[Clostridium difficile outbreak in surgical wards]
van Dalen T. van Dijk Y. Kaan JA. Diepersloot RJ. Leguit P.
Afd. Chirurgie, Diakonessenhuis, Utrecht.
OBJECTIVE: To evaluate the clinical consequences of a hospital outbreak of Clostridium difficile infections in the Netherlands. DESIGN: Descriptive. SETTING: Diakonessen Hospital Utrecht, the Netherlands. METHODS: In the period from 1 August 1995 to 1 September 1996 C. difficile infections were recorded (gastrointestinal symptoms after use of antibiotics and findings at C. difficile toxin assay in faeces, or sigmoidoscopy). The monthly incidence of infections increased to 5 patients in December 1995; at that time strict hygienic measures were implemented and perioperative antimicrobial prophylaxis was adjusted. Data on the clinical course were collected retrospectively from the records of the patients involved. RESULTS: In 20 patients, admitted for various reasons to the surgical wards, hospital stay was complicated by a C. difficile infection. The mean age was 70 years. Eleven patients presented with diarrhoea, eight patients had nausea and vomiting as well. Diagnosis was confirmed by C. difficile toxin determination in most patients (n = 15). Despite antibiotic treatment in 19 patients, recurrences were seen in five patients (25%) and five patients died (25%). The monthly incidence declined to 0-1 per month. CONCLUSION: C. difficile infections in surgical patients carry a significant morbidity and mortality. Preventive hygienic measures are important to control spread of the infection.
[Measurement of colon transit time useful in the evaluation of functional constipation]
Mollen RM. Claassen AT. Kuijpers JH.
Academisch Ziekenhuis, Afd. Heelkunde, Nijmegen.
OBJECTIVE: To determine the colon transit time (CTT) in patients complaining of functional constipation and the correlation between abnormal transit times and the types of constipation and of the symptoms. DESIGN: Retrospective, descriptive. SETTING: Department of Surgery, University Hospital, Nijmegen, the Netherlands. METHOD: The signs and symptoms of 112 patients with infrequent or difficult defaecation, 93 (83%) of them women, with a median age of 42 years (range: 16-72), were recorded by means of a questionnaire. After ingestion of radiopaque markers per day for 10 days, an abdominal survey X-ray was made on day 11. The numbers of markers in the X-ray and per segment (right and left hemicolon and rectosigmoid) were counted; the CTT in hours was calculated by multiplying this number by 2.4. Slowness was defined as more than 45 h for the total CTT and as more than 15 h for the segmental CTT. RESULTS: The total CTT was normal in 33 patients (29%) and prolonged in 79 (71%). The CTT was prolonged only in the rectosigmoid in 14 patients with a normal CTT (42%) and in 50 patients with a prolonged total CTT (63%). Of the patients with a normal total CTT, 13 (39%) had a normal segmental CTT. No statistically significant correlation could be demonstrated between the presence of any symptom and a prolonged CTT. CONCLUSION: Functional constipation may be associated with a normal CTT. Disorders of colonic motility and of rectal evacuation could be distinguished by measuring the total and the segmental colonic transit times.
[Treatment of restlessness in dying patients: more than just sedation]
Jacobs WM. Thiesbrummel AW. Zylic Z.
Katholieke Universiteit, faculteit der Geneeskunde, Nijmegen.
Restlessness can make dying unnecessarily difficult, not only for the patient himself, but also for his family and the physician in charge. Four cancer patients, three men aged 69, 80 and 66 and a woman aged 88, displayed severe terminal restlessness, caused by nicotine abstinence, hypoglycaemia, constipation and urinary retention, respectively. Suitable interventions helped the patients to die in peace and dignity. Facing restless terminal patients the physician should think of withdrawal symptoms, metabolic derangements, full bladder and (or) rectum and intoxication by drugs, frequently morphine. Interventions directed at those problems may bring surprising results.
[Acute pancreatitis in children]
Rottier BL. Holl RA. Draaisma JM.
St. Elisabeth Ziekenhuis, afd. Kindergeneeskunde, Tilburg.
