Level of agreement between cardiac output measurements using Nexfin® and thermodilution in morbidly obese patients undergoing laparoscopic surgery.

Morbidly obese patients are at increased risk of intra-operative haemodynamic instability, which may necessitate intensive monitoring. Non-invasive monitoring is increasingly used to measure cardiac output; however, it is unknown whether the weight-based algorithm utilised in these devices is applicable to patients with morbid obesity. We compared the level of agreement and trending ability of non-invasive cardiac output measurements (Nexfin® ) with the gold-standard thermodilution technique in 30 morbidly obese patients undergoing laparoscopic surgery. Bland-Altman analysis revealed a mean (SD) bias of 0.60 (1.62) l.min-1 (limits of agreement -2.67 to 3.86 l.min-1 ) and the precision error was 46%. Polar plot analysis resulted in an angular bias of 2.61°, radial limits of agreement of -60.08° to 49.82° and angular concordance rate was 77%. Both agreement and trending were outside the Critchley criteria for the comparison of cardiac output devices with a gold-standard. Nexfin has an unacceptable level of agreement compared with thermodilution for cardiac output measurement in morbidly obese patients.

Ticking the right boxes: classification of patients suspected of Lyme borreliosis at an academic referral center in the Netherlands.

To provide better care for patients suspected of having Lyme borreliosis (LB) we founded the Amsterdam Multidisciplinary Lyme borreliosis Center (AMLC). The AMLC reflects a collaborative effort of the departments of internal medicine/infectious diseases, rheumatology, neurology, dermatology, medical microbiology and psychiatry. In a retrospective case series, characteristics of 200 adult patients referred to the AMLC were recorded, and patients were classified as having LB, post-treatment LB syndrome (PTLBS), persistent Borrelia burgdorferi sensu lato (s.l.) infection despite antibiotic treatment or no LB. In addition, LB, PTLBS and persistent B. burgdorferi s.l. infection cases were classified as 'definite,' 'probable' or 'questionable.' Of the 200 patients, 120 (60%) did not have LB and 31 (16%) had a form of localized or disseminated LB, of which 12 were classified as definite, six as probable and 13 as questionable. In addition, 34 patients (17%) were diagnosed with PTLBS, of which 22 (11%) were probable and 12 (6%) questionable. A total of 15 patients (8%) were diagnosed with persistent B. burgdorferi s.l. infection, of which none was classified as definite, three as probable and 12 as questionable. In conclusion, in line with previous studies, the number of definite and probable (persisting) LB cases was low. The overall high number of questionable cases illustrates the fact that it can sometimes be challenging to either rule out or demonstrate an association with a B. burgdorferi s.l. infection, even in an academic setting. Finally, we were able to establish alternative diagnoses in a large proportion of patients.

Borrelia burgdorferi sensu lato serology in the Netherlands: guidelines versus daily practice.

The purpose of this study was to compare guideline recommendations and day-to-day practice of serological testing for Lyme borreliosis (LB) in a laboratory located in Amsterdam, the Netherlands, serving both regional hospitals and primary care physicians. By telephone interview, we obtained clinical information regarding 488 requests for LB serology. Screening for LB was performed with a C6-peptide EIA and confirmed by recombinant immunoblot. A total of 82 % of the requests were not supported by guideline's recommendations and either originated from patients with atypical symptoms and a low a priori chance for LB or from patients for which testing on LB was not recommended for other reasons. C6-EIA screening was positive in 5 % of patients with atypical symptoms, comparable to the seroprevalence in the Dutch population. Interestingly, 10 % of the requests were from patients with atypical skin lesions, of which 20 % was positive, suggesting that serological testing is of additional value in a selection of such patients. Strikingly, only 9 % of the requests were supported by recommendations by guidelines. The percentage of positive confirmatory IgM and/or IgG immunoblots did not differ substantially between the groups and ranged from 56 to 75 %. Guidelines for testing for LB are not adequately followed in the Netherlands. Better education and adherence to the guidelines by physicians could prevent unnecessary diagnostics and antibiotic treatment of supposed LB patients.

[Lyme disease]. / De ziekte van Lyme.

Lyme disease, or Lyme borreliosis, is the most prevalent vector-borne illness in the United States of America and Europe. In the Netherlands, the disease is endemic with an estimated yearly incidence of 133 cases per 100.000 inhabitants. Lyme disease is caused by spirochetes of Borrelia burgdorferi sensu lato and transmitted by Ixodes ticks. Diagnosing the different manifestations of Lyme disease is based on a history of possible exposure to ticks, the appearance of specific clinical symptoms, exclusion of other causes of the symptoms, whether or not combined with serological or other diagnostics tests. Antibiotics are effective in all Lyme disease manifestations and, generally, patients have a good prognosis.

Tired of Lyme borreliosis. Lyme borreliosis in the Netherlands.

Lyme borreliosis has become the most common vector-borne illness in North Eastern USA and Europe. It is a zoonotic disease, with well-defined symptoms, caused by B. burgdorferi sensu lato, and transmitted by ticks. Lyme borreliosis is endemic in the Netherlands with a yearly incidence of approximately 133 cases/100,000 inhabitants. Similar to another spirochetal disease, syphilis, it can be divided into three stages; early, early disseminated and late disseminated manifestations of disease, of which the specific clinical presentations will be discussed in detail. The diagnosis of Lyme borreliosis is based on a history of potential exposure to ticks and the risk of infection with B. burgdorferi s.l., development of specific symptoms, exclusion of other causes, and when appropriate, combined with serological and/or other diagnostic tests. The specific indications for, but also the limitations of, serology and other diagnostic tests, including the polymerase chain reaction (PCR), are detailed in this review. Lyme borreliosis is treated with antibiotics, which are usually highly effective. Recent literature discussing the indications for antibiotic treatment, the dosage, duration and type of antibiotic, as well as indications to withhold antibiotic treatment, are reviewed. This review presents the most recent, and when available Dutch, evidence-based information on the ecology, pathogenesis, clinical presentation, diagnosis, treatment and prevention of Lyme borreliosis, argues against the many misconceptions that surround the disease, and provides a framework for the Dutch physician confronted with a patient with putative Lyme borreliosis.