[Summary of the practice guideline 'Bacterial skin infections' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Bacteriële huidinfecties' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The revised practice guideline 'Bacterial skin infections' developed by the Dutch College of General Practitioners replaces the previous practice guideline from 1998. Most bacterial skin infections can be diagnosed based on the patient history and clinical findings. Skin cultures and serologic analysis (in the case oferythema migrans) are not necessary. Exceptions are made for patients with bacterial skin infection and a high risk of MRSA involvement, or if nasal treatment is indicated for patients with recurring furunculosis. A superficial skin infection can be treated with local therapy. In case of a deep skin infection, oral antibiotics or surgical intervention is recommended. Antibiotic prophylaxis after a tick bite is not recommended. Erysipelas is considered a specific type of cellulitis and is treated as such.

Treatment with UV-B for psoriasis and nonmelanoma skin cancer: a systematic review of the literature.

BACKGROUND: In a cost-effectiveness study currently being conducted of short-contact anthralin treatment for psoriasis in an outpatient setting as compared with the standard treatment with UV-B radiation, the excess incidence (IDD) of skin cancer due to exposure to UV-B could not be ascertained because the study did not last long enough. A meta-analysis of published data was deemed appropriate. OBJECTIVE: To quantify the IDD of nonmelanoma skin cancer as a function of the total dose of UV-B and specific for time since first exposure, age at first treatment, and other treatments received. METHODS: Systematic review of the literature with meta-analysis of all available evidence published in English, French, German, or Dutch between 1980 and 1996. RESULTS: Four articles contained information that enabled us to calculate an overall IDD of nonmelanoma skin cancer. The estimates varied between -0.6 and 2 extra skin cancers per 100 patients with psoriasis treated with UV-B phototherapy per year. However, these estimates were calculated under several assumptions, and do not allow for the construction of a dose-response model specific for time since exposure or age at first treatment. A model based on animal data suggests that a total of 5 excess skin cancers can be expected per 100 treated in the 60 years after the start of treatment with 500 minimum effective doses of UV-B per year from age 25 years. CONCLUSIONS: The available evidence is insufficient for quantifying the IDD of nonmelanoma skin cancer in patients with psoriasis treated with UV-B radiation. However, it seems unlikely that the excess risk exceeds 2% per year. As yet, it is not possible to assess at what level of exposure this IDD occurs, or how long after exposure excess risk is present.

Elderly community residents' evaluative criteria and preferences for formal and informal in-home services.

This article focuses on the evaluative criteria of elderly community residents regarding their preferences in cases of long-term care decision-making. An overall picture of the evaluative criteria which the elderly use to evaluate various alternatives for long-term care are assessed. Furthermore, we determined which of these evaluative criteria may be considered as the most important by the elderly. A good relationship with informal carers appears almost pre-conditional to a preference for informal support. The desire not to burden acquaintances, as well as a positive previous experience with this type of care, are the most important reasons stated for choosing formal or private services. Insights into criteria that are used to evaluate different care arrangements clarify and refine our perspective on future developments.

The economic impact of introducing transurethral microwave thermotherapy in the treatment of benign prostatic hyperplasia: a scenario analysis.

The goal of this study was to assess the economic impact of introducing transurethral microwave thermotherapy (TUMT) in the treatment of benign prostatic hyperplasia (BPH). Different scenarios were constructed using both randomized clinical trial data and observational data on resource use related to BPH treatments. These include a baseline scenario, demand scenarios reflecting the number of men who will be treated by TUMT when it is introduced, and supply scenarios reflecting the number of hospitals that will provide TUMT. In the baseline scenario, costs of BPH treatment equal Netherlands guilders (NLG) 203 million. If the demand for BPH treatment does not increase following the adoption of TUMT, costs may vary between NLG 187 and 189 million, depending on how TUMT is provided. If the demand increases up to 25% following the introduction of TUMT, costs may vary between NLG 457 and 466 million, depending on how TUMT is provided. The introduction of TUMT seems to be cost-saving, but savings depend on the number of men who seek treatment for BPH. There is no indication for a controlled provision.

Sacral rhizotomies and electrical bladder stimulation in spinal cord injury. 2. Cost-effectiveness and quality of life analysis. Dutch Study Group on Sacral Anterior Root Stimulation.

