al. 2020. Ef-fect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19. The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA. 324(13), 1317-1329

24. Salama, C., Han, J., Yau, L., et al. 2020. Tocilizumab in Patients Hospitalized with Covid-19 Pneumonia. New England Journal of Medicine. 384, 20-30.

25. Gordon, A.C., Mouncey, P.R., Al-Beidh, F., et al. 2021. In-terleukin-6 Receptor Antagonists in Critically Ill Patients with Covid-19 – preliminary report. The REMAP-CAP. medRxiv. 2021.01.07.21249390.

26. Rubin, E. J., Baden, L. R., Abdool Karim, S. S., et al. 2021. Audio Interview: Covid-19 in South Africa and a New SARS-CoV-2 Variant. New England Journal of Medicine. 384, e14.

See guidelines for submitting on amsj.nl.

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Ghana during their annual missions (www.operationhernia.nl). Since 2009, ten DOH missions have been organized by a team of sur-geons and residents from OLVG, St. Antonius Hospital, Tergooi and Hospital Amstelland and already more than 1500 patients received surgical treatment. Because of the mission’s short time-frame of only one week, the patient follow-up is normally done by the local hospital staff and a study into results of the DOH missions had nev-

er been performed. For this reason I joined the team to perform a prospective study of this year’s mission in the two participating rural hospitals in Keta and Sogakope, Volta Region of Ghana. Af-ter the mission had fi nished, I stayed in Ghana for six weeks to perform a follow-up of all included patients to measure short-term postoperative com-plications and quality of life. We were happily sur-prised that 90% of all patients returned to the hos-pitals 2-3 weeks after surgery! The results showed acceptable complication rates (comparable with Dutch practice), without any deep infections that would require reoperation. In order to fully assess the results and impact of the mission in terms of chronic pain rates and quality of life improvement, we plan to perform a long-term follow-up visit for all included patients (whenever the COVID-situa-tion allows this).

APPLICATIONThis research internship in Ghana followed right after my semi-arts stage (senior internship) at the Department of Surgery of OLVG Oost, where I got in contact with one of the surgeons who is in the lead in the DOH missions. As we were speaking about the missions and their interest in perform-ing a quality study, the opportunity for me arose to

Research project: Operation Hernia 2020 in Ghana

NINE DE GRAAF1,2

1. DEPARTMENT OF SURGERY, AMSTERDAM UMC, UNIVERSITY OF AMSTERDAM, THE NETHERLANDS

2. DEPARTMENT OF GENERAL SURGERY, FONDAZIONE POLIAMBULANZA INSTITUTO OSPEDALIERO, BRESCIA, ITALY

INTRODUCTIONMy name is Nine de Graaf and I am currently working as a PhD candidate in Hepato-pancrea-to-biliary surgery at the Amsterdam UMC, now based in Brescia, Italy for a research fellowship. In the beginning of 2020 (just before the COVID-19 pandemic) I got the opportunity to join the ‘Dutch Operation Hernia’ (DOH) team on their annual surgical mission to Ghana, where I set up a pro-spective study on the outcomes of the mission as a research project for my master’s thesis.

RESEARCH PROJECTIn Ghana, many inguinal hernia cases remain un-treated due to low capacity for essential surgical care and limited healthcare access for patients. Strangulation of unrepaired inguinal hernias is a severe and emergent complication, leading to needless deaths and permanent disabilities for gen-erally physically fi t and healthy people. Aiming to reduce these strangulation rates, DOH provides free hernia surgery in varying rural hospitals in

join the 2020 mission to set up this study. Another student, and friend of mine, also joined the DOH team to Ghana to perform a different research project for Operation Hernia, so we were able to stay there with the two of us. As we arranged this internship directly with DOH organization, there was no selection process with other students.

EXPERIENCES AND LEARNING POINTSConducting research in Ghana has defi nitely been an experience. The country has a fantastic culture with an admirable positive spirit, beautiful nature and the staff of the hospital put so much dedica-tion and effort into helping us with the project. As expected, though, certainly not everything went smoothly all the time. Some facilities (i.e. electrici-ty, internet connection, printing services) are avail-able to a lesser extent than we are used to in Dutch hospitals and hospital logistics also works differ-ently. Hospitals in Ghana do not work with set ap-pointments; patients just show up. ‘We will do this tomorrow’ actually means ‘this will be done in a few weeks’. This obviously required a change of mindset and a lot of improvisation but at the same time it has been a great learning experience for me. One piece of advice I would like to give to future students performing research projects abroad is to prepare your ethical approvals before your arriv-al, since regulations can differ from those in your home country. This would have saved me a lot of time, paperwork and long bus rides to the capital city’s health service offi ce. For everyone who is up for an adventure, I would defi nitely recommend arranging your (research) internship abroad. It is possibly not the ‘easy way’ and might require you to work a little harder but no doubt you will gain

a lot of experience that is useful for your further career, plus some unforgettable memories!

Keta Municipal HospitalDiocese of Keta-Akatsi P.O. Box 82Keta, Volta Region, Ghana

Richard Novati Catholic Hospital Diocese of Keta-Akatsi P.O. Box SK 95, Sogakope, Volta Region, Ghana

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fective therapy without aggravating the patient’s dissociative condition needs to be investigated.8

Schema therapy (ST) is an integrative therapy that combines the treatment of traditional cognitive behaviors with experience, psychodynamic and interpersonal elements, using therapeutic relation-ships to treat psychological disorders that are not responsive to conventional therapy. ST focuses on how symptoms and difficulties form and how their effects can affect current maintenance factors.9 ST involves painful childhood experiences that play a role in Early Maladaptive Schemas (EMSs) of patients by focusing on re-experiencing and com-municating the most vulnerable circumstances of childhood, where in childhood they required the care of parents or adults in their environment but did not get it.10 In ST, the therapist acts in a patient’s ‘reparenting’ to meet the psychological needs of patients during childhood that were not previously obtained. Likewise, when re-imagin-ing a traumatic experience, it is likely to require a strong trust relationship between therapist and client as a key technique in ST.11 In ST, various identities in DID, which are extreme forms of ex-pression from dysfunctional modes, are reframed into normal modes.12 The aim of this review is to discuss schema therapy as alternative therapy for the treatment of DID.

METHODA comprehensive literature search was performed from January-April 2020 using the PubMed search engine. The following MeSH terms were used in this study: “dissociative”, “dissociative identity”, “dissociative identity disorder”, and “scheme ther-apy”. The inclusion criteria used were full-text in English, the studies conducted were randomized controlled trials (RCTs), clinical trials, or case series and publications not older than the last 10 years. Because the ST-related studies applied to DID were still limited, the inclusion criteria also included the diagnosis of personality disorders with symptoms commonly seen in DID patients. The exclusion criteria used were non-full-text, publication not in English, review or the study was conducted on one subject and publication older than 10 years.

Based on the studies by Bamelis et al (2014), the group with scheme therapy showed better out-

comes than the treatment commonly practiced in the origin country.13 Skewes et al (2015) and Nenadic et al (2017) showed there was a signif-icant reduction of symptoms during short-term (6-7 weeks) and long-term (3-5 years) therapy.14,15

Videlar et al (2017) showed that ST can also be applied to a population with older personality dis-orders (mean age 69 years).16 Huntjes et al (2019) specifically researched the effect of ST in DID patients. This study is focused on adapting and accepting patient experiences that can shorten the duration of therapy compared to existing therapy guidelines.17

DISCUSSIONDID is a psychiatric disorder with difficult treat-ment, with limited studies regarding the application of ST to DID. However, ST is one of the alterna-tives related to the treatment of severe personality disorders.18 One thing that needs to be a concern of ST is its focus on repairing trauma from DID patients.19 Schlumpf et al (2019) showed the im-pact of the focus of treatment on trauma, resulting in the reduction of dissociative and other psycho-pathological symptoms associated with trauma.20

ST can also be conducted in a group, which was done in the study by Fassbinder et al (2016). BPD patients showed a decrease in BPD symptoms, dysfunctional mode (one of which is a dissociative form), and hospitalization followed by improve-ments in quality of life and levels of happiness.21

However, a study by Dickhaut and Arntz (2014) shows that applying ST in groups has a high risk of dropout, so that ST is better done individually de-spite the advantages in terms of cost-effectiveness and ST accessibility as a group.22 ST seems to be working, but it takes a long time before results are reported. Implementation of ST requires an aver-age time of six months to two years. Through ST, patients can improve their quality of life and group therapy can increase the patient’s willingness to recover.18

However, there are several limitations regarding the application of ST for DID therapy.23 The lim-itations that exist are related to the small sample size of the trials conducted and the number of con-trols used. Besides this, the studies that have been carried out are limited to homogeneous population

Schema Therapy for Dissociative Identity Disorder: A Literature Review

MUHAMMAD L. ADNAN1

1. MEDICAL STUDENT, FACULTY OF MEDICINE, UNIVERSITAS ISLAM INDONESIA, SLEMAN,

INDONESIA

INTRODUCTIONDissociative Identity Disorder (DID) is one of the controversial psychiatric disorders because of discrepancy in definition and the number of symp-toms that occur in patients. According to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), DID is an identity dis-order that is characterized by the presence of two or more personalities with discontinuities in the sense of self-feeling and changes that affect behav-ior, awareness, memory, perception, cognition and sensory function.1 DID occurs more in people with a history of childhood trauma, child abuse (both

physically and sexually), Posttraumatic Stress Dis-order (PTSD) and Borderline Personality Disorder (BPD).2 Currently, estimates of DID worldwide range from 5% for psychiatric inpatients, 2–3% for outpatients and 1% for the general population.3 As the incidence of DID increases due to the increased rate of trauma in children, which can increase the risk of DID, so does the interest in developing the most effective therapy for DID patients.4

The major limitation in common DID therapy is the length of time it takes to achieve stabilization of the patient’s symptoms. Therefore, time-ef-

ABSTRACTI N T R O D U C T I O N Dissociative Identity Disorder (DID) is one of the psychiatric disorders that attracts a lot of attention and many studies review this disorder more deeply, one of them is about therapy for DID patients. Schema therapy is an integrative therapy combining cognitive therapy and a combination of therapeutic relation-ships with experiential, psychodynamic and interpersonal elements. The aim of this review is to discuss schema therapies as alternative therapies for the treatment of DID.M E T H O D A literature search in PubMed using keywords: “dissociative”, “dissociative identity”, “dissocia-tive identity disorder”, “treatment of dissociative identity disorder” and “scheme therapy”.R E S U LT Schema therapy, that has been developed as a therapy for chronic psychiatric disorders, can be an alternative treatment for DID. In schema therapy, the collaboration between the therapist-clinician and the patient is needed to achieve the therapeutic goals. However, studies conducted are still limited by the number of samples and further research on the influence of schema therapy for DID patients is needed.C O N C LU S I O N Schema therapy can be a therapy for DID patients. However, further research is needed to test schema therapy in a wider population so that schema therapy can become the best therapy for DID patients.