Acute pancreatitis is probably commoner in children than was previously thought. In children it is most commonly associated with trauma or viral infection. The presentation may be subtler than in adults, requiring a high index of suspicion in the clinician. In three children, two boys aged 4 and 10 and a girl of 15 years, acute pancreatitis was suspected because of the findings at ultrasonography and endoscopic retrograde cholangiopancreatography performed when the disease recurred (the boy aged 4), apathy and immobility without dehydration or other obvious causes (the boy aged 10), and severe abdominal pain in combination with vomiting (the girl). All three patients had severely increased (urinary) amylase levels. Most often, acute pancreatitis in children tends to be a self-limiting disease which responds well to conservative treatment.
[Hepatic steatosis during treatment with zidovudine and lamivudine in an HIV-positive patient]
ter Hofstede HJ. Koopmans PP. van Haelst UJ.
Afd. Algemeen Inwendige Geneeskunde, Academisch Ziekenhuis, Nijmegen.
A 33-year-old HIV-infected man was given antiretroviral therapy with zidovudine and lamivudine. After ten months' treatment the patient had elevated hepatic transaminase levels. Severe hepatic steatosis was found in the biopsy. Clinical history, laboratory, microbiologic and X-ray examination revealed no other abnormalities. The transaminase levels remained high after withdrawal of zidovudine alone, but a decrease was observed when both zidovudine and lamivudine were stopped. Rechallenge of lamivudine therapy caused the levels to increase again. The hepatic steatosis was considered to be caused by the antiretroviral therapy, lamivudine having a synergistic influence on this side effect of zidovudine. Ten months after the therapy was changed to the protease inhibitor indinavir combined with zalcitabine and stavudine, two other nucleoside analogues, hepatic steatosis recurred.
[Hepatitis A epidemic in Heerlen in late 1996, importance of immunization in immigrant children]
GGD Oostelijk Zuid-Limburg, Heerlen.
OBJECTIVE: Description of a local epidemic of hepatitis A in 1996 in Heerlen, the Netherlands. DESIGN: Descriptive. SETTING: Regional Health Service Oostelijk Zuid-Limburg, Heerlen, the Netherlands. METHOD: Semistructured questions were asked by telephone of patients, patients' parents, general practitioners, the day-care centre manager and the head of the primary school, to collect information about cases. RESULTS: In the last four months of 1996, 41 persons (23 children and 18 adolescents and adults) were infected in a city of some 50,000 inhabitants. The primary case was most likely a three-year-old boy from Moroccan parents, who prior to his disease had visited his family in Morocco and although non-immune had not been immunised. From the boy's family the virus spread to a day-care centre and a primary school. In this epidemic patients of 15 different general practitioners were affected. An intervention with hepatitis A immunoglobulin in the day-care centre and primary school and immunoglobulin prophylaxis in affected families was effective in halting the epidemic. CONCLUSION: Special attention is needed for immunisation of children of travelling immigrant parents. Immunoglobulin prophylaxis in affected families and notification of cases to the regional health institute by general practitioners may prevent cases. Serological notification by the regional laboratory as well as notification of infectious diseases by day-care centres and schools will add to the regional infection surveillance and control.
[Pharmacotherapeutic compass 1998]
van Oppenraay ML. van der Beek CM. de Boer JE. Danz M. Schutte MK. Verduijn JP.
Centrale Medisch Pharmaceutische Commissie, Amstelveen.
The Central Medical Pharmaceutical Committee of the Health Insurance Council informs the medical profession annually about the effects of drugs through the Pharmacotherapeutical Compass. The 1998 edition now contains a chapter on pharmacokinetics as well. Compared with previous editions the main alterations of the contents concern an introduction and advice on the antidepressants, two protocols with respect to the medical treatment of patients suffering from epilepsy, advice with respect to oral drugs for the treatment of inflammatory bowel disease, an introduction and advice regarding the treatment of allergic rhinitis, the treatment of patients suffering from AIDS with antiretroviral drugs, the treatment of genital herpes, the taking of insulin lispro by patients with diabetes and the taking of bisphosphonates to prevent or to treat osteoporosis. Two corrections to the 1998 edition are given.
