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Abstracts : June 2005, Vol. 63, No. 6

Contents

EDITORIAL

Clinical guidelines to improve patient care
H. Wollersheim, J. Burgers, R. Grol

A B S T R A C T

The aim of clinical guidelines is to improve quality of care by translating new research findings into practice. There is evidence that the following characteristics contribute to their use: inclusion of specific recommendations, sufficient supporting evidence, a clear structure and an attractive lay out. In the process of formulating recommendations, implicit norms of the target users should be taken into account. Guidelines should be developed within a structured and coordinated programme by a credible central organisation. To promote their implementation, guidelines could be used as a template for local protocols, clinical pathways and interprofessional agreements.

REVIEW

Pulmonary hypertension: its diagnosis and management, a multidisciplinary approach
M.C. Vonk, A.P.J. van Dijk, Y.F. Heijdra, H.F.M. van der Heijden, S.J.H. Bredie, F.H.J. van den Hoogen

A B S T R A C T

Pulmonary hypertension is a devastating complication of various, but rare diseases and can also occur as an isolated entity. It causes morbidity and mortality in all patients. Ongoing research has provided some insight into the pathophysiology and clinical manifestations, and new therapeutic options have recently become available for some types of pulmonary hypertension. In order to provide optimal care for an individual patient it is mandatory to establish the type and severity of the pulmonary hypertension in each patient. The diagnostic protocol used in our hospital is presented along with a description of two case histories. An algorithm of the different therapeutic strategies now available is given as well as recommendations for follow-up.

ORIGINAL ARTICLES

The effect of arginine vasopressin on endothelin production in the human forearm vascular bed
C.T. Postma, S.M.J. Maessen, Th. Thien, P. Smits

A B S T R A C T

Objectives: To study whether arginine vasopressin (AVP) can stimulate endothelin production and/or release in vivo, in the human forearm vasculature. Design: The effect of the infusion of AVP into the brachial artery on endothelin production across the human forearm vascular bed was studied in healthy male volunteers, and was compared with intra-arterial infusion of placebo. In another group the effects of AVP on endothelin production were studied after a prior infusion of L-NG-monomethyl-arginine (L-NMMA), a nitric oxide-synthase inhibitor. In a fourth group the effect of L-NMMA alone, without AVP infusion, on endothelin production was studied. Methods: We measured the effects of AVP, placebo, L-NMMA followed by AVP and L-NMMA followed by placebo on arterial and venous endothelin concentrations in the forearm of four groups, each consisting of five healthy male volunteers. Forearm blood flow was measured by strain gauge plethysmography. The endothelin production was calculated as forearm blood flow times (venous - arterial) endothelin concentration. Results: The group infused with L-NMMA followed by infusion of 8 ng AVP/min per dl forearm volume showed a significant rise in endothelin production from 1.3 (1.8) to 5.0 (2.0) pg/min/dl at 15 minutes (p<0.05, ANOVA). This rise in endothelin production was also significantly different from the endothelin production at 15 minutes in the other three groups (p<0.01, ANOVA). Conclusion: In healthy male volunteers intra-arterial infusion of AVP induced a rise in endothelin production in the forearm within 15 minutes, but only after prior infusion of L-NMMA. This observation suggests that the AVP-induced production of nitric oxide offsets AVP-mediated release of endothelin.

Impact of the introduction of a guideline on the targeted detection of hereditary haemochromatosis
E.M.G. Jacobs, C.F.M. Meulendijks, L. Elving, G.J. van der Wilt, D.M. Swinkels

A B S T R A C T

Background: In 1998 a clinical guideline for the targeted, accurate and early detection and treatment of HFE-related hereditary haemochromatosis (HH), which comprises a test for the causative HFE-gene mutations, was introduced in our outpatient department. Methods: The impact of this guideline was evaluated retrospectively. Data were acquired from medical records of patients with discharge diagnosis codes suggestive of HH (n=878 patients), obtained from a period before (n=422) and after guideline introduction (n=456). Results: Combined measurements of serum transferrin saturation and serum ferritin rose from 12.2% (n=53) to 29.5% (n=138, p<0.001), leaving 70% of the patients eligible for HH not tested for iron parameters. The HFE-gene mutation detection test was correctly used in 11 (40.7%) of 27 tested patients and improperly interpreted in six (22.2%) of these 27 patients. Five new HH patients were diagnosed before and 13 after introduction. Seven of these 13 patients appeared to be incorrectly diagnosed, due to misinterpretation of laboratory results. Diagnostic costs of case detection for each accurately diagnosed patient were Ä 2380 before and Ä 2600 after introduction of the guideline. Conclusion: Evaluation of the introduction of a practical guideline for targeted HH detection reveals a low compliance with the guideline, resulting in both a small percentage of patients tested for HH and overdiagnosis of HH. Therefore, the introduction of the guideline should be combined with a more appropriate implementation strategy which includes education on its most critical points, i.e. the indication and interpretation of the iron parameters and the HFE genotype.

