[Guideline 'Diagnosis and treatment of carpal tunnel syndrome']. / Richtlijn 'Diagnostiek en behandeling van het carpale-tunnelsyndroom'.

--Carpal tunnel syndrome (CTS) is the most frequently encountered peripheral nerve entrapment: about 10% of adult women and less than 1% of adult men in the Netherlands have a clinically and electrophysiologically confirmed CTS. --All medical and paramedical disciplines involved in the diagnosis and treatment of CTS in the Netherlands contributed to the development of a guideline for the diagnosis and treatment ofCTS. --Clinical diagnosis of CTS is based on a history of nocturnal pins and needles, numbeness and/or pain in the median nerve innervated area of the fingers and hand, which often causes the patient to awake. --Provocative tests do not contribute to the clinical diagnosis of CTS. --If invasive therapy is considered, such as corticosteroid injection or surgery, the clinical diagnosis must be confirmed by abnormal findings in electrophysiological tests. --Ultrasound or MRI of the wrist may be of diagnostic value when structural abnormalities in the carpal tunnel are suspected. Given the special expertise needed for ultrasound testing and the limited availability of MRI for CTS diagnostic purposes, these methods are not the first preference. --Depending on the degree of impact on daily functioning, treatment for CTS may be expectative, conservative (wrist splint or local steroid injections) or surgical (endoscopic or open techniques). --If CTS does not restrict daily functioning, adjustment of the working conditions will do. --Furthermore measures aimed at CTS prevention and treatment of an already existing work-related CTS are discussed.

[Relationship between volume and quality of care for surgical interventions; results of a literature review]. / Verband tussen volume en kwaliteit van zorg bij heelkundige ingrepen; resultaten van een literatuuronderzoek.

OBJECTIVE: To examine the relationship between the number of procedures performed per hospital or per surgeon and health care outcomes. DESIGN: Literature review. METHOD: Relevant literature was identified using recent systematic reviews from Germany, England, France and the United States. The Cochrane Library, Medline and Embase were also searched for recent studies (2000-2005) published in German, English, French, or Dutch using the combined search terms 'surgery' and 'volume'; included studies reported mortality or morbidity as measures of health care quality. RESULTS: 5 systematic reviews were found, which described the results of a total of 41 relevant articles. 8 original articles of sufficient quality published since 2000 were also identified. Most of these articles were also included in the reviews. Relationships between volume per hospital and per surgeon and case fatality (or survival) and morbidity were found for a number of surgical procedures. The strongest associations between volume and case fatality were found for pancreatic and oesophageal resection and, to a lesser degree, elective repair ofabdominal aortic aneurysm. For other procedures the relationship was relatively weak, absent, or not studied. CONCLUSION: Volume appears to be related to quality for some surgical procedures. The magnitude of the relationship differs depending on the procedure. For technically less complex procedures, organisation within the hospital appears to have a greater influence on the differences between hospitals than the performing surgeon.

[The guideline 'Psychiatric evaluation in adults']. / Richtlijn 'psychiatrisch onderzoek bij volwassenen'.

Psychiatric evaluation is defined as a systematic evaluation of the causes, the symptoms, the course and the consequences of a psychiatric disorder in order to formulate a diagnosis and a treatment plan, and to answer any questions the patient or referring specialist may have. The main components of a comprehensive psychiatric evaluation are the patient interview and observations of the patient's behaviour. The comprehensiveness of the psychiatric evaluation is affected by contextual, patient-related and situational factors. In the psychiatric diagnosis a distinction is made between the diagnostic classification (according to the DSM-IV-classification) and a structural diagnosis. The sequence ofthe elements ofthe psychiatric evaluation is based on medical tradition. In the mental-status examination all objective and subjective psychiatric symptoms are systematically reviewed. The grouping of the symptoms is based upon the classical division of mental functions into cognitive, affective and conative functions.

[Guideline 'NSAID use and the prevention of gastric damage']. / Richtlijn 'NSAID-gebruik en preventie van maagschade'.

