[National guideline 'Cryopreservation of ovarian tissue']. / Richtlijn 'Cryopreservatie van ovariumweefsel'.

The treatment of children and young adults with cancer increasingly results in cure, but for a number of female patients this is at the expense of infertility. For women and girls with cancer and the wish to have children in the future, cryopreservation of ovarian tissue may be a solution in the absence of alternatives for the conservation of fertility. Because of the uncertain effectiveness and safety of cryopreservation of ovarian tissue, the Dutch national guideline 'Cryopreservation of ovarian tissue' advises removing and freezing ovarian tissue only if this is done within the framework of scientific research. Reimbursement of this procedure and financing of the relevant and necessary research have not yet been arranged.

[Female professors in medicine in 2003: appointment, duties and family life]. / Vrouwelijke hoogleraren in de geneeskunde anno 2003: aanstelling, taakvervulling en gezinsleven.

OBJECTIVE: To inventory (a) how and when female professors of medicine were appointed, (b) how they combined their work with family life, (c) which changes in health care female and male professors expected as a consequence of the increasing number of women physicians, and (d) which changes they wished to see for their successors. DESIGN: Descriptive. METHOD: A questionnaire was used to collect data from the female professors of medicine who worked in the Netherlands as of 1 January 2003 (n = 43), and from the same number of male professors of medicine, who were matched for age and speciality. RESULTS: 39 women and 39 men responded (91%). The women were more often appointed after a closed application procedure (69 versus 51%). Two fifths of the women had a part-time appointment as professor, but they worked at least 45 hours per week. Women were more often present in educational committees than in selection committees. At the time of their appointment most women had no children (n = 16) or children who did not live at home (n = 7); the other 16 (41%) had children at home, as did 33 (85%) of the male professors. Over half of the 23 women with children were at home for at least 2 half-days per week when the children were young and in some cases the partners cared for the children full-time; the opposite was found among the 35 men with children. A quarter of both mothers and fathers was present for activities of their children, like soccer training and final swimming tests, during office hours. The most important recommendations regarding the appointment and the functioning of professors concerned the structure and flexibility of medical education, the carefulness when considering appointments, and the possibilities to work part-time and to have a family life.

[Guideline on 'non-small cell lung carcinoma; staging and treatment']. / Richtlijn 'Niet-kleincellig longcarcinoom; stadiëring en behandeling'.

A national, evidence-based guideline on the staging and treatment of patients with non-small cell lung carcinoma (NSCLC) has been compiled by the various disciplines involved. The initial diagnostic measures in patients with suspected lung cancer include history taking, physical examination and chest x-ray. Additional examinations include CT scan of the chest and upper abdomen, bronchoscopy, and 18F-fluorodeoxyglucose-positron-emission-tomography(FDG-PET)-scintigraphy, if curative therapy is planned. Cervical mediastinoscopy or endoscopic echography with fine needle aspiration can be performed for mediastinal tissue staging. The preferred treatment in stage I, II or limited III is radical resection. Postoperative radiotherapy is recommended in cases of incomplete resection and can be considered in patients in whom mediastinal lymph-node metastases are unexpectedly encountered. Chemoradiotherapy is recommended in locally advanced NSCLC. In patients with NSCLC stage I-III and poor performance status, palliative radiotherapy may be the only feasible treatment. Some patients with NSCLC stage III and stage IV can be offered palliative chemotherapy and supportive care. In cases of doubt about operability, resectability, significant pulmonary or cardiac comorbidity or combined treatment, a specialist centre should be consulted. Diagnostics should be completed within 3-5 weeks. Ensuing surgery or radiotherapy should be carried out within 2 weeks. Follow-up of patients with NSCLC includes history taking, physical examination and an optional chest x-ray. In the first year after treatment patient visits are planned quarterly, in the second year half-yearly and then yearly for at least five years.

[A model code of practice in accordance with the Dutch Embryo act]. / Modelreglement embryowet.