TABLE 1 Current DID Treatment

DID Therapy Limitation

Non-Pharmacology5 Three-phase multimodal therapy (based on the International Society for the Study of Trauma & Dissociation’s (ISSTD) Treatment Guidelines for Dissociative Identity Disorder in Adults).

• Premature traumatic memory obsession.6

• Problems of drug abuse and severe pathologi-

cal personality factors in patients with low levels of self-confidence.6

Pharmacology7 • Antidepressants (SSRIs, Non-SSRIs, tricyclic antidepressants, and monoamine oxidase inhib-

itors)• Mood stabilizers such as carbamazepine

• Maltrexone to reduce self-injury.

Still limited to the treatment of symptoms that

appear in DID patients.7

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2014;77(2):169-189.7. Gentile JP, Dillon KS, Gillig PM. Psychotherapy and

pharmacotherapy for patients with dissociative identity disorder. Innov Clin Neurosci. 2013;10(2):22-29.

8. Brand BL. What We Know and What We Need to Learn About the Treatment of Dissociative Disorders. J Trauma Dissociation. 2012;13(4):387-396.

9. Taylor CDJ, Bee P, Haddock G. Does schema therapy change schemas and symptoms? A systematic review across mental health disorders. Psychol Psychother Theo-ry, Res Pract. 2017;90(3):456-479.

10. Dadomo H, Grecucci A, Giardini I et al. Schema therapy for emotional dysregulation: Theoretical implication and clinical applications. Front Psychol. 2016;7(DEC):1-16.

11. Renner F, DeRubeis R, Arntz A et al. Exploring mecha-nisms of change in schema therapy for chronic depres-sion. J Behav Ther Exp Psychiatry. 2018;58:97-105.

12. Haeyen S. Strengthening the healthy adult self in art ther-apy: Using schema therapy as a positive psychological intervention for people diagnosed with personality disor-ders. Front Psychol. 2019;10(MAR):1-15.

13. Bamelis LLM, Evers SMAA, Spinhoven P et al. Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. Am J Psychiatry. 2014;171(3):305-322.

14. Skewes SA, Samson RA, Simpson SG et al. Short-term group schema therapy for mixed personality disorders: a pilot study. Front Psychol. 2015;5(January):1-9.

15. Nenadić I, Lamberth S, Reiss N. Group schema therapy for personality disorders: A pilot study for implementa-tion in acute psychiatric in-patient settings. Psychiatry Res. 2017;253:9-12.

16. Videler AC, van Alphen SPJ, van Royen RJJ et al. Schema therapy for personality disorders in older adults: a mul-tiple-baseline study. Aging Ment Heal. 2018;22(6):738-747.

17. Huntjens RJC, Rijkeboer MM, Arntz A. Schema ther-apy for Dissociative Identity Disorder (DID): ra-tionale and study protocol. Eur J Psychotraumatol. 2019;10(1):1571377.

18. Tan YM, Lee CW, Averbeck LE et al. Schema therapy for borderline personality disorder: A qualitative study of patients’ perceptions. PLoS One. 2018;13(11):1-20.

19. Reinders AATS, Willemsen ATM, Vos HPJ et al. Fact or factitious? a psychobiological study of authentic and sim-ulated dissociative identity States. PLoS One. 2012;7(6).

20. Schlumpf YR, Nijenhuis ERS, Klein C et al. Function-al reorganization of neural networks involved in emo-tion regulation following trauma therapy for complex

trauma disorders. NeuroImage Clin. 2019;23(December 2018):101807.

21. Fassbinder E, Schuetze M, Kranich A et al. Feasibility of group schema therapy for outpatients with severe border-line personality disorder in Germany: A pilot study with three year follow-up. Front Psychol. 2016;7(NOV):1-9.

22. Dickhaut V, Arntz A. Combined group and individual schema therapy for borderline personality disorder: A pi-lot study. J Behav Ther Exp Psychiatry. 2014;45(2):242-251.

23. Huntjens RJC, Rijkeboer MM, Arntz A. Schema therapy for Dissociative Identity Disorder (DID): further explana-tion about the rationale and study protocol. Eur J Psycho-traumatol. 2019;10(1):1-3.

studies so they need to be repeated in more het-erogeneous population groups.14 Therefore, further

research is needed in larger population studies to support evidence-based therapy in DID patients.

CONCLUSIONSchema therapy can be an alternative treatment for DID which can improve the condition of pa-tients with previous treatment failures. ST prior-itizes the improvement of patients’ experiences to accept themselves, so that patients can control their cognition without dissociative events occur-ring. However, studies on schema therapy are still limited due to population limitations so they can-not be generalized to more heterogeneous popula-tions. Further research is needed to develop better scheme therapies and for the development of other treatments for patients with DID.

REFERENCES1. Brand BL, Sar V, Stavropoulos P, et al. Separating Fact

from Fiction: An Empirical Examination of Six Myths About Dissociative Identity Disorder. Harv Rev Psychi-atry. 2016;24(4):257–270.

2. Huntjens RJC, Wessel I, Ostafin BD et al. Trauma-related self-defining memories and future goals in Dissociative Identity Disorder. Behav Res Ther. 2016;87:216-224.

3. Rehan MA, Kuppa A, Ahuja A et al. A Strange Case of Dissociative Identity Disorder: Are There Any Triggers? Cureus. 2018;10(7).

4. Brand BL, Lanius R, Vermetten E. Where Are We Go-ing ? An Update on Assessment , Treatment , and Neu-robiological Research in Dissociative Disorders as We Move Toward the DSM-5. J Trauma Dissociation. 2012;13(1):37-41.

5. International Society for the Study of Trauma and Disso-ciation. Guidelines for Treating Dissociative Identity Dis-order in Adults, Third Revision. J Trauma Dissociation. 2011;12(2):115-187.

6. Brand BL, Loewenstein RJ, Spiegel D. Dispelling myths about dissociative identity disorder treatment: An empirically based approach. Psychiatry (New York).

Author

(year)Study population

Study

type

Dura-

tionOutcome Effect sizes

Bamelis et

al (2014)13

323 patients with cluster C personality disorder

(schema

Therapy/ST, N=147; treatment as usual/TAU (psychological treatment

in Netherlands), N=135;clarification-oriented psy-

chotherapy/COP, N=41).

RCT 5 years Patients treated with schema therapy had a

greater proportion of

recoveries with better social functioning than

the other two therapy groups.

Effect size were medium between ST and TAU (Cohen’s d= 0.50) and medium to large between ST and COP group (Cohen’s d= 0.53) in Global Assessment of Functioning Scale score and medium to large (Co-

hen’s d= 0.60 and 0.69) in Social and Occupational Functioning Assessment score

Skewes et al (2015)14

8 patients (2 patients drop

out; 6 patients finish) with mixed personality disorder

Pilot

study

5 months Qualitative feedback shows the group helps normalize participants’

psychological experi-ences and difficulties and promotes self-ex-

pression and self-dis-

closure.

Effect sizes between pre-therapy and post- therapy, and pre-ther-

apy and follow-up were all large (Cohen’s d= 1.32 and 1.32 in Global Symptom Index (GSI) questionnaire and 1.66 and 1.69 in Schema Model Inventory (SMI) maladaptive modes.

Nenadic et

al (2017)15

8 patients with borderline personality

disorder (BPD)

Pilot

study

6-7

weeksThere is symptom im-

provement in patient but

it is not correlated with patient satisfaction.

Effect size is large in symptoms

and maladaptive schema mode

(Cohen’s d= 0.857 and 0.693)

Videlar et al (2017)16

8 patients with borderline personality

disorder (BPD).

Multi-

ple-base-

line

study

6 months There is an increase in the patient’s core beliefs

and quality of life.

Effect sizes between pre-therapy and post- therapy is very high

(Cohen’s d= 2.136) in patient’s core belief and medium (d= 0.629) in symptomatic distress,

Huntjens et al

(2019)17

10 patients with DID Case

series

experi-mental

3 years Shorter treatment dura-

tion compared to stan-

dard therapy of ISSTD by suppressing cognitive

avoidance which is the main symptom of DID.

Unable to compute

TABLE 2 Summary of studies related to schema therapy

Inspire other students! Share your expirience in this column. For guidelines and to submit, go to amsj.nl!

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INTERVIEW INTERVIEW

is a dichotomy in our society, the difference in healthy life years between people with a high and a low social economic status is 18 years. This dif-ference is still increasing with the years, while we claim to have been working on this for 30 years already. We know that if you are having problems at work, debts, suboptimal housing or other prob-lems, the ability to take care of yourself decreas-es. We assume people are self-reliant and want to make their own decisions, but sometimes another, more caring, approach is necessary. I think that one of the keys to decreasing the differences between these groups is to stop making economic growth our main priority. This could also be advantageous in dealing with the climate crisis. This asks for a change in government policy.