Cross-sectional relationship between glycaemic control, hyperglycaemic symptoms and quality of life in type 2 diabetes (ZODIAC-2)
N. Kleefstra, L.J. Ubink-Veltmaat, S.T. Houweling, K.H. Groenier, B. Meyboom-de Jong, H.J.G. Bilo

A B S T R A C T

Background: To describe the relationship between glycaemic control, hyperglycaemic symptoms and quality of life (HRQOL) in type 2 diabetic patients. Methods: In a shared-care diabetes project HRQOL was assessed. A total of 1664 patients with type 2 diabetes were identified in 32 primary healthcare practices. Of these patients, 1149 were included. HRQOL was measured using a generic questionnaire (Rand-36), completed by 1006 of the 1149 participants. Results: The number of hyperglycaemic symptoms was higher in women (1.88) compared with men (1.64), without differences in mean haemoglobin A1c (HbA1c) (7.5%). Univariate analyses showed negative relationships between all dimensions of the Rand-36 and hyperglycaemic symptoms (p<0.001), but between only one dimension and HbA1c (p=0.005). Multivariate analyses showed no association between any of the dimensions of the Rand-36 and HbA1c, but the relationship between hyperglycaemic symptoms persisted in all dimensions (p<0.001). Notwithstanding these results, the presence of hyperglycaemic symptoms was related to higher HbA1c. Conclusion: In type 2 diabetic patients, as assessed by a generic questionnaire, there is an evident relationship between hyperglycaemic symptoms and HRQOL and not between HbA1c and HRQOL. Subjective hyperglycaemic symptoms are, independent of HbA1c, important for HRQOL in type 2 diabetic patients, and should therefore not be neglected in the management of diabetes.

CASE REPORTS

Severe early onset osteopenia and osteoporosis caused by antiepileptic drugs
K. Beerhorst, F.C. Huvers, W.O. Renier

A B S T R A C T

We describe two adult patients with epilepsy who received long-term antiepileptic drug therapy, a woman aged 39 years and a man aged 38 years, in whom severe osteopenia and osteoporosis, respectively, were diagnosed. Both had had epilepsy since childhood, both were seizure free and off medication for several years before the epilepsy started again. The female patient first sustained a complicated pelvis fracture after minor trauma. Next, both patients had infractions of several thoracic vertebrae after a generalised tonic-clonic seizure. Dual-energy X-ray absorptiometry for measurement of the bone mineral density revealed osteopenia in both. Bone biopsy was only performed in the male patient and showed moderate osteoporosis. Taking into consideration the young age for osteopenia and osteoporosis and the absence of other underlying causes, the long-term anticonvulsant therapy is the most likely cause of the development of osteopenia and osteoporosis in these patients. Reviewing recent literature data, advice from healthcare organisations and medical guidelines, the authors were surprised by the lack of protocols and preventive measures for patients with epilepsy who have been on antiepileptic drug therapy for many years. With this article we stress the urgent need to develop protocols and guidelines for preventive interventions.

Moraxella catarrhalis sepsis in a patient with juvenile spinal muscle atrophy
I.C.D. Westendorp, M.A. Tiemessen, M. de Jong, A. Soomers, I.M.M.J. Wakelkamp, W.G. Boersma

A B S T R A C T

Moraxella catarrhalis rarely causes severe infections or bacteraemia in healthy subjects. In the literature only four cases of clinical sepsis with M. catarrhalis have been described, mostly in immunocompromised patients. We describe a case of a 34-year-old patient with Kugelberg-Welander disease and low body weight (28 kg) who developed clinical sepsis due to M. catarrhalis bacteraemia. A review of the literature is given.

PHOTO QUIZZES

A patient with fever after a visit to South Africa
P.H.Th.J. Slee

A B S T R A C T

No abstract available.

A patient with dyspnoea, subfebrile temperature and electrocardiographic abnormalities
H.J. Jansen, H. Haerkens-Arends, G. Vervoort

A B S T R A C T

No abstract available.

SPECIAL REPORTS

If apoB is so good, why isnít everybody measuring it? One reason why we need the Netherlands Journal of Medicine!
A.D. Sniderman, M. Rosenbloom

A B S T R A C T

No abstract available.

Awards for best articles published in the Netherlands Journal of Medicine in 2004
Editorial board of the Netherlands Journal of Medicine

A B S T R A C T

No abstract available.




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