Verhaegh MTH, Snijders F, Janssen L
… +6 more, Peters NALR, Mol Y, Kamerman-Celie F, van Galen LS, Nanayakkara PWB, Barten DG
Neth J Med
· 2019 Dec · PMID 31814587
BACKGROUND: Older people increasingly demand emergency department (ED) care. ED visits have a profound impact on older patients, including high risk of adverse outcomes and loss of independency. In this study, we evaluat...BACKGROUND: Older people increasingly demand emergency department (ED) care. ED visits have a profound impact on older patients, including high risk of adverse outcomes and loss of independency. In this study, we evaluated the opinions of patients, caregivers, general practitioners, and ED physicians on the preventability of ED visits. METHODS: Prospective, mixed-method observational and qualitative study of 200 patients aged ≥ 70 years visiting a teaching hospital ED in the Netherlands. Semi-structured interviews were performed with patients, caregivers, and general practitioners. ED physicians were provided with written surveys. Patient data were extracted to determine vulnerability. RESULTS: The mean age of the patients was 79.6 years; 49.5% were male. Ninety-five percent lived independently before the ED visit. Most patients reported domiciliary care (23%), a caregiver (21.5%), or both (29.5%). Patients considered 12.2% of visits potentially preventable, caregivers 9%, general practitioners 20.7%, and ED physicians 31.2%. Consensus on preventability was poor, especially among patients and professionals. While patients most frequently blamed themselves, healthcare providers predominantly mentioned lack of communication and organisational issues as contributing factors. CONCLUSION: Patients and caregivers consider an ED visit preventable less frequently than professionals do. Little consensus was found among patients and healthcare providers, and the perspectives on contributing factors to a preventable visit differ between groups. To help improve geriatric emergency care, future studies should focus on why these perspectives are so different and aim to align them.
Heintjes EM, Houben E, Beekman-Hendriks WL
… +5 more, Lighaam E, Cremers SM, Penning-van Beest FJA, Stehouwer CDA, Herings RMC
Neth J Med
· 2019 Dec · PMID 31814586
BACKGROUND: Quality of diabetes care in the Netherlands ranked second in the Euro Diabetes Index 2014, but data on outcomes are lacking. We assessed trends in cardiovascular disease and mortality among type 2 diabetes (T...BACKGROUND: Quality of diabetes care in the Netherlands ranked second in the Euro Diabetes Index 2014, but data on outcomes are lacking. We assessed trends in cardiovascular disease and mortality among type 2 diabetes (T2DM) patients in the context of risk factor control. METHODS: Annual cohorts of adult T2DM patients were constructed from the PHARMO Database Network. Age-standardised mortality rates and incidence rates (IR) of hospitalisations for acute myocardial infarction (AMI), stroke, and congestive heart failure (CHF) were compared with a diabetes-free population matched on age, sex, and general practitioner. Life years lost (LYL) to T2DM or cardiovascular disease were determined by comparing life expectancy between matched groups. Proportions attaining glycated haemoglobin (HbA1c), blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C) goals were assessed annually. RESULTS: Among 53,602 T2DM patients, slight increases in IR between 2008 and 2016 were proportional to those in diabetes-free controls; on average T2DM increased the risk of mortality by 86%, hospitalisation for AMI 69%, stroke 57%, and CHF 185%. At age 55, LYL to T2DM averaged 3.5 years and established CVD added 1.8 years, irrespective of sex. HbA1c goal attainment increased from 58% to 65%, LDL-C from 56% to 65%, and systolic BP from 57% to 72%. CONCLUSION: Despite highly organised diabetes care, excess incident cardiovascular events and mortality due to T2DM did not decrease over the study period. Life expectancy of T2DM patients is significantly reduced and risk factor control is suboptimal. This suggests there is considerable room for improvement of diabetes care in the Netherlands.