OBJECTIVES: To present a cost-effectiveness analysis of sacral rhizotomies and electrical bladder stimulation compared with conventional care of neurogenic bladder dysfunction in patients with spinal cord injury. METHODS: During a 3-year inclusion period, data on costs and quality of life before the intervention were collected to describe conventional care. Data on the pre-implantation period, the implantation and a follow-up period of 2 years were collected following a strict protocol simultaneous with medical and urodynamic data and were used to calculate the costs and effects on quality of life of the implantation of the stimulator. RESULTS: Between June 1991 and June 1994, 52 patients with complete cervical or thoracic spinal cord lesions underwent sacral posterior rhizotomies and implantation of a Finetech-Brindley sacral anterior root stimulator. Although the initial costs of sacral anterior root stimulation are high, they are earned back in this series in about 8 years after the implantation. General indicators of the quality of life show no significant changes after the implantation. Factors related to psychological well-being and the patients' satisfaction with the emptying of the bladder increased significantly whereas the experienced problems of micturition and incontinence all decreased significantly. CONCLUSION: Sacral rhizotomies and electrical bladder stimulation make a cost-effective method of treatment of lower urinary tract dysfunction in patients with spinal cord injury. Considerable savings on health care costs are possible in the long run with simultaneous positive effects on aspects of health status.

Paroxysmal atrial tachycardia recorded by Holter monitoring during an episode of fear. A case report.

A twenty-four-year-old, white, athletic woman, free of heart disease, experienced an episode of fear when she was assaulted in the street without physical injury while under-going twenty-four-hour Holter monitoring. She developed an important sympathetic response in which, besides the symptoms characterized by palpitations, chest pain, dyspnea, asthenia, dizziness, nausea, and profuse cold sweating, she had an episode of paroxysmal atrial tachycardia. The causes and mechanism of this not well-documented event in humans are discussed.

[Effect of physical activity in the elderly: a review of current literature and the possibility of economic evaluation]. / Effect van lichaamsbeweging bij ouderen: een overzicht van recente literatuur en de mogelijkheid van economische evaluatie.

The Netherlands government emphasizes the importance of preventive care for the elderly. From an economic and preventive point of view the potential of exercise programmes to reduce the use of health care services by the elderly deserves attention. We present an overview of the literature on the effects of physical activity on health and psychological well-being of the elderly and their use of health services. Our review covers the period 1988-1993 and also includes review articles. We found almost sixty relevant articles which about all satisfied our methodological criteria. In men, physical activity probably has a positive influence on the frequency of ischaemic heart disease. Exercise delays the onset of osteoporosis in women. The results for other diseases are ambiguous, despite the large amount of literature. Similarly, it is not clear yet whether physical activity can enhance well-being. Research on the effects of physical activity on the use of health services has hardly been done. We conclude that well-designed studies are needed to determine the cost-effectiveness of exercise programmes in the elderly.

Effects of ACE inhibitors on heart failure in The Netherlands: a pharmacoeconomic model.

A modelling approach is used to analyse the cost effectiveness of prescribing angiotensin converting enzyme (ACE) inhibitors, compared with standard practice, as first-line therapeutic agents in the treatment of heart failure in The Netherlands. Data concerning costs, incidence, prevalence and survival are used to construct an age-dependent semi-Markov-chain model. Two scenarios are compared. The first reflects the continuation of common practice. The second, containing assumptions made on the basis of results from randomised clinical trials, reflects the situation in which ACE inhibitors are given as first-line pharmacotherapy. Conditional on the estimates and assumptions made, it is shown that prescribing ACE inhibitors as first-line pharmacotherapy will improve survival by about 4% over the first 10 years, and will save about 17% in costs over the first 10 years. Sensitivity analysis shows the robustness of the conclusions to all major parameters.

Intrathecal synthesis of anti-HIV IgG: correlation with increasing duration of HIV-1 infection.

We determined intrathecal synthesis (ITS) of anti-HIV-1 immunoglobulin in 62 CSF samples from 51 HIV-1 seropositive homosexual men using an ELISA technique with paired serum and CSF samples diluted to a concentration of IgG of 10 micrograms/ml. All subjects were neurologically normal and none was taking zidovudine. We estimated duration of HIV-1 infection from semiannual serologic testing during the 3-year period before CSF analysis and detected ITS of anti-HIV-1 immunoglobulin in 2 of 12 (17%) of those with less than 18 months of HIV-1 seropositivity, in 3 of 21 (14%) with 19 to 36 months, and in 13 of 29 (45%) with greater than 36 months of HIV-1 seropositivity (p = 0.037). There was a trend toward an inverse relationship between level of ITS and the peripheral blood T-helper lymphocyte count. This study demonstrates that increasing ITS of anti-HIV-1 IgG is related to duration of HIV-1 infection and suggests an inverse correlation with systemic immune status. The detection of ITS of anti-HIV-1 immunoglobulin is not necessarily a marker of clinically overt neurologic involvement.

Unilateral third nerve palsy and somnolent mutism.

A 64-year-old man developed unilateral third nerve palsy and somnolent mutism. Computed tomography (CT) revealed a small unilateral midbrain infarct. Previous reports of somnolent mutism placed the lesion in both sides of the midbrain tegmentum, usually extending into the thalamus. The unilateral third nerve palsy, and high-resolution 4-mm contiguous tomographic sections of the brainstem, helped localize the lesion. To our knowledge, this is the first CT clinical report of somnolent mutism induced by unilateral midbrain infarct.