Nederlands tijdschrift voor geneeskunde
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Ned Tijdschr Geneeskd · Jan 2013
Review[Guideline 'Wound Care': recommendations for 5 challenging areas].
The interdisciplinary evidence-based guideline 'Wound Care' covers the treatment and management of acute wounds in adults and children and by all wound care disciplines. This guideline answers 5 basic questions with 38 recommendations covering wound cleansing, pain relief, instructing the patient, various dressings and the organisational aspects of wound care. The guideline recommendations include not to cleanse wounds that are primarily closed, to cleanse acute open wounds with clean tap water, to use the WHO pain ladder as the basis for the choice of analgesics for continuous wound pain, to administer lidocaine or prilocaine for localized pain relief during manipulation, not to cover primarily closed wounds with dressings, to use simple dressings for open wounds and to give the patient clear instructions. The guideline also advises about wound registration, documentation and hand-over of wound care, and recommends making clear agreements about referrals and responsibilities.
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2 types of infusion solutions are used for volume replacement: crystalline fluids (such as NaCl 0.9% and lactated Ringer's solution) and colloidal fluids made of hydroxyethyl cellulose, albumin or gelatine. The choice of fluids used appears to be determined by the personal preference of the physician or the department. Infusion of colloidal solutions results in rapid recovery of the circulating volume but can cause anaphylaxis, renal insufficiency and an increased bleeding tendency. ⋯ Gelatin-based infusion fluids have not yet been extensively studied. The balanced lactated Ringer's solution, the composition of which is closer to plasma than that of NaCl 0.9%, is being used with ever-increasing frequency. Lactated Ringer's infusion solution does not cause hyperchloremic acidosis and probably less often leads to renal insufficiency than when NaCl 0.9% is infused.
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Ned Tijdschr Geneeskd · Jan 2013
Review[Treatment of cartilaginous defects in the knee: recommendations from the Dutch Orthopaedic Association].
Cartilaginous defects in the knee occur frequently and can cause the patient considerable limitations. They are diagnosed and classified by means of MRI and arthroscopy. The surgical options available to treat deep chondral lesions include bone marrow stimulation techniques (microfracture treatment), chondrocyte therapies (autologous chondrocyte implantation) and tissue replacement therapies (osteochondral autologous transplantation). ⋯ Autologous chondrocyte implantation is a suitable method for treating single symptomatic chondral lesions larger than 2 cm2 in adults up to 50 years of age. There are no significant differences regarding the effectiveness of microfracture treatment, autologous chondrocyte implantation and osteochondral autologous transplantation for small defects: all show good clinical and functional short- and medium-term results. New second- and third-generation autologous chondrocyte implantation techniques seem to yield more sustainable tissue repair and better clinical long-term results for lesions larger than 4 cm2 in comparison to microfracture treatment.
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Ned Tijdschr Geneeskd · Jan 2013
Review Case Reports[Therapy resistant diabetes mellitus and lipodystrophy: leptin therapy leads to improvement].
Lipodystrophy is a congenital or acquired disorder characterized by complete or partial absence of subcutaneous fat tissue, often accompanied by insulin resistance, diabetes mellitus (DM), hypertriglyceridemia and hepatic steatosis. A decrease in both number and function of adipocytes leads to ectopic fat depositions and decreased production of adipokines such as leptin. We present 2 patients with inadequately regulated DM, hypertriglyceridemia and hepatic steatosis who were eventually diagnosed with lipodystrophy: 1 with congenital generalized lipodystrophy (Berardinelli-Seip syndrome) and 1 with congenital partial lipodystrophy (Dunnigan syndrome). ⋯ This resulted in improved plasma levels of triglyceride, glucose and HbA1c and a decrease in liver size. In addition, hepatic triglyceride content decreased from 19.3% to 1.3% in the first patient and from 20.6% to 12.4% in the second. Leptin therapy is an effective and safe treatment for therapy-resistant diabetes and hypertriglyceridemia in patients with congenital lipodystrophy.
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In a reasonably large proportion of patients who take antihypertensive drugs (10-30%), hypertension appears to be therapy resistant; even the use of three antihypertensives does not lower the blood pressure sufficiently. The average nocturnal blood pressure is a better predictor of cardiovascular events than blood pressure measured during the day. ⋯ The exact mechanism of this has not yet been unravelled, but randomised, non-blinded studies suggest that this so-called chronotherapy does indeed lower cardiovascular risk in certain groups. The authors regard this as a promising strategy for patients with therapy-resistant hypertension in whom a nocturnal blood pressure dip does not occur.