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The purpose of the present article was to evaluate indications, regimens, treatment modalities, and predictive factors of response to treatment in locally advanced squamous cell carcinoma of the head and neck (SCCHN).An expert panel including otolaryngology and head and neck surgery specialists, oncologists, radiotherapists and biologists analyzed the literature providing a synthesis and giving some recommendations.Findings from the main randomized phase III trials highlight that the TPF regimen (docetaxel, cisplatin, fluorouracil) represent a preferential option when induction chemotherapy is indicated in either operable or non-operable patients. Given the potential fragility of patients presenting with SCCHN, treatment modalities in routine use require applying preventive measures and tailored follow-up according to each patient's profile. As regards predictive factors of response to TPF regimen, no factor is currently validated, but ongoing trials should provide better knowledge.Progresses in induction chemotherapy have allowed improving the prognosis of patients with locally advanced SCCHN. The TPF regimen represents a major improvement in this indication, and ongoing strategic clinical trials should refine its indications.

Background Uptake of interventions to improve quality of care by clinicians is variable and is influenced by clinicians' attitudes. The influence of clinicians' experience with an intervention on their preference for adopting interventions is largely unknown. Methods Thematic analysis of semi-structured interviews exploring views and attitudes towards an illness-focused intervention (specific communication skills training) and a disease-focused intervention (C-reactive protein, or CRP, point-of-care testing) to optimize management of lower respiratory tract infections (LRTI) among general practitioners (GPs) who had used both interventions for two years in a randomised trial (exposed GPs), and GPs without experience of either intervention (non-exposed GPs). Results All but two of the ten non-exposed GPs indicated that they would prioritise implementation of the disease-focused intervention of CRP testing over communication skills training, while all but one GP in the exposed group said that they would prioritise the illness-focused approach of communication skills training as it was more widely applicable, whereas CRP testing was confirmatory and useful in a subgroups of patients. Conclusion There are differences in attitudes to prioritising contrasting interventions for optimising LRTI management among GPs with and without experience of using the interventions, although GPs in both groups recognised the importance of both approaches to optimise management of acute cough. GPs' experiences with and attitudes towards interventions need to be taken into account when planning rollout of interventions aimed at changing clinical practice.

The first revision of the guideline 'Influenza and influenza vaccination' from the Dutch College of General Practitioners illustrates that influenza has evolved from a supposedly harmless condition to a disease against which growing numbers of patients and healthcare professionals are vaccinated. Although recent studies support its effectiveness, it is still believed that vaccination may prevent serious health problems in the vulnerable patients, notably in homes for the elderly and nursing homes. In order to streamline diagnostic triage in cases of flu-like symptoms, general practitioners must keep abreast of the actual influenza figures, but also be aware that not all patients with flu-like symptoms have influenza. Pneumonia should always be present in the differential diagnosis of influenza.

International audience; BACKGROUND: The EDIFICE survey aimed to investigate the compliance of the general population to the screening tests available in France for the 4 most common cancers: breast, colorectal, prostate and lung. Implementation of breast cancer screening has been generalized in France since 2003: women aged between 50 and 74 years are systematically invited to perform a mammography every second year. Results pertaining to breast cancer are reported hereafter. METHODS: This nationwide observational survey was carried out in France from 18 January to 2 February 2005 among representative samples of 773 women aged between 40 and 75 years and 600 general practitioners (GPs). Information collected included socio-demographic characteristics, attitude towards cancer screening and actual experience of cancer screening, as well as GPs' practice regarding screening. The precision of the results is +/- 4.3% for a 95% confidence interval. RESULTS: Among the 507 participating women aged between 50 and 74 years, 92.5% (469/507) had undergone at least one mammography: 54.6% (256/469) underwent this test on their own initiative and 44.6% (209/469) of women performed it in the framework of a systematic screening plan. Most women participating in the systematic screening (89.0% i.e. 186/209) had a mammography within the last dating from less than 2 years versus 73.8% (189/256) of those who performed it outside the screening program (Chi(2) test; p

