[From the Cochrane Library: ultrasonographic screening for abdominal aortic aneurysm in men aged 65 years and older: low risk of fatal aneurysm rupture]. / Uit de Cochrane Library: echografische screening van aorta abdominalis bij mannen van 65 jaar en ouder: kleiner risico op dodelijke aneurysmaruptuur.

Abdominal aortic aneurysm (AAA) is present in 5-10% of men aged 65-79 years and is often asymptomatic. The major complication is rupture, which requires emergency surgery. The mortality rate after rupture is high: about 80% of those who reach the hospital and 50% of those undergoing emergency surgery will die. Elective surgical repair of AAA aims to prevent death from rupture; the 30-day surgical mortality rate for open surgery is approximately 5%. Currently elective surgical repair is recommended for aneurysms larger than 5-5 cm to prevent rupture. There is interest in population screening to detect, monitor and repair AAA before rupture. A Cochrane systematic review of 4 randomised studies involving 127,891 men and 9,342 women revealed a significant reduction in mortality from AAA in men aged 65-79 years who underwent ultrasonographic screening (odds ratio (OR): 0.60; 95% CI: 0.47-0.78). There was insufficient evidence to demonstrate a benefit in women. Men who had been screened underwent more surgery for AAA (OR: 2.03; 95% CI: 1.59-2.59). These findings should be considered carefully when determining whether a coordinated population-based screening programme should be introduced. A gap in the current research is the balance of benefits and risks in women. Furthermore, detailed studies are needed on how to best provide information on the potential benefits and risks to individuals who are offered screening, and on the psychological effects of screening on patients and their partners.

[From the Cochrane Library: Phosphodiesterase inhibitors are effective in treating erectile dysfunction in diabetic men]. / Uit de Cochrane Library: fosfodiësteraseremmers effectief bij diabetici met erectiestoornissen.

Erectile dysfunction is a common multifactorial complication of diabetes mellitus. In recent years, phosphodiesterase type 5 (PDE-5) inhibitors have been introduced in the management of erectile dysfunction. A recent Cochrane systematic review assessed the effects ofPDE-5 inhibitors in patients with diabetes mellitus and erectile dysfunction from 8 randomized placebo-controlled trials (a total of 1759 participants). The duration of therapy was mainly 12 weeks. The weighted mean difference (WMD) for the International Index of Erectile Function (erectile dysfunction domain) at the end of the study period was 6.6 in favour of the PDE-5 inhibitors arm. The relative risk for answering 'yes' to a global efficacy question ('did the treatment improve your erections?') was 3.8 in the PDE-5 inhibitors arm compared with the control arm. Headache and flushing were the most common adverse events, followed by flu-like symptoms, dyspepsia, myalgia, vision disorders and lower back pain. The overall risk ratio for developing any adverse reaction was 4.8 in the PDE-5 inhibitors arm as compared to the control arm. It was concluded that sufficient evidence exists that treatment with PDE-5 inhibitors can improve erectile dysfunction in diabetic men.

[From the Cochrane Library: Marginally higher chance of cure by antibiotic treatment in acute bacterial conjunctivitis]. / Uit de Cochrane Library: Marginaal grotere genezingskans door antibioticabehandeling bij acute bacteriële conjunctivitis.

Acute bacterial conjunctivitis is one of the most frequently encountered ocular disorders in primary care. It is frequently self-limiting, and the widespread use of broad-spectrum antibiotics has led to concerns regarding antibiotic resistance. Therefore, a Cochrane systematic review of 5 randomised clinical trials that compared antibiotic treatment with placebo in patients with acute bacterial conjunctivitis was recently updated. The chances of clinical and microbiological benefits of topical antibiotics were small but statistically significantly higher compared with placebo in the early stage (2 to 5 days after the first day of the intervention) and late stage (6 to 10 days after the first day of the intervention). The risk of adverse events in patients treated with placebo appeared to be low. Future trials should assess the cost-effectiveness of antibiotic treatment for acute bacterial conjunctivitis.

[From the Cochrane Library: wearing compression stockings during long-distance flights reduces the risk of asymptomatic deep-vein thrombosis]. / Uit de Cochrane Library: door dragen van elastische kousen tijdens langeafstandsvluchten minder kans op asymptomatische diepe veneuze trombose.

A recent Cochrane systematic review assessed the effects of wearing compression stockings during long-distance flights on the risk of deep-vein thrombosis (DVT). Ten randomised trials were included, 9 of which compared wearing compression stockings on both legs during the whole flight (at least 7 hours) with not wearing compression stockings. In these 9 trials, 50 of 2637 participants with 1 week of follow-up had asymptomatic DVT; 3 had worn stockings, 47 had not (odds ratio: 0.10; 95% CI: 0.04-0.25). No deaths, pulmonary emboli or symptomatic DVTs were reported. Wearing stockings had a significant impact in reducing oedema of the lower legs. No significant adverse effects of wearing stockings were reported.

