ABSTRACT
Electrolyte disorders are common and often challenging in terms of differential diagnosis and appropriate treatment. To facilitate this, the first Dutch guideline was developed in 2005, which focused on hypernatraemia, hyponatraemia, hyperkalaemia, and hypokalaemia. This guideline was recently revised. Here, we summarise the key points of the revised guideline, including the major complications of each electrolyte disorder, differential diagnosis and recommended treatment. In addition to summarising the guideline, the aim of this review is also to provide a practical guide for the clinician and to harmonise the management of these disorders based on available evidence and physiological principles.
Subject(s)
Hypokalemia , Water-Electrolyte Imbalance , Diagnosis, Differential , Electrolytes , Humans , Hyperkalemia , Hyponatremia , Practice Guidelines as Topic , Practice Patterns, Physicians'ABSTRACT
The Dutch evidence-based guideline 'Treatment of breast cancer' has been revised, and integrated with the guideline 'Screening for and diagnosis of breast cancer'. The guideline can be found on www. oncoline.nl and on www.cbo.nl. The Internet programme 'Adjuvant!' (www.adjuvantonline.com) can be used to predict both the prognosis and the efficacy of systemic adjuvant therapy for each patient. The indications for adjuvant chemotherapy and endocrine therapy have been widened. The aim is to reduce the absolute probability of death by at least 4-5% within 10 years. The goal of neoadjuvant chemotherapy in operable breast cancer is to enable breast-conserving therapy for large tumours in relatively small breasts. One could consider transferring responsibility for follow-up after 5 years from the hospital to the screening organisation following mastectomy, to the family doctor following breast-conserving therapy, and to an outpatient clinic for hereditary tumours in carriers of gene mutation. Cessation of follow-up above the age of 75 could also be considered.
Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Breast Neoplasms/diagnosis , Breast Neoplasms/therapy , Neoadjuvant Therapy/methods , Practice Guidelines as Topic , Practice Patterns, Physicians' , Breast Neoplasms/mortality , Breast Neoplasms/surgery , Combined Modality Therapy , Female , Humans , Mastectomy , Neoplasm Staging , Netherlands , Prognosis , Societies, Medical , Treatment OutcomeABSTRACT
Revised practice guideline 'Screening and diagnosis of breast cancer' The evidence-based revision of the practice guideline 'Screening and diagnosis of breast cancer' was necessitated by new insights, for instance on the cost-effectiveness of screening modalities other than mammography. Mammography is the only screening modality that is recommended for the general population. In the Netherlands, women from 50-75 years of age are invited for screening. However, in view of the ongoing increase in the incidence of breast cancer and of the image quality advantages of radiological digitalization, a study on the decrease of the lower age limit--preferably 45 years--is recommended. Screening with MRI is indicated for carriers of breast cancer gene mutations. Evaluation of risk factors has resulted in a rearrangement of screening recommendations, based on relative risks (RRs): screening apart from the population screening is only recommended in case the RRis 4 or more and in patients with a positive family history in case of a RR of 2 or more. Additional risks require further genetic evaluation. The 'Breast imaging reporting and data system' (BI-RADS) is now recommended for both screening and diagnostic imaging. Its application has had an impact on the triple diagnostic approach, which has now evolved into a consensus between surgeon, radiologist and pathologist. Axillary ultrasound should be carried out ifa sentinel node procedure is being considered. MRI should be included if the cancer cannot be reliably delineated on mammography or ultrasound. The increased complexity of the diagnostic work-up often means that the final diagnosis is not arrived within one day. Every effort should be made to achieve this goal within 5 working days. Ned Tijdschr Geneeskd. 2008;I52:2336-9
Subject(s)
Breast Neoplasms/diagnosis , Breast Self-Examination , Diagnosis, Computer-Assisted , Mammography/methods , Mass Screening/methods , Practice Guidelines as Topic , Age Factors , Female , Humans , Magnetic Resonance Imaging , Netherlands , Physical Examination , Risk Factors , Societies, Medical , Time Factors , Ultrasonography, MammaryABSTRACT
The practice guideline 'Medical treatment of COPD' completes the practice guideline for diagnostics and non-medicinal treatment. Patients with stable chronic obstructive pulmonary disease (COPD) and minor complaints can be treated with short-acting beta-2-adrenoceptor agonists or anticholinergics or a combination of these. In cases of insufficient clinical control of the condition or if patients use their medication for maintenance, a long-acting bronchodilator is the drug of choice. In patients with severe or very severe COPD (stage III-IV of the criteria of the Global Initiative for Obstructive Lung Disease (GOLD) or with cardiac comorbidity, there is a slight preference for the long-acting anticholinergic tiotropium. Inhaled corticosteroids (ICS) reduce the exacerbation frequency in patients with moderate to severe or very severe COPD (GOLD stage II-IV) and recurrent exacerbations. A combination of ICS with long-acting beta-2-adrenoceptor agonists (LABA) is prescribed in patients with GOLD stage III-IV with at least 2 exacerbations in the past year, a deterioration of the quality of life and with symptoms, if treatment with a LABA alone or an ICS alone results in insufficient improvement. Anticholinergics and beta-2-adrenoceptor agonists have a similar effect on bronchodilation in patients with an acute exacerbation of COPD. If improvement is inadequate, patients with an exacerbation should be treated with prednisolone 30 mg for a period of 7 to 14 days. In outpatients and clinical patients with an exacerbation ofCOPD, an antibiotic is added to prednisolone in very poor lung function (forced expiratory volume in 1 second (FEV1) < 30%) or another risk factor of a severe disease course, such as a respiratory rate > or = 30/min, a systolic blood pressure < 90 mmHg, and disorientation in time, place or person.
