Nederlands tijdschrift voor geneeskunde
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Ned Tijdschr Geneeskd · May 1999
Comment Review[Sedation by non-anesthesiologists should be centralized for considerations of safety].
Sedation and analgesia for diagnostic or therapeutic procedures outside the operating room by non-anaesthesiologist physicians is becoming more frequent. In reaction to sedation casualties a multidisciplinary committee organized by the National Organization for Quality Assurance in Hospitals (CBO) has developed guidelines for sedation and analgesia by non-anaesthesiologists for psychologically or physically distressing diagnostic and therapeutic procedures. ⋯ It may be expected that with these guidelines sedation and analgesia by non-anaesthesiologists will increase further. With a view to the safety of the patient diagnostic and therapeutic procedures which require sedation for psychological or physical reasons should be concentrated in a diagnostic/therapeutic complex, connected to the operating complex, where it is possible to consult the expertise of an anaesthesiologist.
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Ned Tijdschr Geneeskd · Mar 1999
Review[Selective decontamination of the digestive tract reduces mortality in intensive care patients].
Selective decontamination of the digestive tract (SDD) is a strategy designed to prevent or minimize the impact of infections by potentially pathogenic micro-organisms in critically ill patients requiring long-term mechanical ventilation. SDD is a four-component protocol to control the three types of infections occurring in intensive care patients: (a) a parenteral antibiotic, cefotaxime, for a few days to prevent primary endogenous infections that generally occur 'early'; (b) the topical antimicrobial drugs colistine (polymyxin E), tobramycin and amphotericin B (together: PTA) used throughout the stay in the intensive care unit (ICU) to prevent secondary endogenous infections developing in general 'late'; (c) a high standard of hygiene to prevent exogenous infections that may occur throughout the ICU stay; (d) surveillance samples of throat and rectum to distinguish between the three types of infection, to monitor compliance and efficacy of treatment and to detect emergence of resistance at an early stage. ⋯ It failed to detect any report on the emergence of resistance and associated superinfections and/or out-breaks in the 33 studies covering a period of more than 10 years. Using the criterion of cost-per-survivor, four recent randomised trials showed that it is cheaper to produce a survivor using SDD than with the traditional approach.
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Ned Tijdschr Geneeskd · Mar 1999
Review Case Reports[Acute severe headache: a subarachnoidal hemorrhage?].
Five patients, three women aged 87, 50, and 31 years, and two men aged 31 and 32 years, presented with severe headache of sudden onset. A sudden onset of unusually severe headache is suggestive of an intracranial haemorrhage or other serious disease, even in the absence of focal neurologic deficits. ⋯ There are no characteristics from history or examination that accurately discriminate among all these causes; idiopathic thunderclap headache and subarachnoid haemorrhage are commonest. Consultation of a neurologist and further ancillary investigations are necessary for proper diagnosis and treatment.
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Ned Tijdschr Geneeskd · Mar 1999
Review[Roaming through methodology. XII. Pragmatic and pathophysiologic trials: a question of goal formulation].
The design of clinical trials depends on the research question. In pragmatic trials the research question is: 'How do I treat patients with this disease?' In explanatory trials this question is: 'What is the mechanism of this new treatment?' Pragmatic trials are characterised by liberal patient selection, open treatment modalities corresponding with regular care, outcome measures considered from the patient's perspective and intention-to-treat analysis. In explanatory trials patient selection is strict and treatment is double-blind and pathophysiologically pure. Often proxy outcome measures are used and emphasis is on per protocol ('on treatment') analysis.
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Ned Tijdschr Geneeskd · Feb 1999
Review[Management and choice of antibiotics for patients with an allergy to penicillin].
Allergic reactions to penicillin occur in 0.7-8% of treatments. Management of bacterial infections in patients allergic to penicillin depends on the availability of alternative antibiotics and on the type of allergy. Skin tests can be used to exclude the risk of IgE-mediated reactions (e.g. anaphylaxis) to subsequent penicillin administration. If penicillin is the first choice for treatment and the patient has an IgE-mediated allergy (on the basis of a positive skin test), desensitization therapy to the drug can be performed.