Under the terms of the Dutch Embryo Act, institutions that perform in vitro fertilisation must work in accordance with a legally prescribed procedure. A model protocol has been drawn up under the auspices of the Dutch Institute for Healthcare Improvement that can serve as a guideline and that may be amplified in details with regard to local circumstances. In vitro fertilisation is reserved to licensed centres with expert and experienced personnel. These centres must fulfil specific standards for both the clinical part and the laboratory part of the treatment. The decision in favour of ovarian stimulation depends on the wish to be able to select from multiple embryos and must be weighed against the burden on the patient, her age and the risk of developing an ovarian hyperstimulation syndrome. Placing more than two embryos at a time is discouraged. In the contract between the depositors and the depository concerning the storage of embryos (cryopreservation), the points of departure are that the parties involved must agree on the use of the embryos and that each involved person may withdraw his or her permission at any time. In the Netherlands, oocyte donation is performed predominantly in women with premature ovarian failure. The maximum age of the acceptor is 45 years. Legally, the minimum age of a donor is 18 years, but the Committee recommends caution with donors under the age of 30 years; from the point of view of treatment efficacy, the maximum age is 40 years. For each individual oocyte donation procedure, permission is required from the medical-ethical assessment committee of the hospital in question. Often, a written report to the committee from the treating gynaecologist and a psychosocial counsellor will suffice. Because of the increased risk of pregnancy complications after oocyte donation, control and delivery in hospital are recommended. Post-mortem use of gametes or embryos is permitted, provided that the parties involved have given written permission.

[Dutch Institute for Health Care Improvement's standard code of practice entitled, "Donation of fetal tissue"]. / CBO-modelreglement 'Terbeschikkingstelling van foetaal weefsel'.

The Dutch Law on Foetal Tissue (Wet Foetaal Weefsel) sets out conditions and regulations concerning the donation, storage and permissibility of use of foetal tissue. Each institution where foetal tissue becomes available has to formulate an in-house code of conduct describing how the law will be applied within that institution. A committee, including abortion physicians and gynaecologists, has formulated a number of rules of conduct within the standard code of conduct under the auspices of the Kwaliteitsinstituut voor de Gezondheidszorg CBO [Dutch Institute for Healthcare Improvement]. Complying with this standard code ensures that the law is upheld. In clinical practice, one may deviate from this standard code in case of solid reasons only. Generally, all women can be asked to donate foetal tissue. A basic prerequisite for the inclusion of non-Dutch women is that oral and written communication is possible. The committee considers the age of 16 as a minimum threshold and mental incompetence as an exclusion criterion. Much attention should be paid to providing the women with information and to requesting permission. The basic principle is that the decision to terminate a pregnancy should be strictly separated from the decision to donate foetal tissue. As a general rule, foetal tissue should be stored anonymously. Adjustment of the abortion method in view of the intended scientific research is not permitted.

[Dutch Institute for Health Care Improvement (CBO) Guideline 'lymphedema']. / CBO-richtlijn 'Lymfoedeem'.

Lymphedema is a symptom of tissue fluid accumulation which arises as a consequence of impaired lymphatic drainage. This reduced drainage can be either congenital or acquired, for example after breast cancer treatment. Early diagnosis of a swollen limb and adequate treatment are important in order to prevent irreversible tissue changes. The medical history and characteristic clinical presentation form the cornerstone of the diagnostic process. Lymphoscintigraphy can be used to obtain additional information about the functioning of the lymphatic system. Information and recommendations on precautions, preventive measurements and self-management instructions are important to all patients with (risk of) lymphedema. Treatment for lymphedema has to be adjusted to the patient and may consist of several therapeutic options, including manual lymphatic drainage. After volume reduction has been accomplished, a well-fitted compressive garment is essential in the maintenance phase. Surgical procedures for lymphedema are strictly indicated and should be performed by protocol in a multidisciplinary setting with long-term follow-up. Lymphedema is seen in many medical disciplines. A treatment plan is drawn up on the basis of a thorough knowledge of the diagnostics and treatment, with targeted referral to paramedical personnel. As it is a chronic condition, lymphedema requires life-long treatment and follow-up. In view of the complex nature of lymphedema it is recommended that local lymphedema protocols be developed.