Subject(s)
Bronchodilator Agents/therapeutic use , Practice Guidelines as Topic , Pulmonary Disease, Chronic Obstructive/drug therapy , Quality of Life , Administration, Inhalation , Adrenergic beta-Agonists/therapeutic use , Cholinergic Antagonists/therapeutic use , Drug Therapy, Combination , Forced Expiratory Volume/drug effects , Humans , Netherlands , Pulmonary Disease, Chronic Obstructive/pathology , Severity of Illness IndexABSTRACT
The guideline for the treatment of adults with moderate to severe chronic plaque-type psoriasis vulgaris is based on published scientific evidence. The efficacy of the treatment, its safety, the side effects, the patients' discomfort, the patients' preference and the costs of treatment and follow-up are listed as criteria that play a role in the choice of treatment. Photo(chemo)therapy is the treatment of choice for severe forms of psoriasis. Phototherapy with ultraviolet-B light (UVB), especially narrow-band UVB, is preferred above photochemotherapy with ultraviolet-A light and psoralenes (PUVA). Of the oral treatments, methotrexate and ciclosporin are preferred above retinoids and fumarates because they yield a higher percentage of patients with partial or nearly complete remission. Fumarates are not officially registered in The Netherlands and Belgium.
Subject(s)
Dermatologic Agents/therapeutic use , Photochemotherapy/methods , Practice Guidelines as Topic , Psoriasis/drug therapy , Psoriasis/radiotherapy , Ultraviolet Therapy/methods , Cyclosporine/therapeutic use , Humans , Methotrexate/therapeutic use , Photochemotherapy/economics , Safety , Treatment Outcome , Ultraviolet Therapy/economicsABSTRACT
Under the auspices of the Dutch Institute for Healthcare Improvement (CBO), a guideline has been developed for the diagnosis and treatment of aspecific low-back pain, based on the recent scientific literature. So-called 'red flags' are used to identify physical disorders. To obtain insight into psychosocial factors, 'yellow flags' are used. Acute low-back pain (0-12 weeks) is treated in a time-contingent manner. Staying active is better than bed rest. If chronicity threatens, exercise therapy can be advised. As part of an activating management, manipulation can be used. For pain relief, paracetamol is the drug of choice. The treatment of chronic low-back pain is aimed at the optimisation of the patients' functionality. Staying active is preferred here as well. Varied exercise therapy is advised. Back training may be considered. Manipulation can be used as part of an activating management. Paracetamol is preferred for pain relief. There is a limited role for percutaneous lumbar facet denervation. Behaviour therapy can be employed and there is a place for multidisciplinary programmes if other methods of treatment have proved insufficiently effective.
Subject(s)
Back Pain/diagnosis , Back Pain/therapy , Acetaminophen/therapeutic use , Analgesics, Non-Narcotic/therapeutic use , Biomechanical Phenomena , Early Ambulation , Exercise Therapy , Humans , Manipulation, Orthopedic , Netherlands , Time Factors , Treatment OutcomeABSTRACT
The first Dutch evidence-based guideline for the treatment of breast cancer has been developed to realise the optimal care of breast cancer patients in the Netherlands. This was possible due to the close cooperation of the Dutch Institute for Healthcare Improvement [Dutch acronym: CBO] and the Dutch Consultative Committee on Breast Cancer [Dutch acronym: NABON]. A broad, multidisciplinary working group was appointed to develop the guideline. This group consisted of surgeons, radiotherapists, internists, pathologists, a radiologist, a nuclear medicine specialist, a plastic surgeon and a clinical geneticist, all of whom had been given a mandate to represent their respective professional societies. In addition to these medical specialists, there were physiotherapists, oncology nurses, psychologists, staff from comprehensive cancer centres and the Dutch Institute for Healthcare Improvement and representatives from the Dutch Breast Cancer Association. This CBO guideline is divided into seven chapters: local treatment of operable breast cancer, systemic adjuvant treatment, locoregionally advanced disease, follow-up, locoregional recurrence, metastasised disease, and the psychosocial aspects of breast cancer. Although the guideline is not intended as a set of instructions that must be rigidly adhered to, deviations from the guideline must be motivated, principally on the basis of published scientific information. To obtain insight into the actual use of the guidelines 'Screening and diagnostics' and 'Treatment of breast cancer' the work group advocates a nationwide prospective registration of all breast cancer patients, including follow-up. Steps to this end have been undertaken. In this way, the CBO guideline will contribute to a further optimisation of breast cancer care in the Netherlands.
