Nederlands tijdschrift voor geneeskunde
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Ned Tijdschr Geneeskd · Jan 2012
[Endoscopic versus surgical treatment of infected necrotising pancreatitis: the TENSION study].
In patients with infected necrotising pancreatitis there is a significant risk (40%) of complications and mortality with the surgical step-up approach. This approach consists of percutaneous retroperitoneal drainage, if necessary followed by video-assisted retroperitoneal débridement. ⋯ The Dutch Pancreatitis Study Group has recently started the nationwide randomized TENSION-trial, in which in 98 patients the endoscopic step-up approach is compared with the surgical method. The primary endpoint is a composite of mortality and major morbidity (new onset organ failure, bleeding, perforation of a hollow organ or incisional hernia for which intervention is needed).
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A 56-year-old woman presented with retrograde amnesia and confusion at the Emergency Department after falling down the stairs. Physical examination revealed a bilateral periorbital hematoma (raccoon eyes) and bilateral retroauricular ecchymosis, both strongly indicative of a basilar skull fracture.
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Postoperative pain management is an essential part of surgical management. In the Netherlands paracetamol, NSAIDs and, if necessary, opioids are the most commonly used drugs for perioperative analgesia. Metamizole is a non-opioid analgesic that is rarely used in the Netherlands, although it is one of the most frequently used analgesics around the world. ⋯ Its mechanism of action is still under discussion, but the main action is likely to be an inhibition of prostaglandin synthesis in both peripheral tissues and the central nervous system. Based on the current literature, metamizole deserves a role in the management of post-operative pain in the Netherlands. It seems to be a safe and effective drug for acute pain management especially when compared with NSAIDs.
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Ned Tijdschr Geneeskd · Jan 2012
Case Reports[A heart attack: was the patient lucky or unlucky? Circumstances were favourable but outcome ill-fated].
The assessment of signs and symptoms in primary care is an important but difficult task for general practitioners (GPs) who have to decide whether symptoms require immediate action or rather a watchful waiting approach. However, the GP may sometimes just need a bit of luck. This case report describes how the doctor's luck (in taking the initiative to phone the patient shortly after discharge from a hospital where he had undergone surgery on two coronary vessels) and the luck of the patient (a subsequent cardiac arrest at the GP's office) results in an unsuccessful out-of-hospital resuscitation. Based on our analysis of the literature on the prevalence of cardiac arrests and the outcome of out-of-hospital resuscitation, we will leave it up to the readers to decide whether our patient had been lucky or unlucky.
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Ned Tijdschr Geneeskd · Jan 2012
Review[Revised practice guideline 'Management of patients with mild traumatic head/brain injury'].
Recently the out-of-date Dutch guideline 'Mild traumatic head/brain injury' dating from 2001 was revised under the supervision of the Dutch Institute for Healthcare Improvement (CBO). The revised guideline gives underpinned decision rules for the referral of patients to hospital, carrying out diagnostic imaging investigations, and formulating indications for admission. Mild head-brain injury is no longer an indication for a conventional skull radiograph. ⋯ The guideline can be used in both primary care and on the Emergency Departments of hospitals and is applicable to both adults and children. The guideline does not address the rehabilitation or long-term care of patients with mild traumatic head/brain injury, but it does give advice on reducing the risk of long-term symptoms. Regional implementation of the guideline in primary and secondary care is recommended.