[Revised CBO guideline 'Follow-up after polypectomy']. / Herziene CBO-richtlijn 'Follow-up na poliepectomie'.

The purpose of follow-up after polypectomy of one or more colorectal adenomatous polyps, is the timely removal of new adenomas and thereby the prevention of colorectal cancer. The first check-up following index-polypectomy can be carried out after six years if one or two adenomas were encountered during the index polypectomy, and after three years if three or more adenomas were encountered. The same check-up interval of six and three years respectively applies if none to two or more than three adenomas are encountered when a check-up colonoscopy is carried out. A check-up one year after the polypectomy and check-ups more frequently than respectively six and three years after polypectomy are not considered to be useful, while each check-up is accompanied by risks and costs. Check-ups can be suspended for patients in whom cumulatively one adenomatous polyp has been removed: from the age of 65 years, for patients in whom cumulatively two adenomas have been removed: from the age of 75 years, and for patients in whom cumulatively three adenomas have been removed check-ups must be continued for as long as the patient's vitality justifies this. Also if no adenomas are encountered during three consecutive check-ups, a suspension of the check-ups can be considered. Separate guidelines apply to patients with genetically determined adenomas.

Antibiotic prophylaxis for haematogenous bacterial arthritis in patients with joint disease: a cost effectiveness analysis.

OBJECTIVE: To assess the cost effectiveness of antibiotic prophylaxis for haematogenous bacterial arthritis in patients with joint disease. METHODS: In a decision analysis, data from a prospective study on bacterial arthritis in 4907 patients with joint disease were combined with literature data to assess risks and benefits of antibiotic prophylaxis. Effectiveness and cost effectiveness calculations were performed on antibiotic prophylaxis for various patient groups. Grouping was based on (a) type of event leading to transient bacteraemia-that is, infections (dermal, respiratory/urinary tract) and invasive medical procedures-and (b) the patient's susceptibility to bacterial arthritis which was increased in the presence of rheumatoid arthritis, large joint prostheses, comorbidity, and old age. RESULTS: Of the patients with joint disease, 59% had no characteristics that increased susceptibility to bacterial arthritis, and 31% had one. For dermal infections, the effectiveness of antibiotic prophylaxis was maximally 35 quality adjusted life days (QALDs) and the cost effectiveness maximally $52 000 per quality adjusted life year (QALY). For other infections, the effectiveness of prophylaxis was lower and the cost effectiveness higher. Prophylaxis for invasive medical procedures seemed to be acceptable only in patients with high susceptibility: 1 QALD at a cost of $1300/QALY; however, the results were influenced substantially when the level of efficacy of the prophylaxis or cost of prophylactic antibiotics was changed. CONCLUSION: Prophylaxis seems to be indicated only for dermal infections, and for infections of the urinary and respiratory tract in patients with increased susceptibility to bacterial arthritis. Prophylaxis for invasive medical procedures, such as dental treatment, may only be indicated for patients with joint disease who are highly susceptible.

[Waiting times in specialist medical care]. / Wachttijden in de medisch-specialistische zorg.

Waiting times in specialist medical care are difficult to reduce owing to the fast-growing demand with supply lagging behind. These waiting times were the subject of a conference of this Journal, where experts from different backgrounds assessed the problems and discussed promising ways of coping with them at micro, meso and macro level. In the first category, a system developed in Leiden University Medical Centre was presented that provides insight into the expected waiting time per disease category, elucidates the bottlenecks in practice and supports the quality of care and the planning of patient flows. At the meso level, the discussion addressed how the differences within and between institutions and within and between regions may be reduced; this may be done, for instance, by better spread of the work load. This offers a better contribution to a structural solution than extra-regular initiatives. The conference finally discussed the importance of the current shift of important (control) tasks from the government to insurers. Those present expected that stimulation of regional initiatives of hospitals and health insurers by means of more money and latitude, allocated by the government and under its control (inspection), offers the best opportunities to shortening of the waiting lists and improvement of the quality of care.