Subject(s)
Breast Neoplasms/therapy , Female , Humans , Netherlands , Patient Care Team , RegistriesABSTRACT
The revised CBO guideline 'High blood pressure' details the present scientific knowledge about the detection, diagnosis and treatment of elevated blood pressure as well as the implementation of this knowledge in practice. For both systolic and diastolic increased blood pressure the risk of cardiovascular disease and mortality gradually increases. The blood pressure is considered to be elevated if the systolic pressure is > or = 140 mmHg and/or the diastolic pressure is > 90 mmHg. For individuals aged 60 years and over, without diabetes, familiar hypercholesterolaemia or overt cardiovascular disease, 160 mmHg is the cut-off value for elevated systolic pressure. Depending on age or blood pressure level, the diagnosis 'elevated blood pressure' is established after 3 or 5 measurements over a period of some weeks (3 measurements) to 6 months (5 measurements). Where elevated blood pressure is diagnosed, lifestyle recommendations should be considered first and only if these provide insufficient results should medicinal treatments be adopted. The indication area for treatment is laid down in the case of elevated blood pressure and an absolute cardiovascular risk of 20% per 10 years. When the absolute cardiovascular risk is between 10% and 20% per year, treatment may be considered. For treatment the target value is the same as the criterion for elevated blood pressure.
Subject(s)
Blood Pressure , Cardiovascular Diseases/prevention & control , Hypertension/diagnosis , Life Style , Antihypertensive Agents/therapeutic use , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/mortality , Humans , Hypertension/therapy , Netherlands/epidemiology , Practice Guidelines as Topic , Primary Prevention , Reference Standards , Risk , Risk FactorsABSTRACT
New developments in the diagnostic procedures for women with an increased risk for, or symptoms related to breast cancer led to development of new guidelines by a working group under the auspices of the Dutch Institute for Health Care Improvement, the Organisation of Comprehensive Cancer Centres and the National Breast Group of the Netherlands. Based on the best available evidence this working group formulated recommendations on the following topics: indications for screening within the population screening programme, screening outside the population screening programme, the diagnostic procedures of symptomatic and asymptomatic lesions in the breast and the organisation of the diagnostic work-up of patients with breast symptoms. The most important recommendations in the guidelines are: individual screening is recommended to certain groups of women who do not participate in the population screening programme, based on their risk profiles; available evidence does not support the extension of the population screening programme to women 40-49 years of age; diagnosis and treatment have to take place in a structured context, the so-called breast team; to guarantee optimal diagnostic procedures a multidisciplinary clinic is mandatory; the diagnostic work-up of breast abnormalities is based on the triple assessment: physical examination, imaging by mammography and/or ultrasound and needle biopsy. For quality-controlled implementation of this guideline, uniform prospective registration of patients, diagnosis and treatment related data is an important condition.
Subject(s)
Breast Neoplasms/diagnosis , Breast Neoplasms/prevention & control , Mass Screening , Adult , Aged , Diagnosis, Differential , Female , Humans , Mass Screening/methods , Middle Aged , Netherlands , Practice Guidelines as Topic/standardsABSTRACT
The stroke consensus dating from 1991 had to be revised, because of the introduction of new developments in the treatment of patients with stroke. More than 50 representatives from 25 professions and institutions participated. Under methodological assistance of the Dutch Institute for Healthcare Improvement CBO separate working groups (diagnosis, treatment, organization of care, rehabilitation/education, implementation and cost-effectiveness) studied the literature and translated the results into recommendations with explanatory text. The strength of scientific evidence was classified. During a national public meeting the results were discussed. In the field of guideline development cost-effectiveness analyses and specific attention for implementation are new. Care on a stroke unit decreases the risk of mortality, life-long disabilities, and dependence on permanent care with about 20%. Regional stroke services should be instituted, in which continuity and efficient care can be guaranteed. Very early thrombolysis with recombinant tissue plasminogen activator strongly decreases the number of patients dying, or remaining care-dependent in a selected group of appropriate patients. Secondary prevention (lifestyle measures, acetylsalicyclic acid, treatment of hypertension and hypercholesterolaemia, and surgery of the carotids) may decrease the number of residual strokes and myocardial infarctions. In the occurrence of cerebral ischaemia and atrial fibrillation oral anticoagulants are indicated. Early intensive rehabilitation increases the chance of recovery. Silent cognitive defects may hinder rehabilitation. The extensive guideline summarises the scientific literature about treatment of patients with stroke and should serve as a basis for local protocols and appointments.