[Improved prognosis of functional abdominal complaints by attending to psychic factors]
van Dulmen AM. Fennis JF. Bleijenberg G.
Katholieke Universiteit, vakgroep Huisarts-, Sociale en Verpleeghuis-geneeskunde, Nijmegen.
OBJECTIVE: To determine the assessment by physicians of psychic factors in patients with functional abdominal complaints, and the relationship between the assessment and the evolution of the abdominal complaints. DESIGN: Prospective, descriptive. SETTING: Outpatient Clinic Internal Medicine, University Hospital Nijmegen, the Netherlands. METHODS: 120 patients with functional abdominal complaints were asked to indicate by questionnaires the severity and meaning of their complaints prior to and at the end of the visits to their internist. Internists were asked how they rated the somatic and non-somatic complaint dimensions in their patients. RESULTS: Overall, internists perceived the severity and details of the abdominal complaints correctly. Prognostically unfavourable complaint-related cognitions and emotions were perceived less correctly. During the outpatient consulting period, patients' anxiety and somatic attributions diminished, especially when the internist had perceived these aspects correctly. Six months after the first outpatient visit the abdominal complaints of these reassured patients had improved, compared with patients with persistent somatic attributions; the latter made more frequent use of health care services at follow-up (GP visits, drug use). CONCLUSION: Systematic exploration of somatic and non-somatic complaint dimensions by physicians could be an important tool in improving the prognosis and diminishing the medical consumption in patients with functional abdominal complaints.
[The pathophysiology and treatment of cholestatic pruritus]
Wolfhagen FH. Engelkens HJ. van Buuren HR.
Afd. Interne Geneeskunde, Ikazia Ziekenhuis, Rotterdam.
Pruritus is a frequent, distressing and sometimes disabling symptom of liver and biliary tract disorders. Results of treatment are sometimes disappointing and the pathophysiology is still largely unknown. It was recently discovered that endogenous opioids contribute to the perception of itching and that opiate receptor antagonists can reduce the overstimulation of these receptors and thereby attenuate the itching. A stepwise treatment strategy focusing successively on ion exchange resins, rifampicin and opiate receptor antagonists leads to effective alleviation of itching in most patients.
[Preconception screening of parents and carrier state of cystic fibrosis in the Netherlands: expenses and savings]
Verheij JB. Hilderink HB. Verzijl JG. Wildhagen MF. Habbema JD. ten Kate LP.
Rijksuniversiteit, vakgroep Medische Genetica, Groningen.
OBJECTIVE: To evaluate effects, costs and savings for a preconceptional couple screening programme for cystic fibrosis (CF) carriers. SETTING: State University Groningen, the Netherlands. DESIGN: Prospective theoretical evaluation. METHOD: A decision tree and an arithmetic model were constructed for two different strategies of preconceptional CF screening of couples: 'single entry two step' (SETS; start by testing one partner), and 'double entry two step' (DETS; test both partners). The difference between costs of screening and costs of CF illness prevented by screening was determined. RESULTS: DETS couple screening with the assumptions used for e.g. sensitivity and use of options can detect 81.5% of carrier couples in the Netherlands (against 70% for SETS), but results in twice as many positive/negative couples as SETS couple screening. The maximum number of carrier couples identified when screening 100,000 couples would be 88, resulting in a decrease of the number of children with CF of 25 each year. The costs of screening equal the savings if approximately 8,000 couples are screened yearly in the Netherlands. CONCLUSIONS: There are no financial objections to preconceptional couple screening in the Netherlands, even with an uptake ratio of around 10%. Whether screening for CF carriers should be offered or not should be decided on the basis of non-financial arguments.
[Sealing esophagobronchial fistulae: better results with self expanding stents than with an esophagobronchial fistula]
Kooijman W. Taal BG. Boot H.
Nederlands Kanker Instituut/Antoni van Leeuwenhoek Ziekenhuis, afd. Gastro-enterologie en Medische Oncologie, Amsterdam.
