Nederlands tijdschrift voor geneeskunde最新文献

Objective: Examination of the development of socio-economic differences in mortality because of ischemic heart disease (IHD) in The Netherlands during 1996-2022.

Design: Repeated cross-sectional research.

Methods: The socio-economic position (SEP) of people is determined by deciles of the combination of disposable income and wealth of the corresponding household, and subsequently related to IHD-mortality. The data came from Statistics Netherlands.

Results: The socio-economic inequality in IHD-mortality showed for men first a decrease which weakened gradually and subsequently shifted into an increase from 2014 onwards. The difference between lowest and highest financial wealth increased from 4.9 IHD-deaths per 10 thousand to 6.3 IHD-deaths in 2022. For women, the inequality also decreased in the beginning, but remained from 2014 onwards constant.

Conclusion: Inequality in IHD-mortality between high and low SEP persists for both men and women. By taking these differences into account, prevention can be worked on more specifically.

A review in the Annals of Surgery addressed the role of cognitive bias and heuristics in creating surgical complications and death. Bias and heuristics in decision making is not new, but the fact that surgeons and clinicians in general are influenced by them is apparently still noteworthy. The idea that clinicians act purely rational or should persists. But doctors are not computers. Nevertheless interventions aiming at improving behaviour of clinicians is based on the assumption that more knowledge or guidelines will lead to better behaviour. But these elements are seldomly sufficiently adequate or key for better conduct. Medical decision making will never be fully objective. Interventions to improve decision making should be realistic and respond to how clinicians work and make decisions. Biases are there and always will be, sometimes innocent, sometimes harmful, but unrealistic expectations on human decision making will not help. As soon as we are able to realize this, there will be room for improvement.

A healthy 21-month old boy presented with a red purple preauricular swelling. Initial antibiotics were ineffective. Fine needle aspiration revealed an atypical mycobacterium after 6 weeks. The location taken into consideration, we chose a conservative approach to avoid potential facial nerve damage.

In the Netherlands, 80% of paracetamol poisoned patients is treated for 24 hours with 600 mg/kg body weight of acetylcysteine. In the SNAP regimen, 300 mg/kg acetylcysteine is dosed in 12 hours, with the option to extend the treatment. If paracetamol concentration < 10 mg/L, ALT < 100 U/L, and INR ≤ 1.3, acetylcysteine treatment can be discontinued. Seventy percent of patients treated with the SNAP regimen require only 12 hours of treatment. The SNAP regimen has fewer side effects and is as effective as the previous Dutch acetylcysteine regimen and the international 'Prescott 21-hour' protocol. Recently, two treatment guidelines (NVIC and toxicologie.org) have been revised to adopt the SNAP regimen. Apart from a reduction in side effects, implementing the SNAP regimen for the treatment of paracetamol poisoning in the Netherlands likely reduce hospital stay and healthcare costs.

Postcovid is a debilitating persistent multisystem disease for which no specific (curative) treatment is available yet. We present two postcovid patients and evaluate interventions that were tried. We comment on the use of a biopsychosocial approach in the evaluation of postcovid and the identification of possible 'treatable traits'. Interventions in the biological domain are aimed at 'treatable traits' such as pain, sleep problems, POTS and MCAS-type symptoms, as well as comorbidities. Comorbidities may require specialized care, and rehabilitative care may be necessary to stabilize the illness and (hopefully) improve functioning in severely ill patients. Interventions in the psychosocial domain are aimed at psychological complaints that often accompany postcovid (anxiety, depression) and reducing stress (related to work or school, financial insecurity, etc.). In absence of a specific treatment for postcovid, meaningful intervention is aimed at stabilizing the illness and (hopefully) improving functioning by addressing 'treatable traits' in all biopsychosocial domains.

