A Dutch consensus statement on the diagnosis and treatment of ANCA-associated vasculitis.

INTRODUCTION: Despite the availability of several guidelines on the diagnosis and treatment of antineutrophil cytoplasmic antibody-associated vasculitis (AAV), clinical routine practice will only improve when an implementation strategy is in place to support clinical decision making and adequate implementation of guidelines. We describe here an initiative to establish national and multidisciplinary consensus on broad aspects of the diagnosis and treatment of AAV relevant to daily clinical practice in the Netherlands. METHODS: A multidisciplinary working group of physicians in the Netherlands with expertise on AAV addressed the broad spectrum of diagnosis, terminology, and immunosuppressive and non-immunosuppressive treatment, including an algorithm for AAV patients. Based on recommendations from (inter)national guidelines, national consensus was established using a Delphi-based method during a conference in conjunction with a nationally distributed online consensus survey. Cut-off for consensus was 70% (dis)agreement. RESULTS: Ninety-eight professionals were involved in the Delphi procedure to assess consensus on 50 statements regarding diagnosis, treatment, and organisation of care for AAV patients. Consensus was achieved for 37/50 statements (74%) in different domains of diagnosis and treatment of AAV including consensus on the treatment algorithm for AAV. CONCLUSION: We present a national, multidisciplinary consensus on a diagnostic strategy and treatment algorithm for AAV patients as part of the implementation of (inter)national guideline-derived recommendations in the Netherlands. Future studies will focus on evaluating local implementation of treatment protocols for AAV, and assessments of current and future clinical practice variation in the care for AAV patients in the Netherlands.

[Therapeutic prescription of antibiotics and NSAID's by dentists in the Netherlands]. / Therapeutisch voorschrijven van antibiotica en NSAID's door tandartsen in Nederland.

Late in 2015 the Royal Dutch Dental Association (KNMT) conducted a study of the therapeutic prescription of antibiotics and NSAIDs by dentists in general practice in the Netherlands and the factors influencing their decisions. Of the 1,087 dentists contacted 367 (34%) completed the online questionnaire. In the 4 weeks preceding the study they had prescribed an antibiotic to 1.3% of their patients on average. A fifth (20%) found it difficult to decide whether an anti-inflammatory drug is indicated and/or whether this should be an antibiotic or a NSAID. Questioned about medication decisions (whether or not antibiotics are indicated) in 11 fictional cases, 11% of respondents judged every case correctly. 39% undertreated, 24% overtreated and 26% both undertreated and overtreated. In the last two categories, dentists with non-Dutch degrees are overrepresented. More than half (55%) of the respondents say they need a guideline for prescribing antibiotics in dental treatment and 28% (also) need postgraduate education on this matter.

[A woman at the chair is nothing out of the ordinary. Dental practice by female dentists in the Netherlands.] / Een vrouw aan de stoel is heel gewoon. De beroepsuitoefening van vrouwelijke tandartsen in Nederland.

Women currently make up 40% of the dentist population in the Netherlands. On the basis of enrolment in educational programmes their share can be expected to grow to more than half. The literature shows gender differences in preferences regarding work setting and duration of the working week. Men and women also differ from each other with respect to the way dental care is provided. The presented data demonstrate an increase in the number of women working in dentistry and research data have confirmed the presumed differences between male and female dentists. Women are less likely to be the owner of a practice, women who do own a practice are more likely to collaborate with colleagues and have a shorter working week. With regard to providing dental care, women seem to be slightly more orientated to the individual patient and are more likely to pay attention to the patient's general health. Theories about work values provide explanations for these gender differences. Women's preference for collaboration accords with the general development in dental care to work in teams.

Screening for renal involvement in ANCA-associated vasculitis: room for improvement?

