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Editorial: An anniversary

An anniversary

An anniversary is always special: it is a moment of reflection and looking back on accomplish­ments of the past year. The very first edition of the Amsterdam Medical Student journal (AMSj), and the three that followed, the rise of the first Amsterdam Medical Student conference (AMSc) but also the new collaborations that evolved, particularly with the ‘Co-raad’. Together with the Co-raad we arranged the recent workshop on scientific writing and we expect many more collaborations in the near future. As for now we are preparing a workshop on how to get involved in research while bridging time for the start of your internship.

But of course changes also took place inside our editorial board, we said goodbye to Dr. Kim Hurkens and Prof. dr. Wolter Mooi, and have welcomed our new members, Tim de Back and Marthe Ribbink. In like manner, we are sad to announce that Yvo Smulders, our Editor in Chief VUmc, is leaving the journal. Although he will be sorrowly missed, our new Editor in Chief VUmc will soon receive a joyful welcoming. Together we hope to improve and expand the journal even further.

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Solving Statistics: A statistical problem – use of parametric tests for small samples?

A statistical problem – use of parametric tests for small samples?

Question

As a junior researcher I noticed that there are different opinions on when to choose nonparametric tests (like the Mann-Whitney or Kruskal-Wllis test) over parametric tests (like the independent samples t-test or ANOVA). Most researchers know that this decision should be made based on the distribution of the data: parametric tests for normally distributed outcomes, nonparametric tests for non-normal data. Therefore, in every beginners course on Statistics different ways to test/assess normality are discussed (histograms, QQ-plots, the Kolgomorov-Smirnov test, and the Shapiro-Wilk test).

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Clinical Image: A 3 year-old girl with a severe skin disease

A 3 year-old girl with a severe skin disease

[headline_subtitle subtitle=”Can you come up with the proper diagnosis?”]
Presentation

Hanke is a 3-years old girl with constitutional eczema and respiratory problems, who you know from your paediatric outpatient department. By prescribing class 2 corticosteroid a temporarily effect has been achieved. During a telephone call her mother tells you that since 2 days the eczema has exacerbated and new spots have developed.

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Interview: prof. dr. Y. Smulders

prof. dr. Y. Smulders

‘Am I going to die?’, was my first reponse when I was asked to write an In Retrospect. I feel too young to write this.

Anyway, don’t expect me to ‘look back at my career’, as I truly feel as if it has just started. As a docter, I sense that my skills are improving every year still. To find the optimum between knowledge, experience, intuition and communicative skill has been a much more formidable challenge than I ever imagined when I started my career in medicine.

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Subject 101: Hyponatremia: a complex matter simplified

Hyponatremia: a complex matter simplified

Hyponatremia is the most common electrolyte disorder in hospitalized patients. If not treated adequately, it can lead to serious consequences. Despite its high prevalence, hyponatremia is considered one of the hardest electrolyte disorders to grasp. In this review, we aim to give a simplified overview of the key points to be taken into consideration when addressing hyponatremia.

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Trial and Error: Aspiration

Aspiration

The CT-scan of a 75-yrs old male, with recently discovered biliary pancreatitis for which he underwent multiple endoscopic retrograde cholangiopancreaticography (ERCP) showed an increased development of necrosis. Due to this acute setting, indication for video assisted retroperitoneal drainage was determined. Before the procedure, the patient was seen by an anesthesiologist. Because of the emergency setting no pre-operative optimization was feasible. Patient underwent procedural sedation analgesia (PSA), but almost instantly after initiation of sedation regurgitation and aspiration was observed, what made immediate intubation ventilatory support (↓ SpO2) and the placement of a gastric tube necessary. The procedure was continued, during which the patient became hemodynamically instable. The patient was admitted to the ICU afterwards, but four days postoperatively little had changed in ventilation requirements.

The main predisposing factors for aspiration are emergency settings and inadequate anaesthesia.1 This makes one wonder what could have been done differently to avoid aspiration; Postponing the procedure (due to emergency not a real option), placement of a gastric tube pre-procedurally, use of a different patient positioning, or anesthesia with rapid sequence intubation (RSI) instead of PSA? There is no clear evidence for the use of, for instance,  anti-Trendelenburg position during intubation, but it should be avoided in morbidly obese patients2,3. Though, aspiration is reduced in a semi-sitting position4, airway management might be more difficult. The nauseousness caused by the patient’s condition, made him regurgitate. Suctioning via a beforehand placed gastric tube might have reduced gastric volume. However, this would have only worked for clear fluids, more solid contents cannot be suctioned via a gastric tube, thus success of this intervention is debatable. Moreover, the gastric tube had to be removed since otherwise the lower esophageal sphincter remains open increasing the likelihood of regurgitation.  Furthermore, there is no evidence that RSI is able to reduce aspiration and it has several complication of its own.5 Nevertheless, it might have been done, since RSI is recommended for patients at risk of aspiration by all guidelines.

In the future, use of anesthesia with RSI instead of PSA for patients with increased likelihood of regurgitation will most likely be the better choice.

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Changing Perspectives: Third time‘s a charm

Third time‘s a charm

(Psychosurgery: from lesion to insertion)

In the first half of the 1900’s the first real steps into psychosurgery were made. Tens of thousands prefrontal leucotomies (lobotomies) were performed on patients with different psychiatric disorders. Even though this rather crude brain lesioning procedure was already regarded unethical, risky and unscientific, the neurologist Egas Moniz still received a Noble Prize for his work on lobotomies in 1949.

After the introduction of the stereotactic frame the selectivity of subcortical lesioning strongly improved and lobotomies were quickly replaced by stereotactic psychosurgery. However, with the introduction of psychoactive medication in the 1950’s and 1960’s the interest in the invasive and irreversible treatment of psychosurgery subsided strongly.

Since the emergence of deep brain stimulation (DBS) in the 1990’s, the returning interest in the field of neurosurgery has been remarkable. DBS involves the insertion of electrodes that deliver electrical impulses to targeted areas of the brain. Opposed to ablative surgery, DBS is an adjustable and reversible intervention. For several psychiatric disorders the results are promising and the number of psychiatric patients treated with DBS is growing steadily (±300 DBS for obsessive-compulsive disorder patients). Today, DBS is considered a promising treatment for psychiatric disorders and for psychosurgery it seems, third time‘s a charm.

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