Nederlands tijdschrift voor geneeskunde最新文献

Hyperglycemia at admission is associated with complications and mortality. There is only little evidence, however, for beneficial effects of strict glycemic control during hospitalization. Strict glycemic control may prevent postoperative infections. Strict control can increase the risk of hypoglycemia, which is independently associated with mortality. The ideal glucose target values for patients admitted to a general ward range from 5.6 to 10 mmol/L, with consideration for higher targets in certain populations. The sliding scale insulin regimen stands as a hallmark prescription for medical interns in hospital settings, yet the evidence shows this regimen is ineffective. Guidelines have been advising against the sliding scale regimen for almost 20 years. We advocate a basal-bolus insulin regimen for the management of elevated glucose levels, while tolerating mild hyperglycemia.A transition away from sliding insulin towards basal-bolus insulin, has shown promising outcomes. Embracing a paradigm shift towards basal-bolus insulin regimens offers a more nuanced approach to glucose management, leading to better patient outcomes and a lower workload for healthcare providers.

The incidence of a tension pneumothorax is very low. The initial treatment of a tension pneumothorax is needle thoracocentesis. This procedure is not a routine treatment and this invasive treatment is not without risks. Recognition of a clinically relevant tension pneumothorax remains difficult especially in the prehospital setting. Elevation of one half of the chest is a notoriously unreliable observation in relation to the diagnosis of tension pneumothorax. Absence of breath sounds without tension physiology is not a reason to perform a thoracocentesis. With the help of 3 cases we would like to explain and clarify the clinical presentation, the indication for and the correct procedure of thoracentesis.

Many Dutch patients consider sustainability important and are willing to make sustainable choices, even if this means compromising the effectiveness of their treatment. However, they indicate a lack of knowledge to make these choices. Healthcare providers can play a key role by addressing the environmental impact of different treatments and promoting healthy, sustainable lifestyles. However, it is a prior condition to bridge the existing knowledge gaps on this topic. Sustainability is also an argument in the context of 'appropriate care' - by preventing overtreatment and giving more consideration to the option of no (or limited) treatment. Finally, patients are a valuable source of knowledge and experience regarding sustainability in their own care process. Using their feedback will make healthcare practices more sustainable. Although involving patients in sustainable choices is still in an exploratory phase, there are already numerous opportunities to implement this approach. Moreover, patients are actively asking for it!

Objective: Evaluating the safety of a more expectative approach than described in the guideline 'Mild traumatic head/brain injury' (mTBI) within children.

Design: Retrospective chart review.

Method: Children (0-18 years) with mTBI, who visited the emergency department of Isala between December 2018 and July 2022, were included. Outcomes were the percentages of hospital admissions; CT-scans; intracranial hemorrhage, neurosurgical interventions and adherence to the national guideline.

Results: 704 patients with mTBI were included. Hospital admissions and CT-scans were performed in 67.5% and 6.7%, respectively. Intracranial hemorrhage was found in 13 patients (1.8%) and 2 patients (0.3%) underwent a neurosurgical intervention. Guideline adherence was 34.5%. Non-adherence to the guideline existed of choosing for a hospital admission even though a CT-scan was indicated.

Conclusion: The adherence to the guideline mTBI was poor. An expectative approach without initial imaging was sufficiently safe.

A 28-year-old female presented with acute abdominal pain three months after Nissen fundoplication surgery. Imaging revealed a diaphragmatic hernia, with an intra-thoracal colon, stomach and spleen. This highlights the importance of considering (incarcerated) diaphragmatic hernia as a potential complication post-Nissen fundoplication and the necessity of prompt diagnosis and surgical management.

STD-associated questions and symptoms are submitted frequently to general practitioners and STD outpatient-clinics. In this teaching article we address several important clinical questions regarding epidemiology, risk assessment, testing policy, diagnostics and prevention. STD's form a separate category of infectious diseases because of the role of sexuality. Good communication about sexual behavior is indispensable for an adequate diagnosis. We discuss the recognition of extragenital manifestations of STD, which requires alertness. Estimating the STD-risk based on sexual behaviour is essential for testing policy. Persons at high risk are tested for gonorrhoea, syphilis, hiv and hepatitis B. In other cases testing is based on symptoms and complaints. HIV and syphilis are serious std's. Early detection followed by treatment is important in preventing health damage and preventing further spread. Hiv-indicator-conditions are useful alarm-signs for this purpose. PrEP can help not to acquire hiv and increases sexual health. It can be prescribed by gp's and public health clinicians. But condom-use remains crucial in prevention.

Giant cell arteritis is a rare disease that can lead to blindness in people older than 50 years. Early recognition and timely treatment can prevent irreversible damage. Early recognition can be challenging due to the variable presentation of giant cell arteritis. Patients suspected of having giant cell arteritis should be referred within 24 hours to a hospital that ideally has a fast-track clinic, including vascular imaging. Here we present two patients with giant cell arteritis that reflect a number of dilemmas regarding early recognition and treatment, the fast-track clinic and the early start of prednisolone-sparing drugs in giant cell arteritis.

Semaglutide is registered in the Netherlands as a treatment for type 2 diabetes. If semaglutide is prescribed off-label as slimming agent, in principle, patient's costs are not reimbursed by health insurers. With the entry of the Geneesmiddelenwet (Gnw), regulations were provided for off-label prescription of medication. Based on article 68, paragraph 1 Gnw, off-label prescribing is allowed when protocols or standards have been developed. So far, this has not been the case in the Netherlands regarding semaglutide. When protocols and standards are under development, consultation must take place between doctor and pharmacist. The term "protocols or standards under development" is open to multiple interpretations, as shown by case law. Regardless of the chosen interpretation, the scientific evidence for semaglutide as slimming agent seems insufficient. In conclusion does off-label prescribing of semaglutide as slimming agent not meet the requirements of article 68, paragraph 1 Gnw and is therefore not permitted.

Dengue is the most common mosquito-borne tropical disease. Infections are no longer confined to (sub)tropical regions of the world, as vectors are rapidly spreading to new areas, including Europe. In Southern Europe, autochthonous cases are increasingly reported, whereas in the Netherlands, all reported dengue cases are still imported by travellers. In this article, we present a patient who developed dengue haemorrhagic fever following a reinfection with dengue virus, highlighting the potential for severe outcomes, such as dengue haemorrhagic fever and dengue shock syndrome. We discuss the availability of dengue vaccination. While early diagnosis is important for providing appropriate supportive care, prevention remains the best approach, in which dengue vaccination can play a key role.

In this article 10 important questions for physicians and other health care providers who are confronted with death during practice of their profession are answered. In the vast majority of cases, the attending physician can perform postmortem examination of those deceased. This article describes how an postmortem examination should be carried out correctly, what to do in unclear circumstances surrounding death and when an unnatural death should be considered. We also discuss how to correctly complete the cause of death declaration.