Supported by the Dutch Institute for Health Care Improvement (CBO), a committee consisting of rheumatologists, general practitioners, gastroenterohepatologists, hospital pharmacists and a health-economist have developed a national evidence-based guideline for the prevention of gastric damage by non-steroidal anti-inflammatory drugs (NSAIDs). The goal of the guideline is to reduce the number of gastric ulcers with perforation or bleeding as a consequence of NSAID use. It is estimated that 165 patients died as a result of these complications in the year 2000. The guideline comprises chapters on the risk factors for ulceration during NSAID use, the effectiveness and relative toxicity of different NSAIDs for the stomach, the effectiveness of various treatments meant to reduce the risk of gastro-duodenal damage, and the management of dyspeptic symptoms during NSAID use. A strategy is recommended in which prescription of NSAIDs is always preceded by an assessment of the degree to which the risk of gastric damage is increased: the most important risk factors that need to be identified are previous peptic ulcer disease, age over 70 years, and an untreated Helicobacter pylori infection associated with peptic ulcer disease. Whenever an increased risk of gastro-duodenal damage is present, the prescribing physician can choose one of three preventive strategies: addition of misoprostol, addition of a proton-pump inhibitor, or the prescription of a COX-2-selective NSAID. Provided that adequate risk assessment has been carried out, the guideline leaves it to the patient and physician to choose which of these preventive measures, all of which result in roughly equal risk reduction and costs, is the most suitable for individual situations. The use of aspirin or a coumarin derivative increases the risk; several preventive strategies are possible; the guideline discusses the situation that arises when NSAIDs are added to the treatment.

The effect of exercise training programs on bone mass: a meta-analysis of published controlled trials in pre- and postmenopausal women.

With the aging of the population, the medical and social costs of skeletal fragility leading to fractures will cause an immense burden on society unless effective prophylactic and therapeutic regimens can be developed. Exercise is suggested as a possible regimen against involutional bone loss. The purpose of the present meta-analysis is to address a quantitative review of the randomized controlled trials (RCTs) and nonrandomized controlled trials (CTs) on the effects of exercise training programs on bone mass, measured as bone mineral density (BMD) or bone mineral content (BMC), of the lumbar spine (LS) and the femoral neck (FN) in pre- and postmenopausal women. The literature from 1966 through December 1996 was searched for published RCTs and CTs. Study treatment effect is defined as the difference between percentage change in bone mass per year in the training group and the control group. Overall treatment effects (OTs) with the 95% confidence intervals of these study treatment effects were calculated using inverse-variance weighting. Of the 62 articles identified, 25 met the inclusion criteria and were maintained for further analyses. The weighted OTs for the RCTs showed very consistently that the exercise training programs prevented or reversed almost 1% of bone loss per year in both LS and FN for both pre- and postmenopausal women. The two OTs that could be calculated for strength training programs did not reach significance. The OTs for the CTs were almost twice as high as those for the RCTs, which gives an indication of the confounding introduced by the nonrandom allocation of the subjects to groups.

Physical work capacity after 7 wk of wheelchair training: effect of intensity in able-bodied subjects.

PURPOSE: The purpose of this study was to study the effects of a 7-wk wheelchair training program on physical work capacity in able-bodied subjects. Effects of training intensities of 50 and 70% heart rate (HR) reserve (HRR) were studied for different subject groups. METHODS: Twenty-seven able-bodied male subjects participated in this study. They were randomly divided into a control group (N = 8), a 50%-intensity group (N = 9), and a 70%-intensity group (N = 10). The 50%- and the 70%-intensity groups received a 7-wk wheelchair training program: three times a week, one-half hour wheelchair exercise on a motor driven treadmill at an average intensity of 50 and 70% of the HRR, respectively. Before and after the training period, parameters for physical work capacity (maximal isometric strength (Fiso), sprint power (P30), maximal power output (POmax) and peak oxygen uptake (VO2peak)), and submaximal performance (mechanical efficiency, HR) at 20 and 40% of the estimated POmax (ME20, ME40; HR20, HR40) were obtained during tests on a stationary wheelchair ergometer. RESULTS: A two-factor ANOVA for repeated measures on the within-subjects factor "pre-post tests," the between-subject factor training (50% and 70% training vs control) and the interaction term showed that the 50%-intensity group significantly increased on P30 and POmax compared with the control group. The 70% intensity group significantly increased on P30, POmax and VO2peak compared with the control group (P < 0.05). The 70% group did not show significantly higher increases in P30 and POmax over training than the 50% intensity. No significant effects were found for the Fiso and the parameters at submaximal PO. CONCLUSIONS: The wheelchair training at both intensities can have favorable effects on maximal physical work capacity in able-bodied subjects, and possibly also on mechanical efficiency at submaximal power output. Effects are seen in parameters for both aerobic and anaerobic work capacities. Although training at 70% intensity was more effective than the 50% intensity, training at 50% HRR may initially be more appropriate in untrained individuals, such as novice wheelchair users at the start of their rehabilitation, to prevent fatigue and enhance motivation.