BACKGROUND: Chemotherapy-induced febrile neutropaenia (FN) is a common and life-threatening adverse event, which can be largely prevented by the use of granulocyte colony-stimulating factor (G-CSF); G-CSF, however is exp...BACKGROUND: Chemotherapy-induced febrile neutropaenia (FN) is a common and life-threatening adverse event, which can be largely prevented by the use of granulocyte colony-stimulating factor (G-CSF); G-CSF, however is expensive and not without side effects. Although primary G-CSF prophylaxis is recommended when the risk of FN is ≥ 20%, it is unclear during which cycles it should be administered. This study assessed and compared the FN incidence in the neo-adjuvant or adjuvant administration of two chemotherapy regimens that are widely used in breast cancer care to provide clinically useful recommendations for G-CSF use. METHODS: 221 breast cancer patients were included in this retrospective single-centre study. In total, 181 patients received three cycles of 5-flourouracil, epirubicin, cyclophosphamide (FEC) followed by three cycles of docetaxel (3F-3D) (81.9%); 40 patients received four cycles of doxorubicin, cyclophosphamide (AC) followed by twelve cycles of paclitaxel (4AC-12P) (18.1%). The episodes of FN, extracted from the electronic patient files, were analysed and compared. RESULTS: Overall, FN was identified in 27.8% of patients and occurred significantly more in patients receiving 3F-3D compared to patients receiving 4AC-12P (31.5% versus 10.0%, OR 4.14, 95% CI: 1.14-12.18). Comparison of FN occurrence after first exposure to FEC (6.1%), AC (5.0%), docetaxel (20.9%), or paclitaxel (0%) showed a significantly higher risk in patients receiving docetaxel than following administration of the other three agents. CONCLUSIONS: In breast cancer treatment, compared to other frequently-used agents, monotherapy with docetaxel (100 mg/m2) renders a substantial risk of FN (20.9%), thereby justifying the use of primary G-CSF according to international guidelines.
This case report describes a patient with the rare phenomenon of multiple liver abscesses and signs of hepatitis, secondary to disseminated listeriosis. All signs and symptoms resolved with antibiotic treatment only, con...This case report describes a patient with the rare phenomenon of multiple liver abscesses and signs of hepatitis, secondary to disseminated listeriosis. All signs and symptoms resolved with antibiotic treatment only, contradicting current literature. This suggests that the development of multiple liver abscesses following infection with Listeria monocytogenes does not necessarily yield a poor prognosis, even without drainage.
de Martines DGL, Gianotten S, F M Wetzels J
… +1 more, G van der Meijden WA
Neth J Med
· 2019 Oct · PMID 31814577
BACKGROUND: In this article, we present two cases of patients with acute renal insufficiency with a history of exocrine pancreatic insufficiency. In one case, this was caused by pancreaticoduodenectomy; in the other, by...BACKGROUND: In this article, we present two cases of patients with acute renal insufficiency with a history of exocrine pancreatic insufficiency. In one case, this was caused by pancreaticoduodenectomy; in the other, by alcohol abuse. Neither patient had considerable proteinuria or haematuria. Their renal biopsies showed tubulopathy with widespread oxalate crystals, characterised by their birefringence in light microscopy. Restricting oxalate intake and prescribing oxalate binding agents reduced serum oxalate levels. Renal function partially recovered in both patients. Oxalate nephropathy is associated with exocrine pancreatic insufficiency, gastric and pancreatic surgery, and inflammatory bowel disease. Normally, dietary calcium binds oxalate to form calcium oxalate, which is excreted in the stool. In patients with pancreatic insufficiency, fatty acids bind calcium instead, allowing oxalate to be absorbed in the colon. The resulting hyperoxaluria can cause oxalate crystal formation, tubulopathy, and renal insufficiency. Treatment relies on decreasing the amount of absorbable oxalate in the intestinal lumen, as well as lowering urinary oxalate concentrations. CONCLUSION: Secondary hyperoxaluria is a common cause of renal insufficiency and should be considered in patients with a medical history of pancreatic insufficiency and progressive kidney injury.
Mol GCM, Büller HR, Sinnige HAM
… +2 more, Péquériaux NCV, Coppens M
Neth J Med
· 2019 Oct · PMID 31814575
BACKGROUND: Most invasive procedures require the interruption of oral anticoagulation. In 2015, an international randomised trial demonstrated that perioperative bridging caused more harm than benefit in most anticoagula...BACKGROUND: Most invasive procedures require the interruption of oral anticoagulation. In 2015, an international randomised trial demonstrated that perioperative bridging caused more harm than benefit in most anticoagulated patients with atrial fibrillation, leading to a more restrictive Dutch national guideline in April 2016. The objective of the present study was to analyse the integration of the 2016 Dutch guideline for perioperative antithrombotic management from after publication until update of hospital protocols. METHODS: This is a retrospective cohort study of patients on vitamin K antagonists undergoing a surgical procedure between April 2016 and June 2017. RESULTS: The proportion of high-risk patients with venous thromboembolism or atrial fibrillation receiving bridging therapy decreased from 91% and 77%, respectively at the start of the study to 33% in both groups in the last months. In high-risk patients with a mechanical heart valve, the bridging rate remained stable at 70-80% for 12 months and increased to 100% in the last 3 months. Protocol adherence for high-risk patients decreased from 80% to below 43%. The 30-day incidence of major bleeding was 4.1% (15.2% in bridged patients and 0.7% in non-bridged patients) and 10.3% for clinically relevant non-major bleeding (23.9% in bridged patients and 6.0% in non-bridged patients). The incidence of thrombo-embolism was 0.5%. CONCLUSION: New evidence from the Dutch national guideline on perioperative bridging was adopted by physicians before the local hospital protocol was updated. Low incidence of thromboembolism in non-bridged patients and high incidence of bleeding in bridged patients support a more restrictive bridging policy.
