Nederlands tijdschrift voor geneeskunde
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About 15% of hospital admissions of elderly patients in the Netherlands are caused by adverse effects of drugs. With polypharmacy there is an increased chance of adverse effects occurring. It is not always possible to reduce polypharmacy in the elderly. ⋯ The most important pharmacodynamic changes in the elderly concern an increased sensitivity of the target organ. This is particularly the case for substances which have an effect on the central nervous system, such as antidepressants and antipsychotics, but also applies to benzodiazepines, coumarin derivatives and digoxin. When an unexpected adverse effect occurs in a patient or a previously effective therapy suddenly fails, it is wise to consider drug interaction as a possible cause.
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In the resuscitation guidelines revised by the Netherlands Resuscitation Council, the decision has been made to conform with the resuscitation flowchart used elsewhere in the world, and to use the ABC sequence: 'airway-breathing-circulation'. This implies that the CAB sequence ('circulation-airway-breathing'), which has been in use since 1981, has been abandoned. Intrinsic arguments in favour of the CAB scheme are based on animal experiments and observations in humans. ⋯ In addition, this scheme is better suited to the relatively large group of patients with a cardiac cause underlying their loss of consciousness, and to the preference of lay people to limit themselves to heart massage when attending the patient. Intrinsic arguments in favour of the ABC scheme are not based on scientific data. They concern improvement of the ventilation-perfusion ratio with the first heart massage, oxygenation of the blood in the lung capillaries, improvement of the circulation and the palpability of pulses.
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In 2002, the Netherlands Resuscitation Council published a translation of guidelines on Basic Life Support, use of the Automated External Defibrillator, and Advanced Life Support for adults and children, as laid down in 2000 by the International Liaison Committee on Resuscitation. The Dutch situation has altered in that there has been a change from the Netherlands-specific 'CAB' scheme to the internationally accepted 'ABC' scheme. This means that upon encountering a patient, the airways should be checked first (A), then artificial ventilation should be administered twice (B), after which the circulation should be checked in the third place (C) and chest compression should be initiated if necessary. ⋯ Regardless of the number of people attending the patient, the ratio of chest compressions to artificial ventilation in adults is now 15:2 rather than the previously-advocated ratio of 5:1. This ratio is more effective in building up the blood pressure during the chest compressions. In terms of medication, the most important modification is the addition of amiodarone for persistent ventricular fibrillation.
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Pneumococcal pneumonia and bacteraemia are an important cause of morbidity and mortality, especially in a number of risk groups. On the basis of data from available literature, there is no convincing evidence that vaccination of such risk groups, including all people over 65, with a polyvalent vaccine of pneumococcal capsular polysaccharides in addition to influenza vaccination offers any additional protection against the risk of acquiring pneumococcal pneumonia. There is adequate evidence that pneumococcal vaccination does protect against invasive infections and that in this respect vaccination of all elderly persons could be cost-effective. ⋯ Therefore a well-considered assessment of the cost-effectiveness of applying such a strategy in the Netherlands is not yet possible. Vaccination of (imminent) immuno-compromised persons is only effective and of value if an adequate antibody response can be expected. There is as yet no proven advantage of vaccination with a conjugate vaccine in adults.