Zaans Medisch Centrum

ObjectiveTo compare the effects of percutaneous nephrostomy (PCN) and JJ ureteric stent (JJ) for urinary tract decompression in patients with obstructive urolithiasis on health‐related quality of life (HRQoL), pain scores, urinary symptoms, and patient satisfaction.Patients and MethodsIn 11 hospitals, 204 patients with obstructive urolithiasis were randomised to JJ or PCN placement. Patient‐reported outcome measures (PROMs) were assessed until stone passage, surgical removal, or at 3 months.ResultsBoth PCN and JJ effectively improved HRQoL index scores (PCN: pre‐decompression 0.70, 1 day post‐decompression 0.82, P = 0.003; JJ: pre 0.59, post 0.85, P < 0.001), pain scores (PCN: pre 4.9, post 1.3, P < 0.001; JJ: pre 5.5, post 1.3, P < 0.001), and achieved patient satisfaction (score at discharge PCN: 7.9; JJ: 8.2), with no significant differences between interventions in overall HRQoL (generalised estimating equation [GEE] P = 0.7) or mean daily pain scores (GEE P = 0.4). PCN led to more self‐care difficulties (patients reporting no problems: PCN 74%, JJ 91%, P = 0.023), while JJ recipients reported more urinary symptoms and higher peak pain intensity (pain score PCN: 2.3, JJ: 3.7, between groups P = 0.018). Despite symptoms, more JJ recipients preferred the same intervention in future (60%), than PCN recipients (31%) (P < 0.001). Survey‐based data collection may introduce response bias (response rate 59%).ConclusionIn patients with obstructive urolithiasis, urinary decompression with PCN and JJ improved HRQoL and pain comparably. JJ causes more urinary symptoms and peak pain but allows better self‐care. Baseline self‐care and urinary symptoms should guide shared decision‐making. Drainage duration should be minimised.

Abstract Animal bones from archaeological contexts can reveal the interplay between past environments and human societies. Resource acquisition shaped many aspects of past societies and influenced the development of trade networks and migration. Fish have been a cornerstone of human subsistence for millennia, yet the rise of commercial fishing and trade was complex. Here, we synthesised a database of ∼1.9 million zooarchaeological fish records spanning 2000 years across Europe. Using machine-learning of catch compositions alongside fish thermal tolerances, we show that fisheries became less local over time, with homogenisation coinciding with Little Ice Age-associated cooling, a period of documented resource scarcity, concurring with growing trade. Moreover, increased proportions of marine taxa and more specialist marine fisheries were observed in the preceding Medieval Climate Anomaly, to sustain concurrent urban and population growth. Enhanced use of marine protein buffered food insecurity, whilst signalling the transition from localised to trans-regional trade networks.