BACKGROUND: Renal involvement in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) requires prompt and aggressive immunosuppressive therapy. The aim of this study was to evaluate screening practice for renal involvement in AAV and its potential effect on renal outcomes. METHODS: Between 2005 and 2015, ANCA-positive AAV patients in a teaching hospital in the Netherlands were retrospectively included. Complete screening for renal involvement was defined as: assessment of erythrocyturia, proteinuria and serum creatinine within two weeks of the diagnosis of AAV. Characteristics at presentation and at 12 months were compared between patients with and without complete screening. RESULTS: A total of 109 AAV patients (63% male) were identified with a mean age of 62 ±; 14 years. Complete screening for renal involvement was performed in 90 of the 109 patients (83%). Patients with incomplete screening had a lower serum creatinine (86 ±; 53 vs. 190 ±; 185 µmol/l, p < 0.001) and were more often diagnosed outside the renal department (100% vs. 78%, p = 0.02). Three patients with incomplete screening had a rise in serum creatinine of ≥ 30% at 12 months. Incomplete screening was not associated with the development of end-stage renal disease. Urine analysis of patients with renal biopsy-proven AAV (n = 31) showed erythrocyturia in 58% after one sample and in 94% after three samples. CONCLUSION: Screening for renal involvement in AAV was suboptimal, primarily in patients who presented outside the renal department. A higher sensitivity for erythrocyturia is achieved if urine analysis is repeated. Incomplete screening may lead to renal impairment if renal involvement is not treated appropriately.

[The well-being of dentists following a complaint procedure]. / Het welbevinden van tandartsen na een klachtenprocedure.

It is known that a patient's complaint can have a serious impact on the well-being of dentists. But little is known on the nature and the extent of this impact. That's why in 2013 an anonymous survey was conducted among 955 dentists and dental specialists, for whom in the period mid-2008 to mid-2013 a complaint was handled through the Complaint Committee of the Royal Dutch Dental Association (KNMT). Altogether, 413 (43%) of them participated in the study. 71% of the respondents reported that the complaint had influenced their professional practice. 52% reported that it had (also) influenced their attitude towards colleagues and patients, and 60% (also) experienced an impact on their mental and/or physical condition. Altogether, 68% reported that they had unpleasant feelings and 75% stated that the treatment relationship with the patient was terminated as a result of the complaint.

[Evidence-based clinical practice guidelines in oral care 3. Support for the development of clinical practice guidelines]. / Evidencebased klinische praktijkrichtlijnen in de mondzorg 3. Draagvlak voor richtlijnontwikkeling in de mondzorg.

Support is an important factor in the implementation of clinical practice guidelines. Data from 5 studies from 1998 through 2013 offer insight into the support for clinical practice guidelines among dentists, orthodontists, dental hygienists and denturists in the Netherlands. In these, attitudes, opinions, knowledge and behaviour were seen as indicators of support. Dentists have an increasingly positive attitude towards clinical practice guidelines. The majority is aware of and uses at least 1 of the guidelines available to them and are in favour of the development of clinical practice guidelines. Orthodontists and dental hygienists have available few such guidelines, but the majority of both groups favour their development. Among denturists, who also have little experience with clinical practice guidelines, there are fewer supporters for their development. All in all, among caregivers in oral healthcare in the Netherlands, support for the use and development of clinical practice guidelines is growing.

[Dentists' judgement of the complaint procedure of the Royal Dutch Dental Association]. / De KNMT-klachtenregeling beoordeeld door tandartsen.

In 2013, to evaluate the functioning of the complaint procedure of the Royal Dutch Dental Association (KNMT), an anonymous, written survey was conducted among 955 dentists and dental specialists, for whom in the period mid-2008 to mid-2013 a complaint was handled. 413 (43%) participated in the study. 51% of them reported that the complaint was successfully mediated by the Regional Mediation Boards and the Specialist Mediation Board and 17% that the patient had withdrawn the complaint. For the remaining 32% the complaint was handled by the Central Complaint Committee, who determined that 13% was (partially) substantiated, 17% was not substantiated and 2% was settled. Generally, 79% of the dentists are (mostly) positive about the procedure of mediation, while 8% are neutral and 13% are dissatisfied about it. With regard to the complaints procedure this was 60%, 11% and 29% respectively. The judgment of the dentists about the Regional Mediation Boards and the Specialist Mediation Board and about the Central Complaints Committee is influenced by the success of the complaints procedure and by the impact of the complaint that was experienced. The emotional support of dentists during the complaints trajectory is one of the points requiring attention.

[The Data Stations project: a monitor of dental practice in The Netherlands]. / Project Peilstations: monitor van de tandheelkundige beroepsuitoefening in Nederland.

Since 1995 the Dutch Dental Association (NMT) has carried out research on, in particular, the non-clinical aspects of dental practice with the Data Stations project. At present, within this research project 5 studies are conducted on a regular basis: the Dental Consumption Study, the Dental Practice Study, the Omnibus Survey, the Young Dentist Study and the Quality of Oral Care Study. From the results of this research project it appears that during the last decades dentists have increasingly been working cooperatively. This is expressed in dental practices with more dentists and more staff workers, with more dental chairs and more patients. The length of the working week, however, has changed very little over the years. Among both young people and adults gradual changes have taken place in dental consumption during the period 1997-2011. By intensifying the collaboration with clinical dental researchers the scope of the research within this project can be expanded to include the quality of oral care and the effects of care which has been provided on oral health in The Netherlands.