Background Patient expectations are among the strongest predictors of clinicians9 antibiotic prescribing decisions. Although public knowledge, beliefs, and experiences of antibiotics contribute to these expectations, little is known about these public views. Aim To gain insight into public knowledge, beliefs, and experiences of antibiotics and respiratory tract infections. Design of study Cross-sectional, internet-based questionnaire study. Setting Members of the general public aged 16 years and over in the Netherlands. Methods Public knowledge, beliefs, and experiences of antibiotics and respiratory tract infections, as well as predictors of accurate knowledge of antibiotic effectiveness, were measured using 20 questions with sub-items. The questionnaire was given to a Dutch community-based nationwide internet panel of 15 673 individuals. Of these, 1248 eligible responders were invited to participate; 935 responders (75%) completed the questionnaire. Results Of the participants, 44.6% accurately identified antibiotics as being effective against bacteria and not viruses. Acute bronchitis was considered to require treatment with antibiotics by nearly 60% of responders. The perceived need for antibiotics for respiratory tract infection-related symptoms ranged from 6.5% for cough with transparent phlegm, to 46.2% for a cough lasting for more than 2 weeks. Conclusion Public misconceptions on the effectiveness of, and indications for, antibiotics exist. Nearly half of all responders (47.8%) incorrectly identified antibiotics as being effective in treating viral infections. Doctors should be aware that unnecessary prescribing could facilitate misconceptions regarding antibiotics and respiratory tract infections. Expectations of receiving antibiotics were higher for the disease label ‘acute bronchitis’ than for any of the separate or combined symptoms prominently present in respiratory tract infection. Public beliefs and expectations should be taken into account when developing interventions targeting the public, patients, and physicians to reduce unnecessary prescribing of antibiotics for respiratory tract infections.

The objective of this study was to assess compliance with a 10-day treatment of antibiotics or placebo once-daily (OD) and three-times-daily (TD) for lower respiratory tract infections (LRTIs) using electronic monitoring, and to evaluate whether compliance depends on time since the start of treatment and weekday. Taking compliance, timing compliance, correct dosing compliance and mean interdose intervals were assessed using data from 155 LRTI patients who received either a 10-day treatment of amoxicillin TD and placebo OD or roxithromycin OD and placebo TD using a double-dummy technique. Compliance was assessed by electronic monitoring. Taking compliance was 98.0% for the OD regimen and 91.0% for the TD regimen. Correct dosing was 98.1% for the OD regimen and 91.1% for the TD regimen and timing compliance was 48.2% and 10.9%, respectively. The mean interdose interval before the first daily dose for the TD group was particularly prolonged to >13 h. Correct dosing over time showed fewer patients with correct dosing compliance, reaching a low of 79% for the TD group towards the end of the 10-day treatment. Compliance was not influenced by weekday. This study adds important information to the limited evidence on compliance with antibiotics for LRTI, one of the most common reasons for consultation in primary care. Taking compliance was high for both regimens, yet timing compliance was poor. The prolonged mean interdose intervals provide striking new insights into understanding non-compliance with more-than-once-daily regimens. These findings require consideration when exploring ways to improve future compliance in short-term antibiotic treatment for respiratory tract infections.

Huisartsen zien steeds vaker patienten met vragen over (huiduitslag na) een tekenbeet. De laatste jaren is er veel discussie geweest over diagnostiek en beleid bij (mogelijke) lymeziekte. Hoe kun je de patient het best informeren? Wat is het juiste beleid na een tekenbeet?

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Huisartsen zien regelmatig patienten met een rode pijnlijke vinger, die ook vaak warm en gezwollen is. Patienten kunnen de aangedane vinger dikwijls niet goed gebruiken. Het gaat meestal om een paronychia, ook wel nagelriemontsteking of ‘omloop’ genoemd.

Baby’s en peuters vallen vaak, soms ook op het hoofd. Jonge kinderen (< 2 jaar) vallen dikwijls van de commode, bank of een andere verhoging, oudere kinderen vallen vaker tijdens het spelen.

• The Primary Health Care (PHC) working group of the Department of General Practice of Maastricht University in the Netherlands was founded in 1998 specifically to introduce students to patient care, research and education in primary health care settings outside the Netherlands. • Rural health care in Australia is appealing to international medical students because of its unique setting. • In the past 5 years, 42 medical students from Maastricht University have pursued a medical elective in rural Australia, supervised by the PHC working group. • Doctors and coordinators in primary care clinics across Australia have welcomed and supervised students from Maastricht and exposed them to the reality of rural health care. • Future collaboration with other Australian primary care clinics is welcomed.