An increase in pediatric cases of invasive group A streptococcus (iGAS) disease was noted in the Netherlands starting in early 2022. GAS disease can range from mild to life-threatening invasive infections. Clinical and public health decisions rely on timely and detailed reporting of clinical data. To determine risk factors associated with severe pediatric iGAS, defined as requiring admission to an intensive care unit and/or death, and to analyze pediatric iGAS incidence, presentations, and outcome between pre-COVID-19 pandemic (January 2015 to March 2020), COVID-19 pandemic (April 2020 to December 2021), and post-COVID-19 pandemic (January 2022 to June 2024) periods. This observational, retrospective and prospective cohort study in 20 hospitals (tertiary and nontertiary) in the Netherlands was conducted from January 2015 to June 2024, with real-time reporting of data on the study website since January 2022. Children aged 0 to 17 years with iGAS (positive culture or polymerase chain reaction test and/or clinical presentation) were included. iGAS infection. The primary outcome was risk factors for severe iGAS; secondary outcomes included iGAS incidence rate and clinical phenotypes prior, during, and after the COVID-19 pandemic. Risk factors for severity and mortality were analyzed using univariable and multivariable logistic regression analyses, and incidence rate ratios (IRRs) between pre-COVID-19 and postCOVID-19 pandemic periods were calculated using Poisson regression. Of 617 children included, 351 (56.9%) were aged 0 to 4 years. For the 192 participants with detailed data collection, median (IQR) age was 4.2 (1.7-7.1) years and 91 (47.4%) were male. iGAS cases decreased during the COVID-19 pandemic and increased significantly in the post-COVID-19 period (IRR, 2.93; 95%, 2.46-3.49), as compared with the pre-COVID-19 pandemic period. By late 2023, the incidence of iGAS returned to pre-COVID-19 pandemic levels. Factors associated with increased risk of severe disease included a post-COVID-19 pandemic diagnosis (odds ratio [OR], 3.49; 95% CI, 2.31-6.26), pulmonary involvement (OR, 8.64; 95% CI, 5.50-13.55), streptococcal toxic shock syndrome (STSS; OR, 11.71; 95% CI, 4.39-31.18), and meningitis or encephalitis (OR, 4.38; 95% CI, 4.39-31.18). Clinical factors associated with increased risk of severe disease were reduced consciousness (OR, 7.61; 95% CI, 1.84-34.41), dyspnea (OR, 9.89; 95% CI, 3.04-32.14), abnormal auscultation (OR, 6.32; 95% CI, 2.18-18.32), and elevated C-reactive protein (OR, 6.32; 95% CI, 2.18-18.32), while estimated glomerular filtration rate was associated with a decreased risk (OR, 0.64; 95% CI, 0.49-0.84). Disease severity increased in post-COVID-19-pandemic cases, with higher mortality (13 of 294 cases [4.4%] vs 3 of 218 cases [1.4%]) and intensive care admission rates (113 of 294 cases [38.4%] vs 34 of 218 cases [15.6%]), as compared with pre-COVID-19 pandemic cases. Severity of pulmonary iGAS was similar in both periods. In the post-COVID-19 pandemic period, there was a significant increase in the incidence of pulmonary infections (IRR, 5.04; 95% CI, 3.27-7.97) , STSS (IRR, 10.30; 95% CI, 3.88-35.60), meningitis or encephalitis (IRR, 12.30; 95% CI, 4.14-52.70), and necrotizing fasciitis (IRR, 26.10; 95% CI, 5.14-475.00). In this cohort study, risk factors for a complicated course of iGAS in children included pulmonary or central nervous system involvement, STSS, reduced consciousness or pulmonary clinical signs, elevated CRP, and decreased eGFR. Awareness of these risk factors is important to improve timely recognition of at-risk cases and improve clinical outcomes.

SummaryBackgroundMasculinizing genital gender-affirming surgery (gGAS) for transgender and gender diverse people encompasses a complex, heterogenous, and modular set of procedures. To enable evidence-based decision-making or meta-analysis, a uniformity of outcome research is needed. Currently, this is hindered by non-standardized outcome reporting. This study aims to develop a core outcome set (COS) for research on masculinizing gGAS to address this issue.MethodsAn international, multidisciplinary study steering group was established, consisting of 16 professional experts (PE) and lived experience experts (LEE), to advise on and support the development of this COS. The steering group convened online on 16 June 2022, 28 September 2023, 2 May 2024, and 29 August 2024. Potential outcomes were identified through interviews and focus groups with LEE and a systematic literature review convened up to September 2023. LEE and PE were recruited globally via websites, social platforms, scientific meetings, patient organizations, and posters and invited to participate in three e-Delphi survey rounds. In the first round, participants rated each outcome's importance on a 5-point Likert scale and provided reasoning for their rating. In subsequent rounds, participants re-rated the outcomes using illustrative quotes and rankings based on prior ratings to refine consensus. Pre-defined criteria guided outcome inclusion and exclusion. A final online consensus meeting with LEE and PE finalized the COS.FindingsInitial outcome gathering identified 384 unique outcomes, of which 38 outcomes were selected for the e-Delphi survey rounds. Thirty-two LEE and 52 PE participants, most from Europe, the UK, and the USA, completed all three survey rounds (February, May, and July 2024). Final consensus was reached in September 2024 on including one clinical outcome, three adverse events, and six patient-reported outcomes in the COS for masculinizing gGAS. The core outcomes are sensibility in the neo-phallus, additional surgery, ability to achieve orgasm, sexual well-being, and satisfaction with neo-genital aesthetics. For urethral lengthening, additional core outcomes include neo-urethral fistula, stricture, and the ability to void while standing. For phalloplasty, additional outcomes are flap necrosis and donor site morbidity.InterpretationDeveloping a COS for masculinizing gGAS is a crucial step towards standardized outcome measurement and reporting in clinical research. Implementation could facilitate data comparison, meta-analysis and evidence-based guideline development, ultimately improving personalized surgical care.FundingNone received.