OBJECTIVE: To compare the results of plastic endoprostheses and of self expanding stents in patients with an esophagobronchial fistula. DESIGN: Retrospective, descriptive. SETTING: Nederlands Kanker Instituut/Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, the Netherlands. METHOD: Forty-two patients with an esophagobronchial fistula caused by a malignant tumour in the oesophagus, lungs or mediastinum were fitted with an endoprosthesis during the period 1 January 1991-31 August 1995. Use was made initially of a plastic endoprosthesis with a special tulip funnel (n = 24), later of a coated self expanding stent (n = 18). In seven patients, the fistula had been the first manifestation of the tumour; in 35, a recurrence after earlier treatment was involved. The initial characteristics (sex, age, diagnosis, earlier therapy, signs and symptoms) were the same in both groups. RESULTS: Dilatation immediately before insertion of a plastic endoprosthesis was necessary in 23 patients (96%); such dilatation was necessary in four of the patients (22%) fitted with a self expanding stent. Complete sealing of the fistula was achieved in 19 (79%) and 15 (83%) patients, respectively. Reoperations were necessary in eight (33%) and three (17%) patients. Early major complications occurred in four (17%) and two (11%) patients. CONCLUSION: The selfexpanding stent was faster and easier to insert than a plastic endoprosthesis, and effective in sealing an oesophagobronchial fistula.
[Twenty years of childhood coeliac disease in the Netherlands: more diagnoses and a changed clinical picture]
George EK. Mearin ML. Kanhai SM. Franken HC. Houwen RH. Hirasing RA. Vandenbroucke JP.
Leiden Universitair Medisch Centrum.
OBJECTIVE: To assess the incidence of childhood coeliac disease in the Netherlands and to study the clinical features. DESIGN: Prospective. SETTING: Leiden University Medical Centre, Leiden, the Netherlands. METHOD: Cases of childhood coeliac disease in the Netherlands in 1993-1995 were identified by means of the Dutch Paediatric Surveillance Unit. Inclusion criteria were: birth in the Netherlands, diagnosis with at least one small bowel biopsy in 1993-1995 and age at diagnosis 0-14 years. The data were cross checked with the Dutch Network and National Database of Pathology and compared with data from a previous study on childhood coeliac disease, 1975-1990. RESULTS: 297 Coeliac patients were identified by means of the Surveillance Unit, another 32 through the National Database of Pathology. The mean crude incidence rate of diagnosed childhood coeliac disease was 0.51/1000 live births, which was in the range of rates found in other West European countries and significantly higher than the mean crude incidence rate of 0.18/1000 live births found in the Netherlands in 1975-1990. The clinical presentation was classic up to 1990: chronic diarrhoea, abdominal distention and growth failure. From 1993 onward, however, the number of children with chronic diarrhoea and abdominal distention decreased significantly and the number with weight loss, anaemia and abdominal pain increased. Associated disorders were present in 13.7% of the cases. CONCLUSIONS: The incidence of diagnosed childhood coeliac disease in the Netherlands showed a tendency to increase significantly during the past decade. In a period of 20 years a significant trend toward change in the clinical presentation of coeliac disease in Dutch children was observed.
[Mycobacterium genavense infection in 2 HIV seropositive patients in Amsterdam]
Kuijper EJ. de Witte M. Verhagen DW. Kolk AH. van der Meer JT. Dankert J.
Universiteit van Amsterdam, Academisch Medisch Centrum, Amsterdam.
Two patients with an HIV-I infection, a man aged 47 with confusion, aphasia and diarrhoea, and a man aged 32 with dysphagia, a non-productive cough and diarrhoea, were diagnosed as having a disseminated Mycobacterium genavense infection. Both had low counts of CD4+ T lymphocytes. They responded to antimycobacterial treatment. M. genavense was recognized in Geneva in the early nineties as a causative agent of disseminated mycobacterial infections in HIV-seropositive patients with poor cellular immunity. The clinical picture resembles that of a generalized infection with M. avium-intracellulare. M. genavense is a slowly growing mycobacterium which can be isolated and identified using enriched nutrient media and molecular-biological techniques. The infection probably begins in the gastrointestinal tract after oral contamination. DNA of M. genavense can be demonstrated in 25% of the intestinal biopsy samples of non-HIV-seropositive patients.