Evaluation of the threshold value for the Early Warning Score on general wards.

INTRODUCTION: The Early Warning Score (EWS) is used for early detection of deteriorating vital parameters and has been correlated with adverse outcomes. Unfortunately, neither its value on general wards nor the optimal cut-off value have been investigated. We aimed to find the optimal cut-off value for EWS on general wards, and investigated the possibility to raise this value from EWS ≥ 3 without compromising sensitivity too much. METHODS: From May 2010 until May 2011, EWS was calculated from vital parameters in all patients in medical and surgical wards in the Medical Centre Alkmaar. Cut-off value was defined as EWS ≥ 3, unless otherwise specified. Six responses were defined and categorised as interventions (infusion prescription, medication changes, ICU consultation) and other actions (no action, change EWS cut-off value, oxygen supplementation), and it was registered whenever the threshold was exceeded. RESULTS: 71,911 EWS values were obtained, 31,728 (44%) on medical wards and 40,183 (56%) on surgical wards. On medical wards, the cut-off value was exceeded 3734 times, and response was registered in 29% of the cases with 141 (12%) interventions. On surgical wards, the cut-off value was exceeded 3279 times, and response was registered in 19% of the cases with 633 (36%) interventions. Sensitivity and specificity for EWS ≥ 3 could not be calculated. For a calculated cut-off at EWS ≥ 4, sensitivity decreased to 74%. CONCLUSION: Raising the EWS threshold to 4 on general wards in the hospital would lead to an unacceptable decrease in sensitivity. Therefore, we recommend that the pre-defined cut-off should remain 3, with the possibility to personalise the threshold.

[Recently graduated dentists: working situation and future plans]. / Werksituatie en toekomstplannen van recent afgestudeerde tandartsen.

The Dutch Dental Association (NMT) surveyed dentists who graduated in 2004, 2005 or 2006 concerning their work situation and plans for the future. They were also asked about their experiences at the start of their career In general, the recently graduated dentists did not face difficulties at the start of their professional life. Most dentists worked in the practice of a colleague, but the majority ultimately wanted to have their own practice. The latter applied more to men than women. Furthermore, there was a clear preference for working within a team and most of them planned to specialize in a specific branch of dentistry. The survey also revealed that the delegation of tasks to dental hygienists and prevention assistants was more or less taken for granted by recently graduated dentists.

[The restorative care index in children 2. Factors concerning the dentist]. / De restauratieve verzorgingsgraad bij de jeugd 2. Tandartsfactoren.

As part of a broader study of the restorative care index of 5- and 6-year-olds and 11- and 12-year-olds, a sample study was carried out among 1,361 dentists, who were surveyed by means of a web-questionnaire concerning this issue. In total 447 dentists (33%) filled in the questionnaire completely. Concerning the development of dental care of children, opinions differed widely: 46% of those questioned spoke of an increase in the incidence of caries during the past 5 years and 44% reported no change. Furthermore, dentists hold different views on the treatment of the primary dentition. There was no consensus of opinion about the necessity of treating caries in young children and there was a comparable lack of agreement about how and when treatment should be given. The majority of dentists express a need for support in their practice (possibilities for referral, protocols, informational material) concerning routine oral examination, the preventive and/or curative treatment of (young) children.

[The restorative care index in children 1. Factors concerning the child]. / De restauratieve verzorgingsgraad bij de jeugd 1. Patiëntgebonden factoren.

In 2007 a study was undertaken of the restorative care index of the teeth of children under the age of 18. The aim of this study was to gain insight into the factors associated with the restorative care index in children. Factors investigated were (post-) brushing, inspection frequency, sweets-consumption frequency, socio-economic status and treatment or lack thereof by a general practitioner or dentist who works in a clinic for child health care. This study made use of statistics assembled for an earlier study of children formerly covered by public health insurance in the municipality of The Hague and research carried out at child dental clinics. Socio-economic status and the level of oral care were correlated with dental quality. No patient-bound factors were significantly correlated with the level of care. There was however a positive correlation between the'type' of dentist (family dentist or dentist associated with a clinic for child dental care) and the chance of curative treatment (in the case of developing caries).