[From the Cochrane Library: topical antibiotic treatment is more effective than systemic antibiotic treatment for chronic otitis media with eardrum perforation and purulent discharge]. / Uit de Cochrane Library: lokale toepassing van antibiotica effectiever dan systemische voor de behandeling van chronische otitis media met geperforeerd trommelvlies en purulente afscheiding.

Chronic suppurative otitis media with underlying persistent eardrum perforation is a common cause of preventable hearing impairment. A Cochrane systematic review compared topical treatment (antibiotics or antiseptics) with systemic antibiotics to identify which is best. Nine randomised controlled trials were included (833 randomised patients; 842 analysed patients or ears). Topical treatment with quinolones was more effective in stopping (purulent) discharge than systemic treatment with quinolones or non-quinolones. No benefit from adding systemic treatment to topical antibiotics was detected. The effects of topical non-quinolone antibiotics or antiseptics were not clear. Little is known about secondary outcomes (prevention of complications, healing the eardrum, and improving hearing) or about the efficacy and safety of topical antibiotics in the long term.

[From the Cochrane Library: postmenopausal hormone replacement therapy (HRT) does not protect women against cardiovascular disease but does lead to an increased risk of venous thromboembolism]. / Uit de Cochrane Library: met postmenopauzale hormonale substitutietherapie geen bescherming tegen hart-vaatziekte, wel meer kans op veneuze trombo-embolie.

Observational studies in the early nineteen-nineties have strongly suggested that hormone replacement therapy (HRT) has benefits for reducing cardiovascular events in postmenopausal women. A recent Cochrane systematic review assessed the effects of HRT in primary and secondary prevention of cardiovascular disease in postmenopausal women from ten randomized placebo-controlled trials published in the last decade. No protective effect of HRT was seen for any of the cardiovascular outcomes assessed. In contrast, higher risks of venous thromboembolic events, pulmonary embolus and stroke were found in postmenopausal women randomized to HRT compared to a placebo. Initiating HRT in postmenopausal women (with or without cardiovascular disease) for the sole reason of preventing cardiovascular disease should not be recommended. Further, in the case of other risk factors for venous thromboembolic events, the use of HRT for preventive purposes should be discouraged.

[From the Cochrane Library: effective measures are available to prevent falls in the elderly]. / Uit de Cochrane Library: effectieve maatregelen beschikbaar voor valpreventie bij ouderen.

Approximately 30% of people over 65 years of age and living in the community fall each year; the percentage is higher in institutions. A fifth of the incidents require medical attention. A Cochrane systematic review of 62 studies, encompassing 21,668 elderly people, showed that several interventions are effective in preventing falls, especially in people who have already fallen once, including multidisciplinary interventions targeting multiple risk factors, individually prescribed muscle strengthening combined with balance training at home, cardiac pacing for hypersensitivity of the sinus node, and withdrawal of psychotropic medication. Individually tailored interventions delivered by a health professional were more effective than standard or group-delivered programmes. Some potential interventions were of unknown effectiveness or unlikely to be beneficial. Examples of these are physical exercises, the use of dietary supplements and the correction of impaired vision.

[From the Cochrane Library: Improvement of photodamaged skin with retinoid creams and not with other local treatments]. / Uit de Cochrane Library: door zonlicht beschadigde huid te verbeteren met retinoïdecrèmes en niet met andere lokale behandelingen.

A Cochrane systematic review of 30 randomised clinical trials assessed the effects of current treatments for adults with mild-to-severe changes in facial and forearm skin that occurred as a result of prolonged exposure to the sun ('photodamage'). Topical tretinoin > or = 0.02% improved the appearance of mild-to-severe photodamage. Tazarotene 0.01-0.1% and isotretinoin 0.1% provided benefit to patients with moderate photodamage. The treatment duration was 4-11 months. Adverse effects were pain and redness. Both the efficacy and adverse effects were dose-dependent. Other treatments, such as polysaccharides, hydroxy acids, surgical procedures and laser, cannot be recommended.

[From the Cochrane Library: both expectant management and curettage are suitable options in case of miscarriage]. / Uit de Cochrane Library: afwachtend beleid en curettage bij miskraam beide geschikte opties.

A Cochrane systematic review of 5 randomised clinical trials compared the safety and efficacy of expectant management versus curettage for early foetal loss. The expectant-care group was more likely to have an incomplete miscarriage, a need of unplanned curettage, and bleeding. In contrast, curettage was associated with a significantly higher risk ofinfection. Given the lack of clear superiority of either approach, the woman's preference should play a dominant role in reaching a decision.