[CBO-guideline 'Bacterial meningitis']. / CBO-richtlijn 'Bacteriële meningitis'.

Neisseria meningitidis and Streptococcus pneumoniae are the most frequent causes of bacterial meningitis. The incidence of Haemophilus meningitis in the Netherlands is low due to successful Haemophilus influenzae type b vaccination. This implies that there is no need to take account into this microorganism in using initial empiric antimicrobial therapy for bacterial meningitis. Vomiting (especially children), headache, fever, and a stiff neck characterize acute bacterial meningitis. However, even without these signs a patient may still have acute bacterial meningitis. The characteristics in neonates are less specific. An emergency lumbar puncture should be performed in all patients with meningeal irritation or other signs of bacterial meningitis. Examination of the CSF is not indicated for convulsive children (between the ages of 6 months and 6 years) who do not exhibit other clinical signs. In patients who respond adequately to the treatment, it is not necessary to examine the CSF again. Papilloedema or focal neurological symptoms contraindicate a lumbar puncture in patients with bacterial meningitis, until CT results justify that it can be performed safely. Antibiotic treatment should not be delayed until after the CT. General practitioners should treat their patients with suspected meningococcus infection by admitting them to the hospital without first injecting antibiotics. In the Netherlands, patients with suspected pneumococcus meningitis may still be treated with benzylpenicillin. Patients with bacterial meningitis have no fluid restrictions; only in case of the syndrome of inadequate secretion of antidiuretic hormone is fluid reduction indicated. The physician is responsible for prescribing prophylaxis to family members. The Regional Health Services organize chemoprophylaxis for classmates. The latter is only indicated if at least 2 related cases occur in one month.

[Publishing in biomedical journals in the year 2000 and after; report of a symposium]. / Publiceren in biomedische tijdschriften in het jaar 2000 en daarna; verslag van een symposium.

On the occasion of the oration by prof. dr. A.J.P.M. Overbeke, executive editor of the Nederlands Tijdschrift voor Geneeskunde, a symposium was organized on 16 June 2000. The lecturers were (chief) editors of medical journals. Many changes in medical publishing are to be expected in the next 10 years. The new technology will play an important part in this, but the details remain to be seen. Scientific journals can continue to exist in the electronic era if they produce legible, i.e. brief and clear articles in the printed version and offer extra information on the internet: details of methods used and statistical analyses and extensive tables. Also, the contributions of the various authors are printed. Not all, but only a few authors should make certain that the work described has indeed been performed and these would be responsible for the contents of the entire article. It appeared that the main part played by physicians in mass media is that of occasional informants. There still exist possibilities to use the media in distributing and supporting the messages of medicine and in elucidating the dilemmas. While 'archivist' journals mostly record scientific work presented, the task of the 'newspaper journals' consists of informing, interpreting, criticizing and stimulating. In this 'colouring' of the contents of the journal, the independence of the chief editors is of great importance. The innovations in medicine of the past century appear to be based mostly on the work of predecessors, of research physicians opposing established authorities, and on coincidence. The interval between discovery and publication has grown much shorter.

[Antibiotic prophylaxis of hematogenous bacterial arthritis]. / Antibiotische preventie van hematogene bacteriële artritis.

The outcome of bacterial arthritis is generally poor: the mortality is 10-15% and there is loss of joint function in 25-50% of the survivors. Adverse prognostic factors are advanced age, a pre-existent joint disease and an infection of a prosthetic joint. The incidence of bacterial arthritis is low: 2-6 per 100,000 persons per year. Risk factors are advanced age, a joint disease--especially rheumatoid arthritis--diabetes mellitus and presence of a prosthetic joint. Situations that can lead to bacterial arthritis are mainly skin infections of the feet and only rarely invasive medical or dental procedures. Because of the severity of the disease, antibiotic prophylaxis of haematogenous bacterial arthritis in patients with prosthetic joints is advocated in guidelines. However, because of the rarity of the disease it is unclear whether the advantages of prophylaxis outweigh the disadvantages of the large-scale use of antibiotics, such as side effects, costs and increased resistance of bacteria. In a decision analysis of a large group of patients with joint diseases, antibiotic treatment of skin infections appeared to be (cost-)effective in the prevention of haematogenous bacterial arthritis, mainly in high-risk patients. On the other hand, prophylaxis around medical or dental procedures was not (cost-)effective, except possibly in a small group of patients with increased risk.