Purpose: To determine maximum tolerated dose, safety and efficacy of weekly 24 h infusional 5-fluorouracil (5-FU) combined alternately with oxaliplatin and irinotecan. Patients and methods: Advanced colorectal carcinoma patients in first- or second-line chemotherapy received increasing doses of 5-FU (weekly 24 h continuous intravenous infusion without leucovorin) on days 1, 8, 15 and 22, irinotecan days 1 and 15; and oxaliplatin days 8 and 22, every 35 days. Results: Thirty-four patients received 175 cycles. The median age was 64 years (range 47 – 78). Eighteen per cent of patients had the primary tumor in the rectum, with a median of one disease site (range one to three), and liver involvement in 88% and lung in 38%. Six (18%) patients had chemotherapy for prior advanced disease. The most frequent grade 3 – 4 toxicity was neutropenia (41% of patients), but the regimen was well tolerated clinically, with febrile neutropenia in two patients and grade 4 neutropenia lasting >7 days in one; grade 3 – 4 diarrhea, nausea and vomiting in 6% of patients; grade 3 – 4 peripheral neuropathy in 9% of patients. Seventeen patients had a partial response (50%; 95% confidence interval 33% – 67%), 13 had stable disease and one had progressive disease. Five patients underwent metastatic surgical resection after tumor shrinkage. Median response duration was 14 months (range 4.7– 29.2+) and median time to progression was 11.3 months (range 1.1+ – 30.7+). Conclusions: This combination three-drug regimen is feasible and well tolerated without toxicity overlap. Preliminary antitumor activity compares well with standard double combinations, with an unusually long median time to progression. The recommended dose is 5-FU 3000 mg/m 2 , weekly for 4 weeks, irinotecan 100 mg/m 2 days 1 and 15, oxaliplatin 80 mg/m 2 days 8 and 22. Further assess

Le concept de chimiotherapie neo–adjuvante repose sur des bases biologiques et permet d’augmenter le nombre de traitements conservateurs proposes chez des patientes presentant un cancer du sein a priori operable. Meme si cette approche n’est pas consideree comme un standard le rationnel est pourtant fort. Les traitements utilises actuellement permettent un taux de reponses histologiques completes eleve, ceci est important en termes de benefice therapeutique. La chimiotherapie neo–adjuvante represente egalement un modele permettant l’observation in vivo des reponses tumorales et leurs correlations biologiques pour isoler des facteurs predictifs moyennant une contrainte minimale pour les patientes. Peu d’etudes cependant ont ete realisees dans ce cadre et a l’avenir il faudra integrer la biologie moleculaire dans les essais et en particulier dans ce schema d’administration.

Objective: A phase I/II study was carried out to determine the recommended dose (RD) and to assess the efficacy and safety of a weekly docetaxel-vinorelbine combination in advanced breast cancer (ABC) patients. Methods: Twenty-four female patients with histologically proven ABC received intravenous vinorelbine (20 min) followed by intravenous docetaxel (1 h) on days 1, 8 and 15 of a 4-week cycle. Starting doses were 20 mg/m2 docetaxel and 15 mg/m2 vinorelbine. Results: Patients had a median age of 62 years (range 38–74 years), and 92% had performance status 0–1. The most common sites of metastases were the lungs (32%), liver (29%) and bone (14%). Seventy-one percent of patients had received prior chemotherapy. The RDs of docetaxel and vinorelbine were 20 and 15 mg/m2, respectively. Dose-limiting toxicities were neutropenia-induced dose delay and febrile neutropenia. The response rate at the RD was 43%. All responses were seen in non-pretreated patients. Grade 3–4 neutropenia occurred in 80% of patients, 3 of whom experienced febrile neutropenia and died as a possible consequence of neutropenia. Conclusion: This docetaxel-vinorelbine combination as first-line therapy yields a response rate similar to that of single-agent docetaxel as second-line therapy. However, given the high rate of myelotoxicity, higher doses are not feasible.