[From the Cochrane Library: brushing the teeth with an electric toothbrush with an oscllating rotating movement more effective against plaque and gingivitis than brushing with a conventional toothbrush]. / Uit de Cochrane Library: elektrisch tandenpoetsen met oscillerende roterende beweging beter tegen tandplaque en gingivitis dan poetsen met een conventionele tandenborstel.

Removing dental plaque plays a key role in maintaining oral health and reducing gingivitis and parodontitis. A systematic Cochrane review ofrandomised controlled trials encompassing participants from the general public with uncompromised manual dexterity showed that when compared to the use of manual toothbrushes, the use of powered toothbrushes with a rotating oscillation action for a period of three months reduced gingivitis and (although not statistically significantly) plaque. The long-term clinical relevance of the differences is unclear. Electric toothbrushes that did not have an oscillating rotating movement were not consistently better than manual toothbrushes.

[From the Cochrane Library: routine membrane sweeping ('stripping') for induction of labor in full-term pregnancies effective, but not always useful]. / Uit de Cochrane Library: routinematig losmaken van de vliezen ('strippen') ter inleiding van de baring bij aterme zwangeren wel effectief, maar niet altijd zinvol.

Sweeping ('stripping') of the membranes has the potential to initiate labour by increasing local production of prostaglandins and, thus, to reduce pregnancy duration or to pre-empt formal induction of labour with either oxytocin, prostaglandins or amniotomy. A Cochrane systematic review of 22 trials (2797 women) comparing membrane sweeping with no treatment, with prostaglandins and with oxytocin revealed that stripping of the membranes was associated with reduced frequency of pregnancy continuing beyond 41 and 42 weeks. To avoid formal induction of labour in one instance, membrane sweeping must be performed in 8 women. Discomfort during vaginal examination and other adverse effects (bleeding, irregular contractions) were reported more frequently by women allocated to sweeping. When used as a means of inducing labour, the reduction in the use of more formal methods of induction must be balanced against the resulting discomfort and other adverse effects.

[From the Cochrane Library: Routine use of nasogastric tubes after abdominal surgery is not effective]. / Uit de Cochrane library: Routinematig gebruik van een maagsonde na een abdominale operatie niet zinvol.

The routine use of nasogastric tubes after abdominal operations is intended primarily to hasten the return of bowel function. A Cochrane systematic review of 28 studies, encompassing 4195 patients (2108 randomised to routine tube use and 2087 randomised to temporary or no tube use), showed that routine prophylactic nasogastric decompression was not effective in achieving its primary goal. It also appeared not to be statistically significantly effective in achieving secondary goals, such as the prevention of pulmonary complications, wound infection, and ventral hernia, nor in increasing patient comfort and shortening hospital stay. Routine nasogastric decompression should be abandoned in favour of temporary use of the nasogastric tube.

[The practice guideline 'Hormonal contraception' (second revision) from the Dutch College of General Practitioners; a response from the perspective of obstetrics & gynaecology]. / De standaard 'Hormonale anticonceptie' (tweede herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de verloskunde-gynaecologie.

The Dutch College of General Practitioners' (NHG) guideline on hormonal contraception does not follow the WHO criteria for the use of oral contraceptives in contrast to the guideline of the Dutch Society of Obstetrics and Gynaecology. Contrary to the WHO criteria, the NHG guideline considers a blood-pressure measurement before starting with an oral contraceptive to be unnecessary. It also considers no form of migraine to be a contraindication for oral contraceptives. The NHG guideline further disclaims the (slightly) increased risk of developing breast cancer in women using oral contraceptives. It advises initiation of oral-contraceptive use two weeks postpartum in non-breastfeeding women and six weeks postpartum in breastfeeding women, instead of the three weeks and six months, respectively, indicated in the WHO guideline. Lastly, the NHG guideline is too optimistic as to the reliability of oral-contraceptive use, as no distinction is made between efficacy and effectiveness. Such discrepancies between two Dutch guidelines can be detrimental to women's health care. The WHO criteria for contraceptive use may be a valuable tool to overcome differences of opinion so as to achieve a badly needed full consensus.

[Vaginal contraception: new form of administration of hormonal contraception]. / Vaginale anticonceptie: hormonale anticonceptie in een andere toedieningsvorm.

The vaginal contraceptive ring works systemically by releasing 120 micrograms etonogestrel (a third generation progestogen) and 15 micrograms ethinylestradiol per day. As little independent research has been done on the efficacy and effectiveness of the vaginal contraceptive ring, it seems too early for the uncompromising propagation of systemic vaginal contraception. Women who occasionally omit to take the pill and those reluctant to use an intra-uterine device may possibly benefit from this form of contraception.

[The Dutch College of General Practitioners practice guideline 'The menopause'; reaction of the field of obstetrics and gynaecology]. / De standaard 'De overgang' van het Nederlands Huisartsen Genootschap; reactie vanuit de obstetrie en gynaecologie.

