Nederlands tijdschrift voor geneeskunde
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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
Practice Guideline Guideline[Optimizing the antibiotics policy in the Netherlands. IV. SWAB- guidelines for antimicrobial therapy of adults with sepsis in hospitals. Foundation Antibiotics Policy Work Group].
The Stichting Werkgroep Antibioticabeleid (SWAB, Foundation Antibiotic Policy Team) issued guidelines for empirical antimicrobial therapy in the hospital of sepsis in adults. A distinction is made between sepsis in patients with and patients without neutropenia. ⋯ The use of antibiotics with a very broad spectrum, like carbapenems and piperacillin-tazobactam, or antibiotics which can be applied in infections with microorganisms difficult to treat, like quinolones and glycopeptides, is limited in the empirical treatment of sepsis in order to combat development of resistance. It is crucial to streamline antibiotic therapy as soon as the causative agent of the sepsis is known; this includes choosing an antibiotic with the narrowest possible spectrum.
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Persistent abdominal pain in a 15-year-old girl was diagnosed after examination by the GP, the pediatrician, the gynaecologist and finally, the surgeon as rib-tip syndrome. The patient could be treated sufficiently by the injection of local anaesthetics and corticosteroids. In the rib-tip syndrome hypermobility of the lower ribs irritates the intercostal nerves causing pain along the lower edge of the chest. The condition can be established objectively with the aid of fluoroscopy and electrostimulation, electromyography or magnetic stimulation.
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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.