Nederlands tijdschrift voor geneeskunde最新文献

In a 2021 ruling, the central medical disciplinary board changed the requirements regarding the divisions of responsibilities between health care providers by introducing the term 'lead clinician', placing more emphasis on the own professional responsibility of each care provider involved. The lead clinician oversees the continuity and coherence of care, coordinates between caregivers, and serves as a point of contact. Despite concerns about its implementation, national guidelines on responsibility division have adopted the lead clinician concept. However, translating these guidelines into clinical practice of hospitals poses challenges due to unclear responsibilities and the absence of ultimate accountability. Furthermore, variations in interpretation among institutions and professional groups could jeopardize patient safety. Clear standards for the lead clinician role that are coordinated from a national level are essential to mitigate these risks. Until then, it may be unwise for hospitals to relinquish the former role of the practitioner in lead.

Recent research shows that the functional outcome after an acute Achilles tendon rupture is comparable after conservative versus operative treatment. It is therefore recommended to treat patients conservatively, but strong reasons for surgical treatment exist. In principle, no additional radiographic diagnostic exams are indicated for the diagnosis. An appropriate anamnesis, palpable gap and positive Thompson test have an excellent sensitivity. In case of doubt, an ultrasound should be performed as the first step. A shared decision process should be pursued for establishing treatment plan. However, it is recommended that patients be treated conservatively unless strong arguments for surgical intervention are present. It is important to properly inform patients, and thus manage expectations about the expected rehabilitation process. If there is an increased risk of re-rupture, such as in athletes or during physically demanding work, surgical treatment can be considered. Then a surgical technique in which expertise and experience has been gained should be used as no difference in outcome have been found after open versus minimal invasive techniques.

The most controversial issue in the Dutch euthanasia practice concerns the performance of euthanasia in a case of a patient in an advanced state of dementia on the basis of a request that is laid down in an advance directive. This is particularly controversial when such a patient, although lacking decisional capacity on the matter, shows signs of a wish to live. In two important verdicts of April 21 2020 the Dutch Supreme Court has ruled that a request that has been made competently cannot be revoked incompetently. In this comment I consider two recent documents from Dutch professional organisations that are contrary to these decisions, in particular a guideline stating that on a proper understanding of decisional capacity the expression of a wish to live of a demented person, however inarticulate, should always be considered to be made competently.

CRISPR-Cas technology is a revolutionary technology to modify DNA sequences. Owing to its effectiveness and accuracy, CRISPR-Cas holds important promises for 'genetic therapy' for various hereditary disorders. CRISPR-Cas enables researchers to modify specific parts of the genome with unprecedented precision, which, in specific cases, can be applied to correct disease-causing DNA variants. However, several important barriers are complicating the clinical implementation trajectory. There are for example concerns regarding the safety, effectiveness and ethical justification. Nevertheless, as CRISPR-Cas becomes more widely known, doctors and healthcare providers are expected to be well aware of the developments surrounding CRISPR-Cas therapy. Professional expertise and clear communication about the possibilities and limitations to patients with genetic disorders are essential, partly to avoid making promises that are unrealistic in the short term. Altogether, geneticists, medical centers and regulators are now facing the challenges to start translating CRISPR-Cas technology into clinical practice, in an effective and ethical manner.

This case describes a 58-year-old woman who presented to the dermatology outpatient clinic with progressive skin lesions on the hands. Physical examination showed erythematosquamous plaques. The diagnosis zoonotic dermatomycosis was made based on fungal cultures, which showed a Trichophyton erinacei. This dermatophyte is particularly transmitted through hedgehogs. The patient appeared to have taken care of an infected hedgehog.

Objective: Evidence regarding percutaneous vertebroplasty (PV) for chronic painful osteoporotic vertebral compression fractures (OVCFs) remains limited. To compare pain relief, quality of life, and disability between PV and active control (anesthetic infiltration) interventions for chronic OVCF.

Design: Randomized controlled trial.

Methods: This prospective randomized clinical trial was conducted between May 2013 and June 2019 in participants with pain due to OVCF lasting longer than 3 months with bone marrow edema present at MRI. Study participants were randomly assigned to undergo PV (n = 40) or active control intervention (n = 40). The primary outcome was pain severity, assessed with the visual analog scale (VAS) (range, 0-10) during 12 months after treatment. Secondary outcomes included Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) score (range, 0-100) and Roland Morris Disability Questionnaire (RMDQ) score (range, 0-100). Outcomes were analyzed according to a longitudinal multilevel model used to test the difference between groups in change from baseline across follow-up.