Gossypiboma, a rare but clinically significant complication of surgery, is defined as a surgical gauze left inside the patient by accident. Here, we describe a case of gossypiboma of a 45-year-old Syrian patient who presented at the emergency department with chest pain after a pulmonary valve replacement two years ago. Initial investigations, including ECG and blood tests, showed no acute abnormalities. However, a chest X-ray revealed a mass with radio-opaque marker, later identified on CT as retained surgical gauze. Conservative management with pain relief was chosen given risks outweigh the benefits of surgery at this stage. This case highlights the importance of maintaining a broad differential diagnosis, even with potential external influences such as legal or social issues. Preventative measures, including thorough surgical counts and the use of radio-opaque markers, remain essential to avoid such complications.

Objective: Is a call made by a surrogate related to urgency allocation or higher odds of a life-threatening event (LTE)?

Design: Cross-sectional study.

Method: Calls to the OHS-PC were classified into 'patient-initiated call' or 'surrogate call'. Odds ratios were calculated for the relationship between the type of call and (a) urgency allocation, (b) ACS, and (c) life-threatening event.

Results: In total 2428 recordings were included for analysis. Around half of the recordings were surrogate calls, and these more often received a high urgency (80.0%) than patient-initiated calls (57.8%). Of all participants, 13.9% were diagnosed with a LTE; in women 10.3%, in men 18.3%. In the surrogate call group this was 18.8%, in the patient-initiated call group 8.9%.

Conclusions: Surrogate calls on behalf of a patient with symptoms suggestive of ACS receive more often a high urgency, and these patients have a risk twice as high of an LTE.

Semen cryopreservation is a way to preserve sperm before treatments that may affect fertility, such as chemo- and radiotherapy. Typically, semen is collected through masturbation, though alternatives like electrostimulation or testicular sperm extraction (TESE) exist for patients unable to provide a sample. Informed consent is required for these procedures. We describe a case of a young patient sedated in the ICU due to a therapy-resistant status epilepticus. His physicians planned to treat him with the gonadotoxic agent Cyclophosphamide, which can harm sperm quality. His family requested semen cryopreservation before treatment. However, due to the patient's sedation, obtaining his consent was not possible. A multidisciplinary team debated the legal and ethical concerns, balancing respect for the patient's presumed wishes with his right to bodily integrity. The decision was made to collect and store the semen, with future use contingent on the patient's consent.

CT imaging increases cancer risk, although the exact magnitude remains uncertain due to limited primary evidence. A recent study incorporating detailed scanning- and patient data from U.S. nationwide registries and surveys estimated an average cancer risk of approximately 0.17% per CT scan. This study employed a similar risk model also used in the Dutch guidelines. However, the study findings are not directly generalizable to the Dutch context, given differences in radiation doses and assumptions regarding life expectancy. The results therefore do not warrant changes to current policy. However, in an era of growing CT use, it is very important to carefully apply clinical justification of CT scans, in which probability of disease, life expectancy, cost-effectiveness and other patient related factors frequently outweigh radiation risks.

Recreational drug use is common, with a prevalence of 4.7% among Dutch outgoing people. Stimulant drugs and cannabis are associated with cardiovascular complications such as, palpitations, chest pain, syncope, hypertension, tachycardia, QRS-widening, QTc-prolongation, arrhythmia, acute coronary syndrome, and even sudden cardiac death. The self-reported drug use reliability is mostly poor, although specific questioning might increase this reliability. For risk stratification in chest pain patients, the HEART-score can be used, without adjustment. A prolonged observation duration, as previously advised, seems unnecessary. Treatment includes sedatives, antihypertensives, coronary angiography, and specific antiarrhythmics followed by the appropriate intervention for acute coronary syndrome. For arrhythmia, labetalol, carvedilol, lidocaine and sodium bicarbonate can be considered. The use of beta-blockers is still under debate but should be considered in patients with heart failure with reduced ejection fraction. Therefore, always question patients with cardiovascular complaints about recreational drug use, know this changes management, and provide drug counselling.