[Right-sided diverticulitis mimicking acute appendicitis]
Lucas IS. Ibelings MS. Schouten WR. Bonjer HJ.
Afd. Algemene Heelkunde, Academisch Ziekenhuis Rotterdam-Dijkzigt.
The probability diagnosis in two patients, women aged 43 and 41 years, who for the last few days had had pain in the right lower abdomen, without nausea or vomiting, was acute appendicitis; a third patient, a woman aged 49 with the same symptoms, had undergone appendectomy in the past. Peroperative findings and, in two patients, microscopy of the resected specimen showed diverticulitis in the caecum or ascending colon. This is an uncommon disease, which mimicks acute appendicitis. Treatment depends on the severity of the inflammation. In the absence of perforation or abscess, conservative treatment suffices. Otherwise, resection of the colon is necessary.
[Reflux esophagitis; is the preventive eradication of Helicobacter pylori needed in patients on omeprazole?]
Kuipers EJ. Klinkenberg-Knol EC. Festen HP. Meuwissen SG.
Academisch Ziekenhuis Vrije Universiteit, afd. Gastro-enterologie, Amsterdam.
The pattern of Helicobacter pylori gastritis depends on acid secretion. Profound acid suppressive therapy with proton pump inhibitors leads to a decrease of antral gastritis, but an increased severity of corpus gastritis. As such, maintenance therapy with these drugs for gastroesophageal reflux disease has consistently been associated with an increased incidence of atrophic gastritis in H. pylori infected patients. For this reason, the preventive effect of H. pylori eradication in these patients needs to be considered; this is being studied in prospective trials.
[Nothing gained from the determinations of plasma lactate levels in the evaluation of a patient with acute abdomen]
Vahl AC. Out NJ. Kapteijn BA. Koomen AR.
Kennemer Gasthuis, afd. Chirurgie, Haarlem.
OBJECTIVE: To establish the diagnostic value of laboratory tests, especially the plasma lactate concentration, for determination of the indication for acute surgery in patients with an acute abdomen. DESIGN: Cross-sectional study. SETTING: Kennemer Gasthuis, location Elisabeth Gasthuis, Haarlem, the Netherlands. METHOD: The study group consisted of all 200 successive patients presenting at the emergency room with acute abdomen from June 1993 to December 1994 (19 months). Patients with suspected acute appendicitis were excluded. The diagnosis and indication for surgery if any were based on case history, physical examination, radiological examination if performed and standard laboratory tests: ESR, leukocyte count, haemoglobin, creatinine and amylase. The first matter considered was to what extent the indication for acute operation based on these clinical criteria was in agreement with the diagnosis at discharge. The next question studied was what would be the extra value of the plasma lactate concentration which, although determined, had not been reported to the clinician. Statistical analysis was performed using the two-sample Student t test and the chi 2 test. A p-value of < 0.05 was regarded as statistically significant. RESULTS: Fifty-four patients were operated within 24 hours for good reasons, six were incorrectly not operated within 24 hours, 128 correctly received conservative treatment and 12 were correctly treated conservatively and subsequently underwent operation after longer than 24 hours. Diagnostics based on the clinical criteria had a sensitivity of 90%. The mean plasma lactate concentration, temperature and ESR were statistically significant more often increased in the operated patients than in those treated conservatively. The sensitivities of these determinations were 75%, 67% and 40% (all: p < 0.05). The lactate concentration was increased in 50% of the patients who in retrospect had incorrectly not been subjected to acute surgery. CONCLUSION: Neither determination of the plasma lactate concentration nor the results of the separate standard laboratory tests in acute abdomen patients resulted in a better sensitivity for the determination of an indication for acute surgery than clinical examination combined with standard laboratory tests and, if desired, supplementary radiology.
[Clinical presentations mimicking acute myocardial infarction; therapeutic pitfalls]
Elsman P. Alleman MA. Zijlstra F.
Afd. Cardiologie, Ziekenhuis De Weezenlanden, Zwolle.