Are there certain things you would like to see in the field of the general practice in the future? More research should be conducted on the diag-nostic process in the general practice. In the field of prevention you can also think of multiple ques-tions. In our health care system the tasks assigned to GPs are ever-increasing. What are our essential tasks when talking about prevention? How can we do that in an effective way, thus contributing to people’s health? Primary prevention is mainly effective on a societal level.

Do you have any advice for young medical stu-dents who are interested in research? Choose a subject that really interests you and ad-dress a question for which you are really curious about the outcome. It is also important to have good guidance when you start in research. Look for someone who is passionate about research and also likes to guide and coach others.

What are your main research interests?My main area of research is ‘medically unex-plained physical symptoms’. This phenomenon already intrigued me when I studied medicine. I did an extra internship in the internal medicine de-partment, gastro-enterology. I saw a lot of, mostly young, patients with abdominal complaints who received a lot of additional testing, while their probability of having a serious disease were almost zero, based on their symptoms and family history. I devoted my master thesis to this topic. My PhD study concerned the management of patients with Irritable Bowel Syndrome.

Could you name a highlight of your career?Looking back, doing my PhD was a highlight. My dissertation also won the Telesphorus prize for the best dissertation carried out by a GP. I received the prize because I addressed a complicated theme and studied a number of issues on IBS and also added a methodological reflection on doing a clinical tri-al in the general practice and I wrote a systematic review. This was rather unusual then and one of the first systematic reviews, using self-defined criteria.

What was a big challenge in your career?After having finished my dissertation I became coordinator of the vocational training of general practitioners, while combining it with working as a GP. After that I started working as a senior re-searcher and helped with establishing the VU Uni-versity Medical Center General Practice and the academic GP network. The academic GP network works with the department on research and inno-

vation in education and health care and combines this to improve the GP. At some point I was asked to become the head of the department. I had many

doubts at first but in the end I chose to apply for the job. After a year, and some time to reflect, I de-cided that I enjoyed the challenges that came with the job, which offered me an opportunity to lay down a policy that helped to reach relevant goals in education research and practice such as teaching students clinical reasoning and doing research that addressed important issues in daily practice.

You are also working on prevention and pub-lic health. How do you think the current climate change will affect public health in the future? It depends on how you interpret public health, but I do think that if we do not control this climate crisis, it could have consequences for people’s health. Public health and lifestyle are more deter-mined by political decisions and the opportunities that people have and their educational level than by the things doctors do. Prevention is much more effective if implemented on a societal level. There

Prof. H.E. van der Horst, MD

CURRICULUM VITAE

1953 Year of birth

1978 MD, VU university

1984 General Practitioner

1985 Vocational training as general practitioner,

VU medical center

1997 Dissertation

2000 Dutch College of General Practitioners,

several committees

2005 Member Supervisory Board, Reinier van

Arkel group

2007 Appointment as professor (general prac-

tice) and Head of department of General

Practice & Elderly Care Medicine, VU

medical center

2009 Board member CARE research school

2009 Member Supervisory Board, Bronovo and

Bronovo/MCH

2013 Member of the EMGO + board, EMGO+

institute for health and care research

2015 National Health Care Institute of the

Netherlands, member scientific advisory

board and chairwoman Committee

Pharmacotherapeutic Compass

2016 Chairwoman Division VI VU medical center

2016 Editor NTvG (Dutch Journal for Medicine)

2016 Chairwoman NHG congress 2017

2016 Board member AVAG (Academic

Midwifery Amsterdam Groningen)

2018 Chairwoman Committee Redefining the

core values and tasks of general practice

2019 Chairwoman Division 10 Amsterdam UMC

2019 Chairwoman Supervisory board Dutch

College of General Practitioners

2020 Chairwoman Supervisory Board Fibula

‘‘Rheumatology is one of the medical fields most broadly integrated with others like gastro-enterology, internal medicine and many more.’’

Henriette’s career can be described as an impressive combination of working as a general practitioner

(GP) and being active in education, research and multiple board functions. This interview will go into

Henriette’s research career, her view on public health in the Netherlands and general practice in the

future.

Prof. H.E. van der Horst, MD

INTERVIEWED BY MARJOLEIN A. KEESENBERG

DEPARTMENT: VU UNIVERSITY MEDICAL CENTER GENERAL PRACTICE

Foto door: Harry Meijer

ISTEPUP20

December 2020 | AMSj Vol. 21

SPOTLIGHT19


A PhD without a Master’s Degree

MERLE STELLINGWERF, MD, PHD 1

1. DEPARTMENT OF SURGERY, AMSTERDAM UMC, LOCATION AMC

In the column ‘Spotlight’ we shine a light on students who already published their research in other journals or started their PhD course before graduation.

Last year, Merle Stellingwerf (our creative editor), defended her PhD thesis titled 'Surgery in Infl ammatory Bowel Disease: a different point of view. We have invited her to tell us more about her PhD trajactory, which she fi nished before actually obtaining a Master's degree.

During a clinical lecture a young patient with ul-cerative colitis told a story about queuing up for a bar on a Saturday night out, however, she just had a fl are of her disease and was always afraid for ‘accidents’. This happened to her that night as well and she stopped going out. After her J-pouch surgery this suddenly changed and she was able to take part in all activities again and regained her quality of life. This is where my interest in infl am-matory bowel diseases (IBD) started. Moreover, the technical part of the J-pouch surgery fascinat-ed me.

In 2014 during a one-week junior rotation at the surgical department I came into contact with prof. dr. W.A. Bemelman, a colorectal surgeon special-ized in minimally invasive surgery in colorectal cancer and IBD patients. Thereafter he supervised me for my bachelor’s thesis and arranged a scien-tifi c research internship for my master’s degree at the St Mark’s Hospital in London, a specialized IBD hospital. During the week I did research on J-pouch surgery and every Friday I had the oppor-tunity to go to the theatres (i.e. operation rooms) and observe all kinds of surgeries for IBD. Back in Amsterdam I started with my rotations, which I really enjoyed. However, I missed doing research. One year later prof. dr. W.A. Bemelman informed me about a vacancy as PhD candidate in his team, and I got the job!

In order to work as a full time PhD candidate, I had to temporarily quit my studies. Even though the study advisors were sceptic about this aberrant trajectory, it was quite easy to arrange it all. For two years and nine months I worked at the depart-ment of Surgery and the department of Gastroen-terology & Hepatology in the Amsterdam UMC, location AMC, under supervision of prof. dr. W.A. Bemelman, prof. dr. G.R.A.M. D’Haens and dr. C.J. Buskens. Our research focused on new and es-tablished surgical treatment options for ulcerative colitis and perianal Crohn’s disease. I coordinated two large multicenter randomized controlled trials

which were initiated earlier and I received a Zon-Mw grant for a follow-up study; the COSTA study. This study will further evaluate the infl uence of an appendectomy on ulcerative colitis, as we hy-pothesize (and already confi rmed in some studies) that this might have a positive effect on the disease course of ulcerative colitis.

‘‘Even though the study advisors were sceptic about this aberrant trajectory, it was quite easy to arrange it all.’’

Only after publishing most of my manuscripts, I continued with my rotations. As we all know work-ing in the fi eld of medicine can be tough, requiring long days in the hospital. Therefore, I would real-ly advise to fi rst fi nish most of your PhD before continuing with clinical work. Last year I (fi nally ;)) fi nished my rotations and one month later I de-fended my PhD. It requires some effort, but it is defi nitely possible to request a PhD defense date or even defend it without having your master’s de-gree. For the last two months I have been working as a resident at the department of surgery in the OLVG Oost. To keep my affi nity with research and a second passion of mine, creativity, I am now part of the AMSj editorial board as creative editor.

As I had an amazing time during my PhD, I would defi nitely do it again and I would recommend it to everyone. Make sure you research a subject you’re genuinely interested in, ask for help from more experienced colleagues, and most of all be part of a team. By working together and collabo-

rating in (inter)national projects it is much easier to make a change. Furthermore, this will keep you motivated, as doing research comes with ups and downs, and social activities, conferences, journal clubs etc. will defi nitely make it more fun. So do not hesitate, be assertive and ask that one professor to supervise you for your thesis, and before you know it you will have your PhD!

‘‘By working together and collaborating in (inter)national projects it is much easier to make a change’’

MEDICAL BUSINESS

21 22MEDICAL BUSINESS


Dependence on Foreign Medical Supplies in the Netherlands was a Contributing Factor in Early Failure of COVID-19 Pandemic Control

Pauline J. Brandon Bravo Bruinsma11. FACULTY OF MEDICINE, AMSTERDAM UNIVERSITY MEDICAL CENTER, LOCATION VUMC, VU UNIVERSITY

Would the outbreak of the COVID-19 pandemic have been more manageable and controlled more

quickly if all medical supplies would be manufac-

tured in the Netherlands? The partly unexpected, massive and acute outbreak has caused manufac-

turers and distributors of medical devices to con-

tend with large inventory shortages. In the Neth-

erlands, the Landelijk Consortium Hulpmiddelen

(LCH) purchases many of these supplies, such

as FFP1, FFP2 and the high-quality FFP3 masks, disinfectants, diagnostic tests, equipment and res-

pirators, in non-European countries.1,2 Due to the

globally increased demand and usage of these sup-

plies, shortages quickly arose in various branches

of the medical and non-medical community. As a result, protective equipment was withheld from healthcare workers in the field. Consequently, the coronavirus outbreak could not be prevented or

controlled properly in the Netherlands, partly due

to a reduced import and increased demand of med-

ical supplies, and a decrease in quality.

Firstly, the Netherlands purchases many medical supplies from abroad, mainly China, which are primarily delivered by air. However, as air traffic causes increased virus spread, measures were tak-

en to reduce the number of flights. This not only resulted in a rapidly emerging shortage of medi-

cal devices but also in rising costs of transport by

plane.1 Therefore, this could make the import of medical supplies less feasible as each country is

either combatting the disease or already overbur-

dened to supply medical supplies to other coun-

tries.3 This exemplifies the importance of increas-

ing the domestic production of medical supplies to

combat COVID-19, or any pandemic.