BACKGROUND: Adult-onset Still's disease (AOSD) is a rare, chronic, and systemic inflammatory disorder. The current study aims to evaluate the ability of platelets (PLTs), plateletcrit (PCT), mean platelet volume (MPV), p...BACKGROUND: Adult-onset Still's disease (AOSD) is a rare, chronic, and systemic inflammatory disorder. The current study aims to evaluate the ability of platelets (PLTs), plateletcrit (PCT), mean platelet volume (MPV), platelet distribution width (PDW), and PLT to PDW ratio (PPR) in a cohort of patients with AOSD or sepsis. METHODS: Serum samples were obtained from 82 AOSD patients, 48 sepsis patients, and 76 matched healthy controls. Platelet parameters were measured by Sysmex XE 2100 analysers. RESULTS: PPR and ferritin in AOSD patients were significantly higher than those in sepsis patients (22.18 ±; 11.12 vs. 13.80 ±; 8.97, p < 0.001; 3972.90 ±; 5134.04 μg/l vs. 518.92 ±; 382.50 μg/l, p = 0.001, respectively) and they were independent factors to differentiate AOSD from sepsis (OR: 5.86, 95%CI 1.59-21.60, p = 0.008; OR: 54.06, 95%CI 9.57-305.44, p < 0.001; respectively). Furthermore, PPR in AOSD and sepsis was significantly higher than that in matched controls. The area under the ROC curve of PPR, ferritin, and the combination were 0.733 (95%CI 0.646-0.820), 0.887 (95%CI 0.825-0.950), and 0.931 (95%CI 0.884-0.984), respectively. CONCLUSION: PPR can be used as a useful marker to differentiate AOSD from sepsis and the combined identification value of PPR and ferritin is much higher than that of any single factor.
Amaador K, Peeters H, Minnema MC
… +9 more, Nguyen TQ, Dendooven A, Vos JMI, Croockewit AJ, van de Donk NWCJ, Jacobs JFM, Wetzels JFM, Sprangers B, Abrahams AC
Neth J Med
· 2019 Sep · PMID 31582582
Monoclonal gammopathy of renal significance (MGRS) includes all kidney disorders caused by a monoclonal protein (M-protein) secreted by a small plasma cell clone or other B-cell clones in patients who do not meet the dia...Monoclonal gammopathy of renal significance (MGRS) includes all kidney disorders caused by a monoclonal protein (M-protein) secreted by a small plasma cell clone or other B-cell clones in patients who do not meet the diagnostic criteria for multiple myeloma or other B-cell malignancies. The underlying disorder in patients with MGRS is generally consistent with monoclonal gammopathy of undetermined significance (MGUS). MGRS-associated kidney disorders are various and the list is still expanding. The kidney disorders can manifest as glomerular diseases, tubulopathies, and vascular involvement with varying clinical presentations. Diagnosis is often challenging because of the wide spectrum of MGRS, and it is difficult to establish a pathogenic link between the presence of the M-protein or serum free light chains and kidney diseases; further complicating accurate diagnosis is the high incidence of MGUS and/or kidney disorders, independent of MGRS, in elderly patients. However, MGRS can significantly impair kidney function. Because treatment can stop and also reverse kidney disease, early recognition is of great importance. A combined haematologic and nephrologic approach is crucial to establish the causative role of the M-protein in the pathogenesis of kidney disease. Clone-directed therapy, which may include autologous stem cell transplantation in eligible patients, often results in improved outcomes. In this review, we discuss the histopathologic classification of MGRS lesions, provide a renal and haematologic diagnostic workup, discuss treatment options for MGRS, and introduce a Benelux MGRS Working Group.