Background The aim of this retrospective study was to access the benefit of a non-pegylated liposomal doxorubicin (NPLD) treatment beyond the first line therapy in patients with metastatic breast cancer (MBC) after previous exposure to an anthracycline containing regimen. Patients and methods A pharmacy prospectively collected database in the Franche-Comte region, was used to identify a cohort of patients with MBC treated by NPLD regimen between 2003 and 2010.In total, 140 patients were included in the analysis. Progression-free survival (PFS) was chosen as the primary efficacy endpoint. Cox proportional hazard models were fitted to identify factors that could influence both PFS and overall survival (OS) lenght. Survival data were computed according to Kaplan Meier method. Results Primary tumours characteristics were oestrogen receptor-positive, progesterone receptor positive and HER2 positive in 77%, 63% and 20% respectively. Median PFS length was 4 months [95% CI: 2-5] and 33% of patients experienced a PFS longer than 6 months. Overall response (OR) was observed in 27 patients (19.3%, 95%CI [10.2-28.4]). Median OS after NPLD was 13 months [95% CI: 10-14]. In multivariate analysis, prognostic factors significantly related to longer OS from NPLD first exposure were age younger than 50 years old (HR = 0.57 [0.35-0.93], p = 0.02) and HER2 positive tumour (HR = 0.53 [0.30-0.95], p = 0.03). 17 patients (12.1%) discontinued NPLD treatment due to toxicity. In those, 9 (6.4%) patients experienced cardiac toxicity (grade 2 or 3). There were 2 (1.4%) deaths related to cardiac toxicity. Conclusion Re-challenge by an anthracycline-containing regimen should been considered in patients with MBC taking into account this encouraging ORR and the length of PFS and response duration. However cardiac safety of patients must be carefully investigated during the treatment taking into account the number of treatment cessation due to cardiac damage. Of interest the subset of patients with HER2 positive tumour seemed to highly benefit from the NLPD. This finding emphasizes the sensitivity to anthracycline in this subset of HER2 positive tumours and oncologist should not forgot anthracycline containing regimen as a possible option in MBC after failure to numerous lines including chemotherapy and HER2 targeted agents. Disclosure All authors have declared no conflicts of interest.

Slecht eten bij peuters en kleuters komt veel voor. Het merendeel van de ouders zoekt hierover informatie bij het consultatiebureau, het eigen netwerk of internet.

Toegankelijke zorg zonder wachttijden werd door de LHV benoemd als eerste doel van onze beroepsgroep voor de periode 2010-2014.

Aim: Cetuximab combined with platinum is the standard first-line therapy in patients (pts) with R/M SCCHN. DIRECT is the first multicenter prospective observational study evaluating cetuximab RDI in this setting. Methods: Pts were prospectively enrolled. No prior systemic therapy for R/M SCCHN was allowed. Pts received cetuximab in combination with platinum, according to the pivotal study EXTREME schedule, 5-FU if not contra-indicated and maintenance treatment with cetuximab every 2 weeks was allowed. The primary endpoint was the number of pts with cetuximab RDI >80%. Results: High quality of data was obtained by frequent monitoring of sites every 3 months (evaluable data in 93% of pts for baseline characteristics and in 89% of pts for cetuximab RDI). 154 pts were enrolled in 53 centres between 2012/11 and 2013/03: 86% male, median age 59 years, 81% with PS 80% in 68.5%, 64.7% and 93%, during chemotherapy (CT), CT + maintenance or maintenance periods respectively. Planned doses of cetuximab were decreased in 9.7% and delayed in 36% of 154 pts, mostly during CT. 97 pts (63.0%) withdrew the study for progression (48.5%), death (31%), toxicity (6%), lost to follow-up (1%), or other reasons (13.5%). Grade > 2 skin toxicities were observed in 9 (5.8%) pts. Conclusions: In unselected pts, RDI data in DIRECT study confirms the feasibility and the good tolerance of cetuximab combined with platinum previously reported in the pivotal trial. DIRECT study supports the use of cetuximab + CT as standard treatment in clinical practice. Disclosure: J. Guigay: Research funding : GSK; Merck Serono; Novartis Honoraria : Merck Serono; B. Petre-Lazar: Medical advisor: Merck Serono; F. Mornex, P. Ceruse, M. Alfonsi and C. Le Tourneau: Honoraria : Merck Serono; A. Berrier: Research funding : Merck Serono; S. Faivre: membership advisory board : Merck Serono Honoraria : Merck Serono Research funding: Merck Serono; F. Rolland: Honoraria : Merck Serono Expert Testimony : Merck Serono. All other authors have declared no conflicts of interest.