In the beginning, it was strenuous to determine

whether a patient was infected and what the spe-

cific virulence of the virus was. Therefore, calcu-

lations on how much supplies would be needed to treat the infected failed utterly. There was simply not enough knowledge available to determine and predict how fast the virus would spread and what the consequences would be for obtaining equip-

ment. Moreover, it is extremely difficult to deter-mine in advance whether a patient is infected with the virus because the symptoms differ per person

and between different age groups.4 For this reason, it is important that every hospital employee wears appropriate protection with every contact.5 Addi-tionally, the ongoing number of infected patients

has increased the need for intensive care capacity,

due to the increased demand for respirators and

other devices to treat infected patients under criti-

cal conditions.6 Because of this increased demand

and shortage of medical supplies, this could not be

achieved and this may have led to an increased vi-

rus spread.

Due to the globally increased demand for medical

supplies such as mouth masks, large quantities were

ordered from medical supply producing countries,

mainly China. This resulted in an extremely high workload for producers and distributors. Because they wanted to deliver these products as quickly as possible during such a critical period, the qual-

ity of the products deteriorated. Subsequently, the purchased mouth masks did not meet the require-

ments upon arrival in the Netherlands.1 In addition, medical masks have to meet much more stringent

requirements than civil masks. Eventually, there were enough of these civil masks produced by many new Chinese factories, but this was not the case at the beginning of the outbreak.1 It would be useful if the Netherlands controls production and

immediate testing of the products.

On the other hand, it is much more expensive to arrange this production of medical devices in

the Netherlands. Therefore, the Netherlands pur-chases these products from China, since econo-

mies-of-scale is achieved better in China, which results in a much lower purchase price.1 Conse-

quently, buyers can purchase medicine and med-

ical devices worldwide at low costs. Once pro-

duction remains within Europe, the production costs will increase. However, this reduces the risk of an insufficient and unreliable supply chain, which eventually will also result in shorter deliv-

ery times.7 Because of this, any outbreak would be more rapidly under control and would not get out of control as quickly as it did with this corona pandemic.

In conclusion, I believe that if the Netherlands was not so dependent on foreign medical supplies, the

SARS-CoV-2 virus would not have been able to spread at the speed it did. This was not the first pandemic and therefore the Netherlands should

have taken the Chinese reports of December 2019 more seriously. This goal of early control can be reached in future outbreaks if most of our medical

supplies are produced in either neighboring coun-

tries or in the Netherlands itself. It is of great im-

portance to put quality over quantity and introduce

policies to acknowledge the fact that we need to increase domestic production of medical devices

in order to anticipate future outbreaks.

REFERENCES1. Pinxteren, G., 2020. In De Strijd Om Chinese Mond-

kapjes Moet Nederland Risico’S Nemen. [online] NRC. Available at: <https://www.nrc.nl/nieuws/2020/05/01/in-de-strijd-om-chinese-mondkapjes-moet-nederland-risi-

cos-nemen-a3998460> [Accessed 1 May 2020].2. Rijksoverheid, 2020. Opstart Initiatief Landelijk Con-

sortium Hulpmiddelen. [online] Rijksoverheid.nl. Available at: <https://www.rijksoverheid.nl/actueel/nieuws/2020/03/24/opstart-initiatief-landelijk-consor-tium-hulpmiddelen> [Accessed 1 May 2020].

3. Leibovici, F., Santacreu, A. and Peake, M., 2020. US Re-

liance On Others For Medical Equipment | VOX, CEPR Policy Portal. [online] Voxeu.org. Available at: <https://voxeu.org/article/us-reliance-others-medical-equipment> [Accessed 1 May 2020].

4. RIVM, 2020. COVID-19 (Novel Coronavirus) | RIVM. [online] Rivm.nl. Available at: <https://www.rivm.nl/en/novel-coronavirus-covid-19> [Accessed 10 June 2020].

5. Leibovici, F., Santacreu, A. and Peake, M., 2020. COVID-19 And U.S. Reliance On Foreign Medical Equipment. [online] Available at: <https://www.stlouis-

fed.org/on-the-economy/2020/april/us-rely-other-coun-

tries-essential-medical-equipment> [Accessed 1 May 2020].

6. 2020. Coronavirus Disease 2019 (COVID-19) Pandemic: Increased Transmission In The EU/EEA And The UK – Seventh Update. [ebook] Stockholm: European Centre for Disease Prevention and Control. Available at: <http://www.ecdc.europa.eu/sites/default/files/documents/RRA-seventh-update-Outbreak-of-coronavirus-dis-

ease-COVID-19.pdf> [Accessed 1 May 2020].7. Kaplan, D., 2020. How Medical Supply Chains Can

Diversify Beyond COVID-19. [online] Supply Chain Dive. Available at: <https://www.supplychaindive.com/news/coronavirus-health-pharma-medical-cost-diversi-fy/576021/> [Accessed 2 May 2020].

‘‘If the Netherlands was not so dependent on foreign medical supplies, the SARS-CoV-2 virus would not have been able to spread at the speed it did.’’

‘‘Due to the globally increased demand for medical supplies such as mouth masks, large quantities were ordered from medical supply producing countries, mainly China.’’

2423


IN AMSTERDAM UMC, I RAN INTO... IN AMSTERDAM UMC,I RAN INTO...

developing myself. I have been doing this job for quite a long time and I am very familiar with all protocols. Besides this, I have completed all cours-es for this job. However, I must challenge myself to improve temporary care and to search for new developments.

Do you contribute to scientific research?We are regularly approached for collaboration re-garding scientific studies. Currently, we are con-

tributing to a study regarding pilonidal sinus for which the cleft lift procedure results in fewer re-currences.

Which difficult decision have you made?Sometimes we send patients home with the advice to think about treatment options such as lower ex-tremity amputation. These situations are difficult. I also want to keep developing myself and learning new things. A while ago, I applied for the internal training for plaster cast nurse. I would start training next month. Unfortunately, I decided to withdraw due to restrictions caused by COVID-19. All les-sons would be online, and I certainly prefer to get training on location.

What are your ambi-tions?Currently, I lead the proj-ect ‘New Bandages’, in collaboration with the

Purchase Department. I give courses and intro-ductions regarding new materials. I have also been making plans to set up a wound committee.

In the Van Weel-Bethesda Hospital in Dirksland, I ran into… Jolanda Tessers - van Gorsel, wound care nurse

INTERVIEWED BY DEBBY A.M. BOM1 AND JESSICA BALIKJI

2

1. VAN WEEL-BETHESDA HOSPITAL, DEPARTMENT OF EMERGENCY MEDICINE,

STATIONSWEG 22, DIRKSLAND

2. ISALA HOSPITAL, DEPARTMENT OF GENERAL SURGERY, DOKTER VAN HEESWEG 2, ZWOLLE

What is your current profession?I have been a wound care nurse for 15 years, and I have been working in the Van Weel-Bethesda Hospital in Dirksland for seven years now. After I became qualified as a nurse, I followed training in Dermatology at the UMC in Utrecht, and Wound Care at the Radboud UMC in Nijmegen.

What are your work-related activities?I mainly see patients in the outpatient clinic at the General Surgery Department. I perform wound care regarding post-operative problems, skin in-fections, traumatic skin injuries, chronical wounds, diabetic feet, ulcus cruris, and wounds related to casts for bone fractures. One day a week, I see pa-tients at the Dermatology Department concerning open legs, venous insufficiency, dermatologic dis-orders, and postoperative healing problems after excision of skin malignancies. Moreover, my ex-pertise is requested regarding patients on the clin-ical wards. After wound evaluation, I compose a treatment plan and hand this over to the nurses on the ward. When patients are discharged from the hospital, I arrange professional home care when indicated and I invite patients at the outpatient clinic for adequate follow-up.

What is your main task?It is essential to listen carefully to each patient and to pay attention to patients’ individual contexts. Each patient is unique and not every treatment plan is achievable. Following the Dutch V&VN guidelines (Verpleging & Verzorging Nederland Wondexpertise) a treatment plan could be ‘rinse and bandage the wound three times daily’. Howev-er, patients might not be able to climb their stairs to reach the shower. This results in complicated situ-ations that could affect patients’ motivation neg-

atively. Thus, shared decision-making is es-sential in composing an adequate, but also, feasible treatment plan.

What are your activities in collaboration with the Plastic Surgery Department? It is relevant to mention that we see patients who have been admitted to the ICU due to COVID-19. Some patients develop decubitus ulcers up to stage 4. Reconstructive procedures might be indicated, such as rotation flap surgery, in order to repair the defect. In addition, I am involved in wound care regarding traumatic skin defects around joints. Healing of these wounds might be complicated due to tissue scarring, in which skin contractures could limit joint function. Moreover, I see post-op-erative patients after surgery of skin malignancies for which skin grafts are used. When graft failure occurs, I am involved in post-operative wound care.

What do you like most about your profession?I like unexpected requests for consultation regard-ing traumatic wounds, or wounds caused by casts for bone fractures. Besides this, I like to help and calm down desperate patients who visit our out-patient clinic with high thresholds, and have in mind worst-case scenarios like amputation. In 90 percent of these cases, a simple wound plan can be composed whereby healing can be achieved. It is very satisfying to see these patients leave the clinic feeling relieved and happy.

What are the challenges of your profession?To keep up with new developments, and to keep

‘‘It is essential to listen care-fully to each patient and to pay attention to patients’

individual contexts.’’

See guidelines for submitting on amsj.nl.