Incidence and sources of native and prosthetic joint infection: a community based prospective survey.

OBJECTIVES: To determine the incidence and sources of bacterial arthritis in the Amsterdam health district and the maximum percentage of cases that theoretically would be preventable. METHODS: Patients with bacterial arthritis diagnosed between 1 October 1990 and 1 October 1993 were prospectively reported to the study centre by all 12 hospitals serving the district. Data were gathered on previous health status, source of infection, and microorganisms involved. RESULTS: 188 episodes of bacterial arthritis were found in 186 patients. Most of the 38 children were previously healthy. Fifty per cent of the adults were 65 years or older. Of the adults 84% had an underlying disease, in 59% a joint disorder. Joint surgery constituted the largest part of direct infections (33%) and skin defects were the most important source of haematogenous infections (67%). Infection of joints containing prosthetic or osteosynthetic material by a known haematogenous source occurred 15 times (8%). Staphylococcus aureus was the causative organism in 44% of all positive cultures. CONCLUSION: The incidence of bacterial arthritis was 5.7 per 100,000 inhabitants per year. Preventive measures directed to patients with prosthetic joints or osteosynthetic material, and a known haematogenous source would have prevented at most 8% of all cases.

The outcome of bacterial arthritis: a prospective community-based study.

OBJECTIVE: To assess the outcome and adverse prognostic factors of bacterial arthritis (BA). METHODS: In a prospective community survey of BA, data were collected at the time of diagnosis and at a mean of 2 years later. A poor patient outcome was defined as death due to BA or severe overall functional deterioration. A poor joint outcome was defined as amputation, arthrodesis, prosthetic surgery, or severe functional deterioration. Possible prognostic factors were analyzed by univariate analysis. RESULTS: BA was diagnosed in 154 patients, 121 adults and 33 children. One-half of the adults had a preexisting joint disease and 29% of the infected joints contained synthetic material. The patient outcome was poor in 21% of all patients, and the joint outcome was poor in 33% of the surviving patients. Adverse prognostic factors were an older age, preexisting joint disease, and an infected joint containing synthetic material. These factors were interrelated. There was no association between a poor outcome and young age, comorbidity, immunosuppressive medication, functional class, multiple infected joints, type of microorganism, or treatment delay. CONCLUSION: BA had a poor outcome in almost one-half of the patients. Patients who were older, had a preexisting joint disease, and/or had an infected joint containing synthetic material had the poorest prognosis.

Risk factors for septic arthritis in patients with joint disease. A prospective study.

OBJECTIVE: To quantify potential risk factors for septic arthritis, in order to identify a basis for prevention. METHODS: The occurrence of potential risk factors for septic arthritis in patients with joint diseases attending a rheumatic disease clinic was prospectively monitored at 3-month intervals over a period of 3 years. Potential risk factors investigated were type of joint disease, comorbidity, medication, joint prosthesis, infections, and invasive procedures. The frequencies of risk factors in patients with and those without septic arthritis were compared using multiple logistic regression analysis. RESULTS: There were 37 patients with and 4,870 without septic arthritis. Risk factors for developing septic arthritis were age > or = 80 years (odds ratio [OR] = 3.5, 95% confidence interval [95% CI] 1.4-8.6), diabetes mellitus (OR = 3.3, 95% CI 1.1-10.1), rheumatoid arthritis (OR = 4.0, 95% CI 1.9-8.3), hip and/or knee prosthesis (OR = 15, 95% CI 4.1-54.3), joint surgery (OR = 5.1, 95% CI 2.2-11.9), and skin infection (OR = 27.2, 95% CI 7.6-97.1). CONCLUSION: These findings indicate that preventive measures against septic arthritis in patients with joint diseases should mainly be directed at those with joint prostheses and/or skin infection.