Activity

When dosing renally excreted drugs in patients with kidney disease, it is important to have a reliable estimate of renal function. The estimated glomerular filtration rate (eGFR) is often used in the clinic, although this measure can be inaccurate in certain situations. Choosing the appropriate drug and dosage should therefore not be solely based on the eGFR. In this review, we discuss the physiology behind renal function estimation and drug dosing and propose a step by step approach to dosing renally excreted drugs in patients with kidney disease.A pediatric case study showed that genetic testing to obtain a diagnosis becomes increasingly complex. Expectant parents found out prenatally, with an ultrasound that their child has skeletal abnormalities. The search for a diagnosis that followed after this test result shows how complex this can be. This case study furthermore shows that professionals might have aims for testing which differ from parents’ wishes. While professionals in this case wanted to have a diagnosis in an efficient way, the parents involved in this case did not want further testing, supported by their religious believes. As they explained, they will accept their child unconditionally. But when the health problems of their daughter become more severe they accepted testing. This difference in opinions about genetic testing pleas for pre-test counselling which focusses on exploring parental values. Discussing values contributes to a satisfactory diagnostic trajectory and follow-up.Radiologically inserted gastrostomy (RIG) is an alternative to percutaneous endoscopic gastrostomy (PEG) for patients with eating difficulties who need long-term enteral nutrition. This articles provides an overview of the technique of RIG as well as an analysis of the results of RIG at our institute over the last five years and a discussion of the literature. The number of centres in the Netherlands offering RIG is growing and therefore we want to raise awareness amongst colleagues who are not familiar with this alternative to PEG.

Frontal lobe epilepsy (FE) is a diagnosis which can be easily missed due to the variety in symptoms. The symptoms depend on the location of the epileptical activity in the frontal lobe.

A 48-year-old man of Moroccan descent is diagnosed with frontal epilepsy, but this diagnosis is rejected based on the 24-hours EEG. Instead he is diagnosed with psychogenic non-epileptic seizures (PNES). Upon this diagnosis, he develops reactive depressive symptoms and he is referred to the psychiatrist. However, based on the clinical presentation the diagnosis PNES is overruled and replaced with frontal lobe epilepsy. The patient recovers when he is treated with valproic acid.

The article describes the symptoms of FE and those of PNES. This case description demonstrates the difficulties and illustrates the importance of a good history when diagnosing FE.

The article describes the symptoms of FE and those of PNES. This case description demonstrates the difficulties and illustrates the importance of a good history when diagnosing FE.

The Implanon NXT is a commonly used contraceptive. Incorrect localization of the implant can cause complications.

A 41-year-old woman is seen in the gynaecology outpatient clinic with a request to remove a recently placed Implanon NXT because of worsening mood symptoms. The implant can’t be found on physical and ultrasound examination. Duringsurgicalexplorationthe implant is not found at theinsertion site’ By means of X-ray scanning the implant becomes visible around the humeral head. The implant appears to be located in the cephalic vein and is subsequently removed.

In case of a referral due to because of worsening mood symptoms after an Implanon NXT exchange, it is possible that the implant is localized incorrectly. It is recommended to use additional imaging before performing surgical exploration. Furthermore, it is important to insert the Implanon NXT according to the supplied instructions to prevent this complication.

In case of a referral due to because of worsening mood symptoms after an Implanon NXT exchange, it is possible that the implant is localized incorrectly. It is recommended to use additional imaging before performing surgical exploration. Furthermore, it is important to insert the Implanon NXT according to the supplied instructions to prevent this complication.

The levels of carbohydrate antigen 19-9 (CA19-9) are often tested to stage pancreatobiliary tumours or to monitor the effects of treatment of such tumours. Benign diseases can also be associated with elevated CA 19-9 levels, but extreme elevation is rare in such cases.

An 84-year-old man was diagnosed with cholecystitis at the emergency department and received conservative treatment with antibiotics for this. After 5 weeks, the patient came to the outpatient clinic with unexplained icterus. Additional imaging revealed indications of malignancy and the CA19-9 concentration was 4240 kU/l. We suspected pancreatobiliary malignancy. However, ERCP revealed obstructive choledocholithiasis and we subsequently performed laparoscopic cholecystectomy. Based on histopathology examination of the gallbladder, a diagnosis of xanthogranulomatous cholecystitis was made. After surgery, CA19-9 levels decreased and the patient swiftly recovered.

Significantly elevated CA19-9 levels are not proof of pancreatobiliary malignancy. Our case underscores that CA19-9 is not an ideal tumour marker and that the results of CA19-9 tests should therefore be interpreted with some caution.

Significantly elevated CA19-9 levels are not proof of pancreatobiliary malignancy. Our case underscores that CA19-9 is not an ideal tumour marker and that the results of CA19-9 tests should therefore be interpreted with some caution.Use of machine learning has been proposedtoimprovethediagnostic performance of medicalhistorytaking, whichwould first have tobestandardized. mTOR activation Thiscommentary reviews theoretical, practical andethicalconsiderationswithregardtothisproposal.A broad range of acyclic primary and secondary 2,4,6-triisopropylbenzoate (TIB) esters have been used in lithiation-borylation reactions, but cyclic TIB esters have not. We have studied the use of cyclic TIB esters in lithiation-borylation reactions and looked at the effect of ring size (3- → 6-membered rings) on the three key steps of the lithiation-borylation protocol deprotonation, borylation and 1,2-metalate rearrangement. Although all rings sizes could be deprotonated, the cyclohexyl case was impractically slow, and the cyclopentyl example underwent α-elimination faster than deprotonation at -78 °C and so could not be used. Both cyclobutyl and cyclopropyl cases underwent rapid borylation, but only the cyclobutyl substrate underwent 1,2-metalate rearrangement. Thus, the cyclobutyl TIB ester occupies a “Goldilocks zone,” being small enough for deprotonation and large enough to enable 1,2-migration. The generality of the reaction was explored with a broad range of boronic esters.