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Jolanda Tessers - van Gorsel

ARTICLE ARTICLE

25 26


sionals have a critical attitude towards nationwide EHR, the argument being concerns about the risk of privacy violations.9 The fear does not only relate to the acquisition of information by a third party but also to medical professionals who could abuse their access to records.10 The most known exam-ple is of medical professionals peeking in to ce-lebrities’ medical records, such as those of George Clooney, Prince and the Dutch Barbie.11,12

Dutch initiatives to improve EHR exchangeThere are multiple initiatives that have been pro-posed in the Dutch health care system. One of these initiatives is the Nationwide Transfer point, Landelijk Schakelpunt (LSP), which is not a da-tabase, but a medium through which consulting the EHR system of another caregiver is possible. Medical professionals can only use LSP with ex-plicit consent of the patient (opt-in). Also, medical professionals can only request information within their own region. Patient data is shared in the form of Professional Summary (PS) which is a summary of a patient file, standardized by the National Gen-eral Practitioners’ Society.13 However, the Dutch central bureau of statistics found that there were concerns about privacy violation and lack of secu-rity.14 Following public opinion, the Dutch senate voted unanimously against implementation of a nationwide EHR system.15

Another initiative, Whitebox Systems, provides the possibility to choose which medical profes-sional uses a patient’s data. Access is given via an app or code, which is provided by the patient. Be-cause patient data are retrieved from the EHR of a medical professional and not from a central server, the protection of this data is covered by the profes-sional secrecy of the given medical professional. Thus, a decentralized system. Also, Whitebox uses an adapted form of PS, which includes less patient data.16

Yet another format currently being tested is pa-tient-controlled EHR. In these EHR, the patient is in charge of their own file.17 The ease with which data can be requested by a healthcare professional is yet to be determined. An initiative of the Minis-try of Public Health and Wellbeing, MedMij acts as a hallmark for these EHR to ensure the safety of data sharing. However, medical professionals can

not directly share data without interference of the patient.18 Another possible downside of this format might be the lack of medical expertise in the gener-al population, leading to inaccurate files.

Inspiration from abroadIn comparison to other countries, the Netherlands is a leader in digitalization and implementation of EHR.19 However, opportunities for further devel-opment of data exchange can be inferred from suc-cessful initiatives abroad.

Reports from Norway, Estonia and Finland show that nationwide systems exist and can effectively enable interoperability between all healthcare in-stitutes. They function as either a translating plat-form or a centralized database.20, 21 The approach

to minimize privacy issues is characterized by enabling patients to give access permission to rel-evant caregivers promptly, in an effortless way, as well as to monitor their files and who has had access.

CONCLUSIONIn the Netherlands the main barriers to simplifying the EHR data exchange are the European privacy legislation and the lack of trust from patients and healthcare professionals in the safety of EHR ex-change systems.

There have been several initiatives to create a bet-ter system in the Netherlands, but all have their drawbacks. LSP only has a regional scope, White-box does not have a fast and easy way to operate in emergency situations, and MedMij.nl requires a patient that updates and maintains their own file, possibly resulting in incomplete files.

In countries around us systems for data exchange have been successfully and safely implemented. Differences in infrastructure and the public opin-ion seem to be reasons why similar systems have yet to be implemented in the Netherlands.

RECOMMENDATIONConsidering the information presented in this pa-per, a recommendation can be formulated to im-prove the exchange of EHR between different healthcare professionals in the Netherlands.

Sharing is caring - A narrative review and recommendation: Improving health data sharing between healthcare professionals in the Netherlands utilizing electronic patient records

LOTTE J. VAN DEN OORD1, ANNE KNEGT

1, EVA HEELING1, ASABI LELIVELD

1, THOMAS J. VAN DER MEER1

1. AMSTERDAM UMC LOCATION AMC, UNIVERSITY OF AMSTERDAM

INTRODUCTIONWhen exchanging electronic health records (EHR), healthcare professionals deal with poor interopera-bility between different data systems and complex organization of obtaining and registering patients’ consent.1 Sharing patient information between healthcare professionals could be made more ef-ficient, while maintaining high privacy standards.

Since April 2020, it has been possible for emer-gency posts to gain access to the general practi-tioner’s patient record without consent in case of the patient’s inability to do so, using an opt-out approach.3 The COVID-19 crisis showed us that changes within healthcare in The Netherlands can take place quickly.

This raises the question: How can we improve the exchange of patient information by means of

electronic health records (EHR) between different healthcare professionals in The Netherlands?

Difficulties holding back EHR exchangeMultiple barriers to EHR sharing in the Neth-erlands exist. First, different EHR data systems made by different companies are used between hospitals, making it technically difficult to link all programs.5 Second, EHR sharing is regulated by privacy laws, such as the European law “General Data Protection Regulation” (GDPR). The GDPR states that the patient’s consent is required to share medical data between medical professionals.6

Third, patients’ concerns regarding privacy viola-tions arise. The cause of concern is the use of med-ical information by a third party, especially health-care insurance companies.7 Another issue that may have driven the public point of view is the lack of information available.8 Last, many medical profes-

ABSTRACTIn terms of sharing electronic health records (EHR), healthcare professionals in the Netherlands deal with poor in-teroperability between different data systems and complicated organization of obtaining and registering patients’ consent. These difficulties can lead to treatment delay, complicated interhospital collaboration and an increased burden of administrative tasks for healthcare professionals. This paper aims to provide insight into the factors holding back data exchange in healthcare and propose a new way to improve the exchange of health data.

The main barriers in easing EHR data exchange are non-interoperable EHR systems, tight privacy laws and the lack of trust from patients and healthcare professionals. Inspirational incentives are being developed in the Neth-erlands and abroad that could offer a solution to these problems.

The presented incentives show that different systems can be developed to facilitate interoperability between data systems and that governmental guidance can promote adoption of information standards. Moreover, they show that providing patients with control over their records might be an effective way to increase perceived privacy. A decentralized system might be less susceptible to privacy violation.

We propose a framework for introducing a system that facilitates and accelerates the exchange of health data between medical professionals without endangering patient privacy. This system aims to combine the strong suits of EHR systems implemented both in the Netherlands and abroad into one system.

CLINICAL IMAGE

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March 2021 | AMSj Vol. 22

ARTICLE

27


We conclude that a decentralized sharing system is the best option to aggregate all data. A decen-tralized system, which works in the same manner as Whitebox, reduces chances of privacy violation by unauthorized access through division of data over multiple servers, each located in different health institutions. A system that functions as a sharing platform and translator of data from differ-ent sources could serve as a safer alternative. The system can be accessed by medical professionals with their General Medical Council number. In this way it is possible to monitor who consulted the patient’s EHR to ensure the patient’s privacy. The medical professional requesting access will receive a summary of the relevant medical infor-mation generated by the system.

REFERENCES1. Warren L, Clarke J, Arora S, et al. Improving data shar-

ing between acute hospitals in England: an overview of health record system distribution and retrospective ob-servational analysis of inter-hospital transitions of care. BMJ Open. 2019; 9(12), e031637. doi:10.1136/bmjop-en-2019-031637

2. Ben-Assuli O, Shabtai I, Leshno M. Using electron-ic health record systems to optimize admission deci-sions: the Creatinine case study. Health Informatics J. 2015;21(1):73-88.

3. Ministerie van Volksgezondheid, Welzijn en Sport. Stap-penplan landelijke invoering elektronisch patiënten dos-sier. http://zoek.officielebekendmakingen.nl › kst-27529-38-b1. Published April 2008. Accessed July 1, 2020

4. Jha AK, Doolan D, Grandt D, et al. The use of health in-formation technology in seven nations. International jour-nal of medical informatics, 2008. 77(12), 848–854.

5. Barjis J. Dutch Electronic Medical Record - Complexity Perspective. Paper presented at: 43rd Hawaii Internation-al Conference on System Sciences; 5-8 January, 2010; Honolulu, HI, USA.

6. Schermer BW, Hagenauw D & Falot N. Handleid-ing Algemene verordening Gegevensbescherming en Uitvoeringswet Algemene verordening gegevens-bescherming. https://www.rijksoverheid.nl/binaries/rijksoverheid/documenten/rapporten/2018/01/22/handle-iding-algemene-verordening-gegevensbescherming/Han-dleiding+Algemene+verordening+gegevensbescherm-ing.pdf. Ministerie van Justitie en Veiligheid. Published January, 2018. Accessed July 1, 2020

7. Katzenbauer M. Artsen vullen het ‘bezwaarformulier EPD’ massaal in. Medisch Contact. 2009; 20,880-3.

8. Masman W, Brabers A, Reitsma-van Rooijen, et al. Het landelijk elektronisch patiëntendossier: de kennis en voorkeuren van burgers in Nederland met betrekking tot het landelijk EPD. 2012. Nederlands Instituut voor Onderzoek van de Gezondheidszorg (NIVEL). https://www.nivel.nl/nl/publicatie/het-landelijk-elektronisch-pa-tientendossier-de-kennis-en-voorkeuren-van-burgers.

Published April 2, 2014. Accessed July 6, 2020.9. Katzenbauer M. Te vroeg voor landelijke EPD. https://

www.medischcontact.nl/nieuws/laatste-nieuws/artikel/te-vroeg-voor-landelijk-epd.htm. Published May 14, 2009. Accessed July 1, 2020.

10. Ploem MC, Zwaanswijk M, Wiesman FJ, et al. Ver-trouwen van zorgverleners in elektronische infor-matie-uitwisseling en het landelijk EPD Een juridische en sociaal-wetenschappelijke studie naar de positie van zorgverleners. Amsterdam/Utrecht: Academisch Medisch Centrum/NIVEL, 2011.

11. Kraaijeveld M, Gluren in medische gegevens Barbie kost HagaZiekenhuis bijna half miljoen euro. Algemeen dag-blad. https://www.ad.nl/den-haag/gluren-in-medische-ge-gevens-barbie-kost-hagaziekenhuis-bijna-half-miljo-en-euro~a332a557/?referrer=https%3A%2F%2Fwww.google.com%2F Updated July 16, 2019. Accessed Octo-ber 20, 2020

12. Moneypenny M, The ultimate list of HIPPA violations. Etactis. https://etactics.com/blog/celebrity-hipaa-viola-tions Updated October 28, 2020. Accessed October 29, 2020

13. Reinierse PAJ, Van Althuis TR, Westerhof R, et al. Richt-lijn Gegevensuitwisseling huisarts en Centrale Huisart-senpost (CHP). Nederlands Huisartsen Genootschap. https://www.nhg.org/sites/default/files/content/nhg_org/uploads/richtlijn_waarneming-v4-1mei13.pdf. Published May 1, 2013. Accessed July 6, 2020.