Results: The mean age of the 80 participants (54 women) was 69 years ± 10 (SD) in the PV group and 71 years ± 10 in the active control group. VAS score was 7.6 (95% CI: 7.0, 8.2) in the PV group and 7.3 (95% CI: 6.9, 7.8) in the active control group at baseline (P = .47) and 3.9 (95% CI: 3.1, 4.8) and 5.1 (95% CI: 4.3, 6.0), respectively, at month 12 (P = .045). At month 12, the group difference from baseline was 1.3 (95% CI: 0.1, 2.6; P = .02) for VAS, 5.2 (95% CI: 0.9, 9.4; P = .02) for QUALEFFO, and 7.1 (95% CI: -3.3, 17.5; P = .18) for RMDQ, favoring the PV group.

Conclusion: In the treatment of pain caused by chronic OVCFs, PV is more effective for pain relief and quality of life improvement than anesthetic injection alone, with similar improvement for disability between the groups.

Background: Cognitive disorders usually develop slowly over years and are mainly caused by untreatable neurodegenerative disorders. Rapidly progressive cognitive disorders should raise suspicion of an underlying and treatable psychiatric, internal or neurological condition. Timely recognition of these conditions is important.

Case: We present the case of a 68-year old man, presenting on the emergency department with a history of progressive cognitive impairment since several weeks. Cerebral MRI showed T2-hyperintensities in the left hippocampal, mesotemporal and insular regions; lesser so in the right mesotemporal region. After initial treatment for herpesencephalitis and autoimmune encephalitis, we diagnosed neurolues and started treatment with benzylpenicillin.

Conclusion: It may be difficult to diagnose neurolues because the vast variety of clinical symptoms and radiological signs. This case shows that neurolues should be considered in a patient with rapidly progressive cognitive disorders and that neurolues can mimic a herpesencephalitis or an autoimmune encephalitis. Timely recognition is important to prevent irreversible damage.

In palliative care patient problems often are complex and have elements that relate to more than one dimension and therefore require a multidisciplinary approach.In this article the methodical approach of "palliative reasoning" is described, which helps to analyse, treat and follow up complex patient problems in the palliative phase. Furthermore, tips, general recommendations and treatment options are described based on existing Dutch clinical practice palliative care guidelines, literature and expert opinion.

Effective primary-secondary care collaboration is crucial for patient care. However, this collaboration does not come naturally and requires specific attention during education and training. This article outlines what needs to be learned, how to approach it, and provides examples. The authors highlight the need for clear communication, understanding of mutual roles and responsibilities, and the value of mutual respect and trust. The learning should ideally take place in daily patient care, with time for reflection in a safe environment. Role models in collaboration are of ultimate importance. The authors encourage the implementation of cross-disciplinary education for postgraduate medical trainees; not occasionally, but structurally. This also counts for interprofessional education between for example the medical and the nursing professions. We no longer work from silos of one professional group, but in dynamic networks. Therefore, learning and education should also be shaped collectively.

Objective: In recent years, several international studies have been published, that describe a relationship between country of origin and the occurrence of work-related injury. Since we regularly treat migrant workers in our hospital after work-related injury, we wanted to gain more insight into the characteristics of this group.

Design: Descriptive retrospective cohort study.

Method: Patients were identified from the Dutch Nationwide Trauma Registration (LTR). Patients that were included in the study were admitted and treated in our hospital after a work-related injury from 2017 to 2021. Additional information regarding patient characteristics and outcomes were retrieved from our electronic hospital information system.

Results: 14,9% of the 397 patients were found to have an injury with an Injury Severity Score (ISS) of 16 or higher. The most common mechanism of injury was a fall from height (ISS≤15: 26.0%, ISS≥16: 57.6%). In the study population, 15,4% had a non-Dutch origin. The majority consisted of employees with an Eastern European nationality (70,5%), mainly from Poland. Within this group relatively more often patients were encountered that had no valid insurance (14% of patients with an Eastern European origin) or were intoxicated (19% of patients with Eastern European origin).

Conclusion: A relatively large part of our patient population consisted of migrant workers. We did not observe large differences in mechanism of injury, severity of injury and outcome between native patients and migrant workers. We did observe a relatively high frequency of insurance problems and intoxications among migrant workers.