Huidinfecties komen vaak voor. De bijbehorende roodheid of pijn is voor de patient meestal de reden om naar de dokter te gaan. Bij diepe huidinfecties gaat het meestal om het been, de arm of het gezicht en de klacht gaat regelmatig gepaard met koorts en algehele malaise.

To understand which clinical criteria physicians use to diagnose pneumonia compared to bronchitis and upper respiratory tract infection (URTI).Retrospective chart review of adults diagnosed with pneumonia, bronchitis, or URTI.Logistic regression analysis identified rales, a temperature100 degrees F (37.8 degrees C), chest pain, dyspnoea, rhonchi, heart rate, respiratory rate, and rhinorrhoea, as the best explanation for the variation in diagnosis of pneumonia compared to either of the alternative diagnoses (R2 = 59.3), with rales and a temperature100 degrees F explaining 30% of the variation. Rales, chest pain, and a temperature100 degrees F best predicted the ordering of a chest x-ray (R2 = 20.0). However, 35% (59/175) of patients diagnosed with pneumonia had a negative chest x-ray. Abnormal breath sounds were the best predictors for prescribing antibiotics (R2 = 38%). A significant number of patients with acute bronchitis (93% excluding sinusitis) and URTI (42%) were given antibiotics.The presence of abnormal breath sounds and a temperature100 degrees F were the best predictors of a diagnosis of pneumonia.

This multicentre, double-blind, double-dummy, randomised trial was designed to compare the efficacy and safety of single intravenous doses of dolasetron mesilate and granisetron in the prevention of acute emesis and nausea due to high-dose (or = 80 mg/m2) cisplatin. Single intravenous doses of 1.8 or 2.4 mg/kg of dolasetron mesilate or 3 mg of granisetron hydrochloride were administered in a volume of 50 ml over a 5-min period, beginning 30 min prior to cisplatin (or = 80 mg/m2) administration. The number and timing of emetic episodes, time to administration of escape anti-emetic medication, severity of nausea by visual analogue scale (VAS), and safety were monitored for 24 h after the start of cisplatin-containing chemotherapy. Investigators' evaluations of overall efficacy and patients' satisfaction with therapy were recorded at the end of the 24-h study period. Of the 474 patients evaluable for efficacy, complete responses were achieved by 54, 47 and 48% of patients given dolasetron mesilate 1.8 mg/kg, dolasetron mesilate 2.4 mg/kg and granisetron, respectively. Statistically, treatment groups had comparable complete and complete plus major responses, times to first emesis, and use of escape medication; patient maximum nausea severity and treatment satisfaction ratings; and physician nausea severity and overall efficacy assessments. For the majority of efficacy endpoints, 1.8 mg/kg dolasetron mesilate produced numerically superior responses compared with the 2.4 mg/kg dose. Gender and prior chemotherapy were significant predictors of complete response; males and chemotherapy-naive patients had higher responses. The overall incidences of adverse events were comparable among the treatment groups; headache and diarrhoea were most common. In conclusion, 1.8 and 2.4 mg/kg of dolasetron mesilate and granisetron (3 mg) were equally effective in preventing nausea and vomiting induced by highly emetogenic cisplatin-containing chemotherapy. In addition, because no additional benefit was observed with 2.4 mg/kg of dolasetron mesilate and numerically greater responses were observed with the 1.8 mg/kg dose, the lower dose of 1.8 mg/kg is optimal for further clinical development.