14. Het Centraal Bureau voor de Statistiek (CBS). Helft zegt geen toestemming te geven voor delen medische gegevens. https://www.cbs.nl/nl-nl/nieuws/2019/20/helft-zegt-toestemming-te-geven-voor-delen-medische-gegevens. Updated May 17, 2019. Accessed July 8, 2020.

15. Eerste Kamer der Staten Generaal https://www.eersteka-mer.nl/nieuws/20110405/eerste_kamer_verwerpt_unaniem. Accessed october 12th, 2020

16. Whitebox Systems. Visie. www.whiteboxsystems.nl/visie. Accessed July 7, 2020.

17. Rijksoverheid. Wat is een persoonlijke gezondheidsom-geving (PGO)? https://www.rijksoverheid.nl/onderwer-pen/digitale-gegevens-in-de-zorg/vraag-en-antwoord/wat-is-een-persoonlijke-gezondheidsomgeving-pgo. Ac-cessed september 2nd, 2020

18. Medmij. Gebruikersvoorlichting voor zorgaanbieders. https://www.medmij.nl/gebruikersvoorlichting-voor-zor-gaanbieders/#:~:text=De%20PGO%20biedt%20al-leen%20de,via%20MedMij%20onderling%20infor-matie%20uitwisselen. accessed september 2nd, 2020.

19. HIMSS Analytics. European Annual eHealth Survey. https://www.himssanalytics.org/europe/ehealth-ba-rometer/ehealth-trend-barometer-annual-europe-an-ehealth-survey-2019. Published November 6, 2019. Accessed July 4, 2020.

20. Norwegian Ministry of Health and Care Services. Melding til Stortinget 9, Én innbygger – én journal. https://www.regjeringen.no/no/dokumenter/meld-st-9-20122013/id708609/. Published November 2012. Accessed July 4, 2020.

21. Tiik M, Ross P. Patient opportunities in the Estonian Electronic Health Record System. Stud Health Technol Inform. 2010;156:171-177.

of the seatbelt. It stretches in a horizontal line

along the waist and the diagonally to the clavicle

or neck. The most common internal injuries, as a

result of this force, are bowel and mesenteric inju-

ries together with lumbar spine fractures.

D. Although a bigger change in velocity often re-

sults in more damage, the name of this sign is more

specific for the cause of this bruising pattern.

REFERENCES1. Al-Ozaibi L, Adnan J, Hassan B, Al-Mazroui A, Al-Badri

F. Seat belt syndrome: Delayed or missed intestinal inju-

ries, a case report and review of literature. Int J Surg Case Rep. 2016;20:74-76. doi:10.1016/j.ijscr.2016.01.015

2. Huecker MR, Chapman J. Seat Belt Injuries. [Updated 2020 Oct 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470262/

3. Thoma T. National Highway Traffic Safety Adminis-

tration (NHTSA) Notes. Review of studies on pedes-

trian and bicyclist safety, 1991-2007. Ann Emerg Med. 2012;60(4):495-496.

Answers: 1 C

A young man with a distinctive trauma sign

D. GHANTOUS1, FAY SANDERS

2


2. DEPARTMENT OF TRAUMA SURGERY, AMSTERDAM UMC, LOCATION AMC

QUESTION 1What is this phenomenon called? A. Linear bruise signB. Steering wheel syndromeC. Seatbelt signD. High velocity mark

Hints:

A. The observed skin defect is more extensive than

a linear bruise only.

B. Although the bruise looks like it is circular, it is

unilateral and this pattern is not expected from an

impact by the steering wheel.

C. This is the correct answer. The seat belt sign is

a pattern of bruising corresponding with the place

CASEA 31-year-old gentleman is presented at the ER after a high energetic trauma. No previous med-ical history was documented. On presentation, he was conscious, breathing and vitally stable. His main complaint was pain in the lower back and abdomen. At physical examination, the fol-lowing linear discoloration was seen. The abdo-men showed mild generalized tenderness. He also had an open fracture of the right elbow.1

BACKGROUNDThe three-point seatbelt was invented by the Swed-ish Volvo engineer Nils Bohlin in 1973.2Seatbelts are designed to transmit the energy of the collision to the anterior superior iliac spine (ASIS), chest wall and clavicle. According to the NHTSA, seatbelts reduce fatal injuries by approximately 43%.3 But when the seatbelt is not worn correctly or for example is too long, force is transmitted to softer parts like the neck and abdomen, sometimes resulting in major injuries, such as spine fractures, bowel entrapment and liver and spleen lacerations.

29


INTERVIEW

student society, with many social activities. As a result of these characteristics, I nearly always went to lectures, but I didn’t sit in the front row.

Why did you choose to focus on gender differenc-es in rheumatic disease?During my medical education I came across sev-eral cases with severe ankylosing spondylitis (AS, Bechterew disease) who were referred to rheuma-tology by orthopedic surgeons. These also includ-ed female patients who presented with a disease severity which was completely opposite to what was known in literature up to that point, which described AS as having a mild course in women. In addition, several female patients proved to have rheumatic diseases while they were misdiagnosed with for example fi bromyalgia instead of axial spondyloarthritis. The presentation simply differed too much from known patterns, which were most-ly based on early research in such diseases with male-biased populations.

How do you want to draw more attention to gender differences in rheumatic diseases?I am active as board member of the Dutch Soci-ety of Gender and Health (Ned. Vereniging van Gender en Gezondheid). We are now working on a plan to create more awareness on gender differ-ences. In addition, I am also politically active by contributing to the Tweede Kamer nota on Gender Sensitive health care and at EULAR to draw more attention to gender differences and equal represen-tation in both studies and policy positions.

Next to gender differences, are there other areas in rheumatology that deserve more attention?Despite great progress in the treatment and under-standing of axial spondyloarthritis, there is cur-rently still no quantitative functional test or mea-surement possible. Our clinical evaluation is still very much based on questionnaires and self-re-porting from patients. I hope to see this change in the future, to a more independent and reliable

measurement of disease.

Prof. Dr. Irene E. van der Horst-Bruinsma

INTERVIEWED BY MERVE KOCYIGIT1, WOUTER H. VAN BINSBERGEN

2

1 FACULTY OF MEDICINE, AMSTERDAM UMC, LOCATION VUMC

2. DEPARTMENT OF RHEUMATOLOGY AND CLINICAL IMMUNOLOGY,

AMSTERDAM UMC, LOCATION VUMC)

What drew you to Rheumatology?I wanted to do something that was not too nar-rowly defi ned, but still had a clearly defi ned focus without sacrifi cing the interconnected nature of medicine. Despite initially looking at dermatolo-gy/ophthalmology, I realized that rheumatology was both clearly defi ned as a fi eld, and not isolated to a single organ. It was (and is) one of the medical fi elds most broadly integrated with others like gas-tro-enterology, internal medicine and many more.

Is there something you are particularly proud of?I am proud of the growing cooperation between

the departments of Ophthalmology and Rheuma-tology, as these can overlap in several diseases and early detection, referral and treatment are of para-mount importance. Of course, I am also proud of the work I have done with the EULAR (European League Against Rheumatism) to promote aware-ness of gender differences in rheumatic disease and the progress made therein. There is, however, still a long way to go.

What would you advise students and your researchers?I would advise them to think critically about all information they receive and to not blindly accept everything they read in an article. Of course, I would advise them to remain aware of gender dif-ferences and to incorporate these into both clinical practice and future research.

What kind of medical student were you during your studies?I was a conscious student, but also a member of a

Prof. Dr. Irene E. van der Horst-Bruinsma

CURRICULUM VITAE

Current position(s): Professor of Rheumatology, Amsterdam University Medical Center, location Vrije Universiteit Medical Center

E-mail address: [email protected]

1960 Year of birth

1987 Graduation Medicine at LUMC

1987 Start ANIOS Rheumatology

1990 Start AIOS

1997 Function as specialist

1998 PhD Finished: The relationship between

HLA Class II polymorphism and the

susceptibility to and progression of

rheumatoid arthritis

2018 Appointment as Professor of Rheumatology

‘‘Rheumatology is one of the medical fi elds most broadly

integrated with others.’’

A rheumatology professor once said: “Disease can be different in

men and women, and every physician should remain aware of that fact.”.

That professor was Prof. Dr. I.E. van der Horst-Bruinsma, Department of Rheumatology, AUMC, Am-

sterdam. We were privileged to ask her about her career, passion for rheumatology and the reasons she

has been such a strong advocate for the awareness of gender differences in (rheumatic) disease.

31


32RADIOLOGY IMAGE


CHANGING PERSPECTIVES

Globally, there is a growing number of older adults, persons of 65 years and over. Typically, older per-sons have multiple coexisting conditions for which they use medication. Consequently, nearly half of older adults have polypharmacy, the chronic use of fi ve drugs or more daily.1 Polypharmacy is associ-ated with adverse drug effects, leading to negative health outcomes such as cognitive decline, falls, unplanned hospital admissions, and even death.2

Both the risks and benefi ts of medication use change with time and the ageing process. In gen-eral, older adults are more susceptible to adverse drug effects compared to their younger counter-parts. Evidence suggests that one out of every fi ve medications taken by an older adult is inappropri-ate (a medication where the harms may outweigh the benefi ts or that does not fi t with the treatment goals and preferences of the individual).3,4

In 2017, the World Health Organization launched a global initiative aiming to reduce the level of drug-related severe, avoidable harm by 50% over the next 5 years.5 To achieve this goal, it is neces-sary to critically review current medications, and to withdraw (or reduce the dose) of inappropriate medication, supervised by a healthcare profession-al, aiming to achieve better health outcomes.6 This process is called deprescribing, a term fi rst coined in 2013.6 Despite growing interest in deprescribing over the last decade, and literature showing prom-ising results on the effect of deprescribing (e.g. im-provements in cognition, fewer falls and improved survival7), deprescribing is currently underutilized in clinical practice.