Surgical techniques for perineal hernia repair after abdominoperineal resection have evolved over time. Synthetic mesh repair is currently the preferred technique, but recurrence rates are high. The aim of this study is to compare the outcomes of mesh-only repair with combined mesh and tissue flap repair. Between 2006 and 2022, patients who underwent perineal hernia repair with synthetic mesh or any mesh combined with tissue flap were retrospectively identified from three referral centres. The primary endpoint was recurrent perineal hernia. Seventy-two patients with primary perineal hernia were included, of whom 58 underwent mesh-only repair and 14 mesh with flap repair. Postoperative perineal wound complications occurred in 21% in both groups. Meshes were explanted solely within the mesh-only group (n = 3). There were no technical flap failures. Recurrence of perineal hernia occurred in 34% (n = 20/58) of mesh-only patients and in 14% (n = 2/14) of mesh with flap patients (p = 0.12), during a median follow up of 53 months [interquartile range (IQR) 20-81 months] and 24 months (IQR 14-58 months), respectively. Time to recurrent hernia was a median of 16 months (IQR 3-31 months). Crossover to mesh with flap after failed mesh-only repair was successful in 4/4 patients. Mesh combined with tissue flap repair of a perineal hernia seems more effective than synthetic mesh-only repair, based on an absolute 20% difference in recurrence rate. There was a lack of statistical power due to this being a low-volume type of surgery, even in this largest published series so far.

Introduction Transgender individuals considering feminizing genital gender-affirming surgery (gGAS) face multiple options and potential decisional conflict (DC). Shared decision-making (SDM) between patients and healthcare professionals (HCPs) can support personalized care and improve outcomes. To aid trans women during the decision-making process for gGAS, a decision aid, the GenderAid (GA), was developed. Methods This study aimed to investigate the effect of the GA on SDM and DC levels during the decision-making process for feminizing gGAS. An observational cross-sectional mixed methods study was conducted at the departments of Psychology and Plastic Surgery at the Center of Expertise on Gender Dysphoria of the Amsterdam UMC between 2020 and 2023. Questionnaires administered before and after implementing the GA included the validated translations of the SDM-Q-doc and SDM-Q-9 and the Decisional Conflict Scale. Qualitative data from interviews explored trans women’s perceptions of the concepts of SDM and DC when deciding on feminizing gGAS. Results Significantly higher levels of SDM experienced by trans women were observed after the introduction of the GA, while no such difference was observed for HCPs. The GA facilitated more thorough discussions with HCPs, and trans women felt well prepared for consultations by the decision-aid. DC was low before and after introduction of the GA; however, both quantitative as qualitative data revealed trans women experienced uncertainties during the process, due to new information on (non-)surgical options for gGAS. Discussion This study suggests that the GA enhanced SDM in individuals seeking feminizing gGAS and had limited impact on DC by offering extensive information on all (non-)surgical options. However, the improved information overview regarding surgical options also resulted in increased decision uncertainty among trans women. Future controlled research should further explore optimizing information provision throughout the care process, managing uncertainties, and implementing the use of decision-aids by HCPs.

The clinker in cement largely determines the environmental footprint of concrete. Therefore, concrete recycling should focus on retrieving high-quality cementitious fractions to replace clinker. This requires a shift from current traditional recycling techniques towards innovative recycling methods, enabling recovery of not only clean secondary aggregates, but also residual cementitious fines (RCF), potentially eliminating the carbon dioxide emissions associated with them. The production and upcycling of RCF offer new implementation routes that were previously deemed unfeasible. However, the properties of RCF may vary based on their origin, affecting their replacement and upcycling potential. Consequently, assessing the original concrete quality, with a focus on the binder type, before demolition is important. A handheld x-ray fluorescence technique appears promising for this purpose. To achieve effective separation of clean secondary aggregates from the original cementitious content, innovative crushing and separation techniques are needed. Additionally, electrostatic separation shows significant research potential for further optimizing RCF.