Introduction Nivestim™ is a European Union (EU)-licensed biosimilar filgrastim used in the treatment of chemotherapy-induced neutropenia and febrile neutropenia. Nivestim™ has similar pharmacokinetic and pharmacodynamic properties to its reference compound Neupogen®, and has demonstrated equivalent safety and efficacy in clinical trials. However, the safety of biosimilars in general is closely scrutinised. We present designs for two observational phase IV studies that will examine the safety profile of prophylactic and curative Nivestim™ in patients treated with cytotoxic chemotherapy in real-world clinical-practice. Method NEXT (Tolerance de Nivestim™ chez les patients traites par une chimiotherapie anticancereuse cytotoXique en praTique courante) and VENICE (VErtraglichkeit von NIvestim™ unter zytotoxischer Chemotherapie in der Behandlung malinger Erkrankungen) are multicentre, prospective, longitudinal, observational studies that aim to monitor 2000 adult and 700 adult and paediatric patients respectively 12 months. The primary objective of the studies is to assess the safety of Nivestim™ in patients undergoing cytotoxic chemotherapy for malignancy through the evaluation of adverse events in all organ system classes, as required by EU pharmacovigilance guidelines. Secondary objectives include obtaining data on efficacy outcomes, lab values, patterns of use of Nivestim™, dose intensity, indications for treatment, patient characteristics, physician knowledge of filgrastim prescribing, and the reasons for choosing Nivestim™. VENICE will also include data on levels of CD34+ cells to assess predictive value as a marker of response. Data will be gathered over 3 patient visits: 1) inclusion visit, 2) first follow-up after first course of Nivestim™, and 3) second follow-up after completion of chemotherapy. Results Accrual figures as of 1 May 2012 are 630 (NEXT) and 136 (VENICE). Completion dates are June 2013 and June 2014 respectively. Conclusion Data from NEXT and VENICE will provide additional information on the long-term safety and efficacy of Nivestim™ in patients receiving cytotoxic chemotherapy in clinical practice. Disclosure S. Fruehauf: Receiving support from Hospira for the conduct of the VENICE study, C. Berthou: Receives support from Hospira for the conduct of the NEXT study, S. Lepretre: Receives support from Hospira for the conduct of the NEXT study, L. Cals: Received support from Hospira for the conduct of the NEXT study, F. Maloisel: Receive support from Hospira for the conduct of the NEXT study, D. Kamioner: Receives support from Hospira for the conduct of the NEXT study.

Aanbrengen van lubrificerende gel op het speculum leidt tot minder pijn bij het gynaecologisch onderzoek. Amerikaanse onderzoekers vergeleken glijmiddel met het gebruik van water in een sympathiek gerandomiseerd onderzoek naar deze alledaagse handeling.

Calciumantagonisten en losartan zijn de beste antihypertensiva voor patienten die een verhoogd risico op jicht hebben. Dat concluderen onderzoekers in de British Medical Journal op basis van patientengegevens uit Britse huisartsenpraktijken.

Orale anticoagulantiegebruikers die zelf hun INR controleren hebben een significant verlaagde kans op tromboembolische complicaties. Uit een recente meta-analyse inThe Lancet blijkt tevens dat jongere patienten en patienten met een kunstklep het meest profijt hebben van zelf INR prikken.

Twaalf procent van de patienten die voor het eerst een syncope doormaakt, ontwikkelt binnen een jaar een ernstige cardiovasculaire complicatie. Vlaamse onderzoekers concluderen dat de syncope een onafhankelijke risicofactor is bij de oudere patient.

Borstkankerscreening in verschillende Europese landen heeft niet gezorgd voor dalende sterfte aan borstkanker. Dit beweert een internationale onderzoeksgroep die naburige landen met elkaar vergeleek in een artikel in het British Medical Journal.

Stretchen zorgt niet voor minder spierpijn na sport. Een recente Cochrane review bevestigt dat zowel spieren rekken voor de inspanning als erna geen stramme spieren kan voorkomen.

Kinderen die zwemmen, hebben geen verhoogde kans op astma. Britse onderzoekers volgden kinderen in een groot cohortonderzoek tien jaar lang vanaf de geboorte. Zwemmen verbeterde de longfunctie juist, vooral bij de vroege piepers.

Patienten met het prikkelbaredarmsyndroom die een antibioticakuur kregen, rapporteerden minder buikklachten volgens twee grote placebogecontroleerde interventieonderzoeken. Brede klinische toepassing is echter een brug te ver.

wat is het probleem? Hartgeruis komt bij kinderen frequent voor en wordt vaak bij toeval gevonden. Soms constateert de huisarts hartgeruis bij klachten of nadat de consultatiebureauarts het verzoek tot verwijzing bij hem heeft neergelegd. Vroege opsporing van congenitale hartafwijkingen is belangrijk, omdat de meeste afwijkingen goed zijn te behandelen en vroegtijdige behandeling ernstige complicaties kan voorkomen. Het merendeel van de hartgeruisen is echter onschuldig. Adequate differentiatie tussen onschuldige en pathologische hartgeruisen kan complicaties van eventuele hartafwijkingen voorkomen en onnodige bezorgdheid bij ouders (en kind) wegnemen. Het onderscheid is in de eerste lijn echter niet altijd eenvoudig te maken.