Literature shows that prescribers may be reluctant to deprescribe because they perceive their knowl-edge to be insuffi cient.2,6 Also, emotional and psy-chological aspects are involved: deprescribing may go against our belief that a good medical doctor is

supposed to heal diseases by ‘giving something’.6

Also from the patients’ point of view, the ‘drugs equals health’ mindset can be a deep-rooted value. Moreover, deprescribing can be perceived by the patient/carer as being “given up on”.2 To overcome these challenges, a culture change is needed, start-ing in medical education, where more focus should lie on the process of deprescribing and the under-lying aim of maintaining the best quality of life. In fact, the WHO states that “one component of good prescribing is deprescribing”.5 Therefore, depre-scribing fi ts in our basic goal of achieving quality of care while complying to our ethical principle

“primum non nocere”.

REFERENCES 1. Endsley, S. (2018). Deprescribing unnecessary medica-

tions: a four-part process. am Pract Manag. 2018 May-June;25(3):28-32.

2. Garfi nkel, D. (2016). Overview of current and future research and clinical directions for drug discontinua-tion: psychological, traditional and professional ob-stacles to deprescribing. European Journal of Hospital Pharmacy, 24(1), 16–20. https://doi.org/10.1136/ejh-pharm-2016-000959

3. Rochon, P. A., & Gurwitz, J. H. (1997). Optimising drug treatment for elderly people: the prescribing cascade. BMJ, 315(7115), 1096–1099.https://doi.org/10.1136/bmj.315.7115.1096

4. Masnoon, N., Shakib, S., Kalisch-Ellett, L., & Caughey, G. E. (2017). What is polypharmacy? A systematic re-view of defi nitions. BMC Geriatrics, 17(1), 0 https://doi.org/10.1186/s12877-017-0621-2

5. Medication without harm. https://www.who.int/initia-tives/medication-without-harm.

6. Garfi nkel, D. (2019). Poly-De-prescribing vs Polyphar-macy - The Weapon to Fight an Iatrogenic Epidemic: An Overview. European Journal of Geriatrics and Ger-ontology , 1 (1), 1–10. https://doi.org/10.4274/ejgg.gale-nos.2019.14

7. Iyer, S., Naganathan, V., McLachlan, A. J., & Le Couteur, D. G. (2008). Medication Withdrawal Trials in People Aged 65 Years and Older. Drugs & Aging, 25(12), 1021–1031. https://doi.org/10.2165/0002512-200825120-00004

Primum non nocere

KARLIJN VORSTERMANS1 AND DR. EVELINE VAN POELGEEST

2

1. MEDICAL STUDENT, AMSTERDAM UMC, LOCATION VUMC

2. DEPARTMENT OF GERIATRIC MEDICINE AND COMMUNITY CLINIC, AMSTERDAM UMC LOCATION

AMC, UNIVERSITY OF AMSTERDAM

Radiology image: Knee complaints aft er surgery

SANNE VAN BEEM1 AND MARIO MAAS

2


2. DEPARTMENT OF RADIOLOGY, AMSTERDAM UMC, LOCATION AMC

QUESTION 1 What do you see?A. Lateral Notch signB. Defect in the fat body of HoffaC. Cyclops lesionD. Arcuate signE. Bucket handle tear

Hint: What does it look like?

CASEA 30-year-old football player presents at the GP with sudden complaints of the knee. He recent-ly underwent surgery due to an injury acquired during a football game, however he is unsure what procedure was performed exactly. An MRI of the knee was made.

QUESTION 22. What surgery was most likely per-formed?A. PCL procedureB. ACL procedureC. Partial meniscectomyD. Hemi knee

Hint: What kind of injury do you expect with the

sports history?

QUESTION 33. What would be the patient’s chief com-plaint?A. Limited extension of the kneeB. Inability for exorotation of the kneeC. Limited endorotation of the knee

D. Limited fl exion of the kneeE. Instability

Hint: How are movements in the knee produced?

What structures are involved in the movement and

in which of these structures is the lesion located?

?Answer on page 37

INITIATIVES WITH IMPACT INITIATIVES WITH IMPACT33 34


BACKGROUNDI am (was) a clinical cardiologist in the Academic Medical Center, always with an interest in acute medicine. In cardiology there are many opportu-nities for that: acute myocardial infarction is the prime example, because there is indeed a “golden hour” for early intervention to save myocardium. “Time is muscle” is a well-known statement. Between 1978 and 1984 I intensively collaborat-ed with the Amsterdam Ambulance Service in a randomized trial to try to prevent sudden death in the ambulance from ventricular fi brillation. During that process I became interested in ventric-ular fi brillation itself. Knowing that many victims of an acute myocardial infarction die from cardiac

arrest due to ventricular fi brillation before an am-bulance can arrive, it became clear that for cardiac arrest there is no golden hour but only a few gold-en minutes. Any help and electrical defi brillation that would be given later than 5 to 10 minutes after collapse would almost certainly result in death of the patient – and ambulances typically arrive me-dian 8 to 11 minutes after a 112 call for a collapsed person.1,2 In a study between 1995 and 1997 we could convincingly prove that dramatic decrease in survival in the fi rst few minutes after collapse from cardiac arrest: each year approximately 8.000 persons had a cardiac arrest in the Netherlands and received cardio-pulmonary resuscitation (CPR) but survival to hospital discharge was only 9%.1

Value of the Automated External Defi brillationTraditionally, electrical defi brillators were only available in hospitals and since the early 1970s in ambulances. When our study was fi nished in 1997 the fi rst Automated External Defi brillators (AEDs) had just been developed in the USA. AEDs have an internal algorithm that can recognize ventricu-lar fi brillation automatically and do not require the expertise of professionals. (FIGURE 1) Therefore,

the community would be the ideal context for its use because of the long delay for ambulance help in case of cardiac arrest. Public access to AEDs could be a possible solution to the problem of poor survival after cardiac arrest.

The police-AED studyFrom the fi ndings of our fi rst study on cardiac ar-rest the idea emerged to introduce AEDs to allow non-medical persons to defi brillate before ambu-lance arrival. But such a new system would only be accepted in the community and by medical pro-fessionals once its effectivity and safety had been proven in a scientifi c study. Because of the wide spread of cases with cardiac arrest in the commu-nity, unpredictability where they would occur and

the inability to obtain thousands of AEDs and train thousands of volunteers, we decided to ask police and fi refi ghters to be our “study group” to test the AED and to ask the ambulance dispatch centers to notify police and fi refi ghter dispatch centers in case of a possible cardiac arrest. As police and fi re engines are more densely distributed within the community than ambulances, it was expected that they would arrive several minutes earlier. Police forces of Kennemerland and Zaanstreek-Water-land and the fi refi ghters of Amsterdam-Amstelland agreed to participate.

Next, fi nances were needed. We needed money to purchase AEDs, to hire data managers to record in detail all actions taken in the early response to the cardiac arrest, for a car to go to the used AED to download the recorded data in the AEDs with all detailed time points, etc. Not to forget the PhD stu-dent who needed to do all management, data anal-ysis and writing of scientifi c papers! It took a full year before we had approval from the Dutch Heart Foundation. They funded the study with a record amount of €600,000 over four years. We also had to make a choice between potential AED manufac-turers and found the best scientifi c support from the American company Physio Control, the manu-facturer of the fi rst AED LifePak 500.But it did not end there. We needed approval from the Medical Ethics Board to conduct a randomized trial. And there was a hurdle we had not expected: after having fi nalized all preparations, the Nation-al Health Inspectorate did not consent to the study because the BIG law did not allow police and fi re-fi ghters to defi brillate. It was for medical person-nel only, according to the BIG law. It took a year

to convince the Health Inspectorate that the study could be approved under certain conditions.We performed the study successfully, and pub-lished it in 2003 with proof of effectivity and safe-ty.3 We could convince the Minister of Health to add to the BIG law to allow AED use for lay res-cuers.4

Accepted in the NetherlandsThe success of the AED in the Netherlands was fast. Many offi ces, sport facilities, shops etc. purchased AEDs and trained their personnel. We could document the increased use of AEDs in pub-lic and prove that the observed increase in survival could be attributed to the increased deployment of AEDs.2,5 After that, the AED was introduced nationwide by police in 2009, and to local near-by volunteers, activated by text-message from the dispatch center (burgerhulpverlening). We could document the expected reduction in time to de-fi brillation when these text-message responders were activated.6

Early defi brillation in the community: an initiative with impact

DR. RUDOLPH W. KOSTER1

1. AMSTERDAM UMC, LOCATION ACADEMIC MEDICAL CENTER,

DEPARTMENT OF CARDIOLOGY

EMAIL: [email protected]

FIGURE 1 Example of the start of an AED registration. At A, the electrodes of the AED are connected and the rhythm analysis begins. At B (9 seconds later), the AED has determined that there is a “shockable” heart rhythm and the AED charges itself. At C, the rescuer delivers a shock. The heart rhythm is immediately present again. At D chest compressions are started at a speed of approximately 105 per minute, recognizable by the green line. Each time mark indicates one second. Figure reproduced with permission from the publisher from literature reference 9.

‘‘Any help and electrical defi brillation that would be given later than 5 to 10 minutes aft er collapse would almost certainly result in death’’

3635


SOLVING STATISTICS SOLVING STATISTICS

straight line has to be drawn through the observa-tions and the characteristic of the line is that the distance between the line and the observed values is as small as possible. This line is then character-ized by two parameters, the b0 and the b1. The b0 (known as the intercept) refl ects the value of BMI when physical activity equals 0 and the b1 refl ects the difference in BMI when physical activity dif-fers with one unit (see FIGURE 1).