Acute myocardial infarction remains one of the commonest causes of death. The pathogenesis is usually an occluding thrombus superimposed on a ruptured atherosclerotic plaque. However, several cardiac as well as non-cardiac diseases may give a presentation remarkably similar to acute myocardial infarction. Four patients are described, one woman aged 56 and three men aged 72, 63 and 60 years, who displayed the typical symptoms and ECG signs of acute myocardial infarction. The real conditions, however, were gallstones in two, a phaeochromocytoma in one and myocarditis in one. Two patients died, partly as the consequence of the failure to arrive at the correct diagnosis in time; the other two patients after adequate treatment were discharged in good condition.
[Clinical reasoning and decision making in the practice. A woman with abdominal complaints]
Bosch FH. de Meijer PH.
Ziekenhuis Rijnstate, afd. Interne Geneeskunde, Arnhem.
A female patient aged 28 years suffered from recurrent episodes of diarrhoea. Giardia lamblia was isolated once. By rigorous application of basic clinical skills, such as thorough history taking and physical examination, together with laboratory tests the correct diagnosis was established (in this patient systemic lupus erythematosus). Two important aspects of clinical reasoning, viz. returning to the patient when new information becomes available (cyclic way of working) and pattern recognition ensured a fruitful diagnostic process.
[The quality of life after stem cell transplantation: problems with fatigue, sexuality, finances and employment]
Hendriks MG. van Beijsterveldt BC. Schouten HC.
Academisch Ziekenhuis, afd. Interne Geneeskunde, Maastricht.
OBJECTIVE: To determine the quality of life in patients after high dose chemo/radiotherapy followed by bone marrow stem cell transplantation for the treatment of a malignancy. DESIGN: Structured questionnaire and in-depth interview. SETTING: Academic Hospital Maastricht, the Netherlands. METHODS: All patients who had undergone stem cell transplantation (SCT) at least 6 months previously (n = 54) were asked to participate in an analysis of their quality of life using the 'Quality of life questionnaire' (QLQ-C30) developed by the European Organization for Research and Treatment of Cancer (EORTC) and an in-depth interview. RESULTS: The EORTC QLQ-C30 was answered by 52 (96%) of the patients and 46 (85%) participated in the interview. The patients were divided in cohorts of 6-24 (n = 16), 25-48 (n = 22) and more than 48 months (n = 14) after SCT. Quality of life was 73.9 on a 100 per cent scale. There were no significant differences between various cohorts after SCT. However, patients transplanted more than 4 years before had significantly more complaints of nausea and vomiting. The structured interview revealed significant problems with fatigue, sexuality, finances and return to work. No clear relation with time elapsed after transplantation was found. CONCLUSION: SCT has a significant impact on several quality of life issues, which should be considered in the application of this modality in palliative situations. The EORTC QLQ-C30 may be helpful to analyse overall quality of life after transplantation, but provides no information on individual effects on quality of life.
[Drug treatment of Crohns disease]
van Deventer SJ. Tytgat GN.
Academisch Medisch Centrum/Universiteit van Amsterdam.
The medical management of Crohn's disease has changed in recent years, but the mainstay of treatment is still prednisone. A substantial fraction of steroid-treated patients are refractory to therapy and addition of azathioprine or methotrexate has a corticosteroid-sparing effect and increases duration of remission. Controlled ileal release budesonide (9 mg daily) induces clinical remission in 60-70% of patients with Crohn's ileitis or right-sided colitis, and continued budesonide treatment has a finite effect on the duration of remission. The efficacy of mesalazine in active Crohn's disease is limited and high doses are required (4000 mg/day). The role of mesalazine in Crohn's disease in remission is disputed, and there is no evidence of a corticosteroid-sparing effect.
[Compartment syndrome in both lower legs after prolonged surgery in the lithotomy position]
Ho GH. van Laarhoven CJ. Ottow RT.
Academisch Ziekenhuis, afd. Chirurgie, Utrecht.
A 35-year-old man developed bilateral compartment syndrome in the lower legs after prolonged colorectal surgery in the lithotomy position. This complication of a prolonged non-physiological operation position is a rare event and the diagnosis is therefore often delayed, with sometimes serious irreversible neuromuscular damage. In this case the complication was successfully treated by four-compartment fasciotomy and forced diuresis (to prevent renal insufficiency caused by myoglobin nephrosis).