Nederlands tijdschrift voor geneeskunde最新文献

A substantial part of our expenditure on medical treatment aims to cure the patient from the disease. The effectiveness of these treatments has been proven by Evidence Based Medicine and is assessed by comparing groups of patients. However, not all individual patients benefit from the treatment. In trials this effect is measured by calculating the number needed to treat (NNT). The NNT can be seen as a proxy for the inefficiency of a medical intervention. Usually the NNT is 5 to 50 for both medical and non-medical interventions, which means that a substantial number of patients will not reach the primary endpoint. This is accompanied by adverse effects and costs and is in conflict with our intention to do no further harm. An increase in phase IV post marketing research is needed to reduce the inefficiency of medical treatment. Doctors, government and others should prioritize this type of research.

A 65-years-old woman developed low-grade fever several weeks after emergency-endovascular-repair of an abdominal aortic aneurysm. 18F-FDG PET/CT imaging showed intensively increased peri-aortic metabolic activity. The inflammation was considered to be either of autoimmune or infectious nature, (un)related to the repair intervention. Analysis showed positive serological and PCR results for Coxiella burnetii pointing to Q-fever periaortitis.

Objective: To study the long-term outcomes of anti-VEGF treatment for neovascular age-related macular degeneration (nAMD) in the Netherlands, where off-label bevacizumab is used as the first choice, compared to countries that typically use ranibizumab or aflibercept.

Design: Prospective real-world observational study.

Methods: A total of 1,617 Dutch eyes were compared with 8,667 eyes from a reference group derived from 13 socio-economically comparable countries. The primary outcome was the mean visual acuity (VA) measured at annual intervals up to 60 months. Secondary outcomes included injection frequency and the rate of switching to an alternative injection type.

Results: Dutch eyes exhibited higher VA, received two additional injections annually and switched to alternative treatments more frequently (65.2% vs. 50.1%) and sooner (14.6 months vs. 17.9 months).

Conclusion: Dutch patients achieved higher VA after 60 months compared to the reference group. This higher VA was associated with a greater number of injections and a tendency to switch to a more expensive registered anti-VEGF injection type.

A 27-year-old patient came to the dermatology outpatient clinic of the Erasmus MC because of progressive swelling, pain, itching and skin lesions of the left foot for two days. The symptoms initially started with erythematous urticarial papules and vesicles. After a day severe swelling of the forefoot, bullae around the toes and several slowly progressive serpiginous plaques developed without systemic complaints. A week before the onset of the symptoms, he had returned from a trip to Colombia. Under the working diagnosis of cutaneous larva migrans, ivermectin 0.2 mg/kg for two consecutive days, clobetasol, cetirizine and local compression therapy were started. Two weeks after the start of the treatment, the patient was symptom-free. The disease is self-limiting. In case of multiple lesions or severe reaction, treatment may be considered.

In recent years, there has been a notable rise in referrals to specialised chronic intestinal failure centres of patients with self-reported intolerance to enteral feeding. Despite incomplete or inconclusive diagnostic procedures and no convincing clinical evidence for the presence of intestinal failure, patients often urge physicians to start with total parenteral nutrition (TPN). The frequent use of opioids in these patients is a complicating factor concerning the diagnostic workup for motility disorders and the interpretation of clinical symptoms. Despite TPN administration, these patients continue to pose a significant burden to medical staff and hospital resources because of persistent complaints, no improvement in quality of life and the occurrence of severe life-threatening complications. Therefore, we strongly advise against initiating TPN in patients with intolerance for enteral nutrition who are not diagnosed with intestinal failure. Instead, we encourage our colleagues to consult an expert centre and engage a mental healthcare professional early.

Feeling down is notalways a symptom of depressive disorder. Mostly the feeling is understandable in the light of the circumstances. The first approach should be a good conversation about what is happening, about the patient's aims and possibilities: the person-centered approach. However, when the patient has recurrent depressive episodes, has severe limitations in functioning or periods of mania, then the disease-centered approach is necessary, resulting in diagnosing depressive disorder (or bipolar disorder) and treating the patient according to the guidelines. In primary care, systematic screening of suicidality in depressed patients is not effective; case-finding is the preferred strategy.

Treating a patient requires his or her informed consent. The Dutch Medical Treatment Contracts Act (WGBO), however, contains three exceptions in which cases permission from the patient is not required. In emergency cases a physician is allowed to treat an incompetent patient, even against his or her will. The treating physician can both be a general physician or an emergency physician in a hospital considering to treat a patient against serious somatic injuries or threats. As long as the patient is incompetent and the emergency situation continues a physician is not required to invite the crisis intervention team to assess the competence of the patient and the potential harm the patient's condition may cause under the Compulsory Mental Healthcare Act (WVGGZ). In fact, more care may be provided than initially considered essential to save the life of the patient as long as the emergency situation lasts. However, the longer the emergency situation exists, the more necessary it becomes to involve the crisis intervention team and ask for a crisis measure for the patient under the WVGGZ.

Some fear of cancer recurrence is normal and may even be adaptive. However, high levels of anxiety may become problematic as it often results in for example sleeping problems, rumination, avoiding (incl. medical appointments) and/or physical complaints. For general practitioners and specialists it is important to recognizing this fear, discuss and ask questions about it and know how to intervene and refer. Validation and psychoeducation may be sufficient when fear is relatively low and manageable. When fear starts to interfere with normal life referral to a psychologist in the hospital or specialized mental health services for an evidence based treatment may be appropriate.

Disorders in alcohol consumption are among the most common, having the highest impact on morbidity and mortality, in mental health care. Treatment strategies differ greatly between institutions and the aim for controlled alcohol consumption remains controversial. The risk of (somatic) complications of alcohol abuse increase with a higher quantity of consumption, however there is no clear threshold regarding the development of certain health issues due to numerous factors determining individual susceptibility. Problematic alcohol abuse is treated either by aiming for complete abstinence, abstinence for the duration of therapy or controlled alcohol consumption. Considering a medical perspective aiming for abstinence in alcohol consumption is preferred, which however results in large amounts of untreated patients and limited effectivity. In our opinion, this advocates for a role of controlled alcohol consumption as 'harm reduction', focusing on the perspective of personal and communal recovery.

Objective: To determine gender differences in career progression of physicians.

Design: Retrospective cohort study.

Method: We examined career progression until 2023 of 715 physicians who received their PhD in the Netherlands in 2007/2008. We also pooled data from 7 national grant programs from 2005 up until Jan 1, 2023.

Results: Fifteen years after their PhD defence, 43% of physicians worked in academia, similar for men and women. Men published more than women (9[3-27] vs. 6[2-15] publications; p=0.001), especially in academia. Women were less likely than men to be appointed full professor (10/330 vs. 27/385; odds ratio[95% CI]: 0.41[0.20-0.87]), which was mediated for 55% by their number of scientific publications. Women increasingly applied for research grants over time, with an equal number of women and men receiving 'early career' grants since 2015. More men applied for 'established investigator' grants, without any gender differences in award rates.

Conclusion: Career perspectives in the early phase after obtaining a PhD, including grant allocation, are similar for male and female physicians. Differences in their later career phase were partly related to a higher number of scientific publications by men, compared to women.