One of the advantages of using regression analysis is that adjustments for potential confounders can be made and that potential effect modifi cation can be investigated. Confounding indicates that the re-lationship which is observed is partly caused by something else (e.g., sex). In FIGURE 2, the black

dots indicate females, while the bleu dots indicate males. It can be seen that physical activity is high-er for males, while BMI is lower. Because of that, the earlier observed relationship between BMI and physical activity is totally caused by sex differenc-es. In the lower part of FIGURE 2 it can be seen that the relationship between BMI and physical activity is reduced to zero when an adjustment is made for sex. It can also be seen that adjusting for sex in a regression analysis actually means that for both males and females a different intercept is estimated (b0 [= 12] for males and b0 + b2 [= 18] for females).

Effect modifi cation indicates that the estimated ef-fect (i.e., the estimated relationship between BMI and physical activity) is different for different groups (e.g., for males and females). The concept of effect modifi cation is illustrated in FIGURE 3. In FIGURE 3, again the black dots indicate females,

while the bleu dots indicate males. It can be seen that in the situation illustrated in fi gure 3, the rela-tionship between BMI and physical activity it to-tally different for males and females. For males the regression coeffi cient for physical activity equals -6 (i.e., b1), while for females the regression co-effi cient for physical activity equals 0 (i.e., b1 + b3 [-6 + 6]).

It should be realized that regression analysis can be used for continuous independent variables such

as physical activity, but it can also be used for di-

chotomous and categorical independent variables. The basic principles of regression analyses are al-ways the same.

Read a paper, but question the

statistical analyses? Let us know via AMSj.nl or our Facebook page!

Regression Analysis: the key method to analyse medical data

Jos W. R. Twisk11. DEPARTMENT OF EPIDEMIOLOGY AND DATA SCIENCE,

AMSTERDAM UMC, LOCATION VUMC

Impact on societyThe introduction of the AED and in particular the involvement of police and nearby lay responders in residential areas has dramatically increased sur-vival. These days, in more than 50% of cases, an AED is connected to the victim by the time the ambulance arrives.5 Overall survival to discharge was only 9% in 1995 and has increased to 22% now. This corresponds with approx. 1000 extra survivors each year in the Netherlands. The cogni-tive function and quality of life of survivors, mea-sured approximately 6-12 months after the cardiac arrest, was normal in 81-90%, dependent on the measurement.7 In a recent study of 28 countries in Europe, the Netherlands had the highest survival of all countries!8

REFERENCES1. Waalewijn RA, de Vos R, Koster RW. Out-of-hospital

cardiac arrests in Amsterdam and its surroundings: results from the Amsterdam resuscitation study (AR-REST) in Utstein style. Resuscitation 1998;38:157-167.

2. Zijlstra JA, Stieglis R, Riedijk F, et al. Local lay rescu-ers with AEDs, alerted by text messages, contribute to early defi brillation in a Dutch out-of-hospital cardiac ar-rest dispatch system. Resuscitation 2014;85:1444-1449.

3. Van Alem AP, Vrenken RH, De Vos R, et al. A Con-trolled Clinical Trial in the Use of the Automated Exter-nal Defi brillator by First Responders in Out-of-Hospital Cardiac Arrest. BMJ 2003;327:1312-1316.

4. Schriftelijke antwoorden AO Intensieve Care van 8 de-cember 2005. Kamerstuk, CZ/IZ-2666223, 19-4-2006.

5. Berdowski J, Blom MT, Bardai A, et al. Impact of Onsite or Dispatched Automated External Defi brillator Use on Survival After Out-of-Hospital Cardiac Arrest. Circulation 2011;124:2225-2232.

6. Blom M, Beesems SG, Homma PC, et al. Improved survival after out-of-hospital cardiac arrest and use of Automated External Defi brillators. Circulation 2014;130:1868-1875.

7. Beesems SG, Wittebrood KM, de Haan RJ, et al. Cognitive function and quality of life after success-ful resuscitation from cardiac arrest. Resuscitation 2014;85:1269–1274.

8. Gräsner JT, Wnent J, Herlitz J, et al. Survival after out-of-hospital cardiac arrest in Europe - Results of the EuReCa TWO study. Resuscitation 2020;148: 218-226.

9. Bak, M.A.R., Blom, M.T., Koster, R.W,.et al. Resuscita-tion with an AED: putting the data to use. Neth Heart J (2020). https://doi.org/10.1007/s12471-020-01504-z

‘‘Overall survival was only 9% in 1995 and has increased to 22%’’

Although there are many, many different statis-tical methods available to analyze medical data, most of these methods are built on the basic prin-ciples of regression analysis. So, it is quite import-ant to understand these basic principles. There are many different regression methods available and the details differ depending on the kind of out-come variable used. When the outcome variable is a continuous outcome (e.g., blood pressure, BMI, etc.) linear regression analysis must be used, but when the outcome variable is dichotomous (e.g., depression, myocardial infarction, etc.) logistic regression analysis must be used. Besides logis-

tic and linear regression analysis, there are many more regression analyses available; however, the most simple way to explain regression analysis is by linear regression analysis. Suppose we want to analyze the relationship between body mass index (BMI) and physical activity. In statistical nomen-clature, BMI is known as the outcome variable, the dependent variable or the y-variable, while physical activity is knowns as the independent variable, the x-variable or the covariate. The fi rst step in the analysis is to display the data in a scat-terplot, which contains the observed data. Then, a

FIGURE 1 Basic principles of (linear) regression analysis

FIGURE 2 Adjustment for confounding in (linear) regression analysis

FIGURE 3 Eff ect modifi cation in (linear) regression analysis

ARTICLE38


RADIOLOGY IMAGE37


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Amsterdam Medical Student journal (AMSj) is a scien-tifi c medical journal with the purpose to enable medical students to publish clinical observations, research articles and case reports. The journal was founded by students from the Amsterdam UMC, location AMC and VUmc, in Amsterdam with the intention to provide education and development of academic skills for medical students. The entire journal is created and published by staff members and students from both medical faculties.

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EDITORS IN CHIEFD.S. Umans, E. Beijer, G.E. Linthorst, F. Daams

BOARDH. Aoulad Ahajan, M. Bektas, H. F.E. Feikema, A. Kohn, V. Ligtvoet, L.J. Van den Oord, K. Yah

CONTENT EDITOR & NATIVE EDITORD.E. Vecht, N.M.C. de Jong

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STAFF REVIEWERSN.H. Sperna Weiland, G. de Waard, L.A. Gerbens, M. Zamaray, J. ten Kulve, A. Volkers, B. Hesselink, A. Mank, E.P. van Poelgeest, J. Molkenboer, J. Cloos, L. Vogt, M.C. Brouwer, J. Driessen, R.J. Molenaar, R.W.A. Spek, M. Engel, F. Abbink, D.A. Bom, P.P. de Koning, J. Aman, M. Maas, W.H. van Binsbergen, J. Stiekema, F.R. Sanders, A. Emanuel, S.W. de Jonge, J.W.R. Twisk, P. Schober

STUDENT REVIEWERSM.A. Keesenberg, S. Novin, H. El Khattabi, C. Kapoen, E.M. Corazolla, T. van Ramshorst, A.S.T. Moerkamp, T. van der Putten, K. Vorstermans, C. Lese-man, S. Zwetsloot, A. Boes, S. Amlal, T. White, S. Roos, M. Tachaout, M. Žugaj, S. Laabar, J. Balikji,

N.M. Rosenberg, S. van Beem, M. Kocyigit, A. Ashraf, D. Ghantous, J. da Silva Voorham

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COPYRIGHT & WARRANTYStatements, opinions, and results of studies published in Amsterdam Medical Student journal are those of the authors and do not refl ect the policy of the Amsterdam UMC, location AMC and VUmc, the Editors or the Board of AMSj. The Amsterdam UMC, Editors and the Board of AMSj provide no warranty as to their accuracy or re-liability.

This volume of Amsterdam Medical Student journal is licensed under a CC BY-NC-ND 4.0 license. For more information on your rights to share this work, please see the full license on bit.ly/1weyPUN

EDITORIAL BOARD

David Vecht, Content Editor

Nina de Jong, Native Editor

Merle Stellingwerf, Creative Editor

Devica Umans, Editor in Chief AMC

Elise Beijer, Editor in Chief VUmc

COVERPhotographer: Caroline Sellers

Answers ‘Knee complaints aft er surgery’SANNE VAN BEEM AND MARIO MAAS

Correct answers: 1C, 2B, 3A

EXPLANATIONThe patient underwent an ACL procedure, which can be seen by the presence of a tibial tunnel in-dicated by the arrow, as a result of an ACL injury acquired during a football game. ACL injuries are common in sports involving pivoting, decelera-tions and jumping, and are often preceded by an exorotation in valgus trauma. ACL injuries present with instability and require surgery if this hampers patients in their daily life. One possible compli-cation of an ACL procedure is a cyclops lesion in which a nodule of granulation tissue surrounded by fi brous tissue is formed from several structures in the knee, including the bone, the infrapatellar

fat pad, synovium, cartilage and fi brous tissue. Cyclops lesions often progress into fi brocartilagi-nous soft tissue. The exact pathophysiology is un-known, but is most likely the result of debris that is formed during drilling the tibial tunnel or due to the impingement of ACL fi bers that are exposed during the surgery. The cyclops lesion derives its name from the resemblance to the eye of the hom-onymous mythical creature. This lesion prevents extension of the knee as in this movement the in-tra-articular space decreases. Lesions are removed arthroscopically.

REFERENCES 1. Van der Hart, C. De voorste kruisband. Kniechirurgie.nl

(2020). Geraadpleegd op 11-01-2021.2. Dhanda S, Sanghvi D, Pardiwala D. Case Series: Cyclops

lesion - extension loss after ACL reconstruction. Indian J Radiol Imaging. 2010;20(3):208-210. doi:10.4103/0971-3026.69361

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