In the Dutch College of General Practitioners' (NHG) practice guideline on the menopause (which also covers hormone therapy), menopausal transition is considered as a physiological life process with inconveniences which can generally be settled by providing information, while leaving hormonal treatment for women who experience serious restrictions in their daily life as a consequence of vasomotor flushes or urogenital atrophy. In those cases, the guideline says, hormonal treatment should not be given for longer than three to six months, after which it should be stopped until a relapse arises. However, it usually takes at least six months of oestrogen replacement therapy to restore urogenital atrophy as well as for the woman to recover from its discomforts such as dyspareunia. Dosages of oestrogens in different hormonal therapies should be 50% or 25% of those advocated in the guideline, as the lowest effective dosage of oestrogen is sufficient. More generally, a woman affected by menopausal inconveniences is not a patient. She deserves to decide for herself whether or not she is willing to use hormone replacement therapy, and if so, she should be allowed to decide on the duration of hormone treatment. The physician should provide adequate information and benevolent supervision.

[Health Council of Netherlands recommendation 'Serum screening for risk assessment of Down syndrome for all women' poorly supported]. / Gezondheidsraadadvies 'Kansbepalende serumscreening op Down-syndroom voor alle vrouwen' onvoldoende doordacht.

The Health Council of the Netherlands has recommended a new policy of offering triple test-based serum screening for Down's syndrome to all pregnant women rather than the current policy of maternal age-based screening for pregnant women aged 36 years and above. In these older pregnant women, this risk-assessment serum screening would indeed prevent many miscarriages caused by the invasive procedure. However, in pregnant women under 30 years of age this policy would imply the need to counsel almost 80,000 young pregnant women each year, and the need to perform 2,200 invasive procedures in order to detect 29 Down's syndrome cases, while 45 cases would still remain undetected. Moreover, as only 11% of the detectable Down's syndrome cases are found in women under 30, it would appear advisable to only offer the risk-assessment serum screening to pregnant women aged 30 years and above.

[Modern intra-uterine contraception: a better option]. / Moderne intra-uteriene anticonceptie: het betere alternatief.

Users of oral contraceptives have an increased risk of developing venous thromboembolism as well as mammary cancer. This raises the question as to whether locally applied (intrauterine) contraceptives can offer a valuable alternative with respect to efficiency and safety. During the past decade the use of modern intrauterine devices (IUDs) has made substantial progress in comparison with the use of IUDs during the 1970s and 1980s. Modern IUDs have become more efficient than oral contraception. Arguments against the use of IUDs (problems and complications in IUD insertion, the risk of pelvic inflammatory disease, ectopic pregnancy and infertility as well as side effects such as menorrhagia, pelvic cramps and IUD expulsion) generally appear to be based on a lack of awareness with respect to recent developments and on misunderstandings derived from bad experiences during the 1980s and earlier.

Clinical outcome after unilateral oophorectomy in patients with polycystic ovary syndrome.

The objective of this study is to report retrospectively on the clinical outcome of unilateral oophorectomy in 14 women with polycystic ovary syndrome who had undergone this treatment 14-18 years ago in our hospital for clomiphene citrate-resistant anovulation and long standing infertility or for severe hirsutism. The main outcome measures were menstrual cycle, pregnancy, hirsutism, testosterone concentrations, and premature ovarian failure. Unilateral oophorectomy restored regular menstrual cycles in 12 of the 14 patients. Thirteen years later, nine out of 12 patients still had regular menstrual cycles. Ten patients wished to become pregnant. Seven of them conceived spontaneously. Eleven patients complained of severe hirsutism. After unilateral oophorectomy, hirsutism regressed subjectively in six. Testosterone blood concentrations decreased significantly within the first year after unilateral oophorectomy in 11 patients. None of the women entered menopause within 14-18 years after surgery. Our results indicate that unilateral oophorectomy restores ovulatory function for many years in the majority of patients and does not result in premature ovarian failure. However, unilateral oophorectomy should not be recommended as a standard treatment for clomiphene citrate-resistant patients with polycystic ovary syndrome.

[The family practitioner and the postcoital test]. / De huisarts en de post-coitumtest.

There is still a great deal of controversy on the value of the postcoital test. Some consider it to be a valuable method for the general practitioner to evaluate the interaction in vivo between spermatozoa and cervical mucus, in spite of the poor predictive value of the test. The postcoital test is in fact only an indirect method for the detection of the production of moving sperms. As a negative postcoital test is frequently due to bad timing of the test, multiple mandatory intercourse is often necessary, which may lead to frustration and sexual dysfunction. Moreover, there are no indications that the postcoital test with its poor discriminatory power may be better in general practice than the fertility evaluations by a specialist as standardisation and reproducibility problems are equal in both settings. Therefore semen analysis appears to be a better option, for the general practitioner as well.