[Patient education in a dental practice]. / Voorlichting in tandartspraktijken.

Patient education is an important part of the care provided in a dental practice. Explanations concerning dental treatments is in the majority of practices exclusively the responsibility of the dentist. Information about oral hygiene and prevention is generally provided by oral hygienists and prevention assistants. It is striking that agreements are made concerning the form and content of patient education, the division of responsibilities and the use of teaching aids in only 39% of practices. It is possible that this has to do with the relatively few hours that oral hygienists and/or prevention assistants are active each week in the practice, and the judgement of the dentists that sufficient time has to be devoted to discussing a proposed treatment with the patient.

[Dentists on continuing dental education]. / Tandartsen over bij- en nascholing.

In support of its quality policy, the Dutch Dental Association (NMT) has undertaken a survey to examine dentists'views on continuing education, accreditation, and their postgraduate course attendance. In December 2004 a written questionnaire was sent to a sample of 710 dentists, of whom 504 (71%) responded. The data were analysed using SPSS. Most dentists (93%) attended one or more courses since January 2003. They tend to concentrate on a few subjects, mainly on clinical procedures. About half (45%) of the respondents are in favour of continuing education accreditation for dentists. Compared to opponents, supporters are more positive about continuing education in general and spend more time reading specialist literature. Furthermore, the greater part of dentists indicates that it is important to have some kind of quality mark for postgraduate courses.

[Accelerated elimination using hemoperfusion in a patient with phenobarbital intoxication]. / Versnelde eliminatie door hemoperfusie bij een patiënte met fenobarbitalintoxicatie.

A 44-year-old female was found comatose after attempting suicide. Toxicological screening showed phenobarbital intoxication. The patient was treated symptomatically. After ten days her serum level of phenobarbital still had not decreased and she was not clinically recovered. The patient was transferred to another hospital for hemoperfusion to decrease the level of phenobarbital. After hemoperfusion the level of phenobarbital dropped significantly and the patient recovered neurologically. Phenobarbital has a long elimination half-life and for this reason it is advisable to use means to accelerate clearance until the clinical condition of the patient shows improvement. Multiple-dose activated charcoal effects the elimination of phenobarbital. If elimination needs to be speeded up, then hemoperfusion can be considered. If this technique is unavailable, hemodialysis is a good alternative.

Ex-situ conservation of Black poplar in Europe: genetic diversity in nine gene bank collections and their value for nature development.

Populus nigra L. is a pioneer tree species of riparian ecosystems that is threatened with extinction because of the loss of its natural habitat. To evaluate the existing genetic diversity of P. nigra within ex-situ collections, we analyzed 675 P. nigra L. accessions from nine European gene banks with three amplified fragment length polymorphism (AFLP) and five microsatellite [or simple sequence repeat (SSR)] primer combinations, and 11 isozyme systems. With isozyme analysis, hybrids could be detected, and only 3% were found in the gene bank collection. AFLP and SSR analyses revealed effectively that 26% of the accessions were duplicated and that the level of clonal duplication varied from 0% in the French gene bank collection up to 78% in the Belgian gene bank collection. SSR analysis was preferred because AFLP was technically more demanding and more prone to scoring errors. To assess the genetic diversity, we grouped material from the gene banks according to topography of the location from which the accessions were originally collected (river system or regions separated by mountains). Genetic diversity was expressed in terms of the following parameters: percentage of polymorphic loci, observed and effective number of alleles, and Nei's expected heterozygosity or gene diversity (for AFLP). Genetic diversity varied from region to region and depended, to some extent, on the marker system used. The most unique alleles were identified in the Danube region (Austria), the Rhône region (France), Italy, the Rijn region (The Netherlands), and the Ebro region (Spain). In general, the diversity was largest in the material collected from the regions in Southern Europe. Dendrograms and principal component analysis resulted in a clustering according to topography. Material from the same river systems, but from different countries, clustered together. The genetic differentiation among the regions (F(st)/G(st)) was moderate.

[Dental professionals in the future: flexible team players. The vision of dental professionals on future professional structure and occupation]. / Tandheelkundige professionals van morgen: flexibele teamspelers. De visie van het tandheelkundig beroepsveld op de toekomstige beroepsstructuur en beroepsuitoefening.

The project 'From care-demand for care to a social dental occupational and educational structure' was carried out to reach an agreement about the organization of the future social occupational and educational structure and the future performance of one's profession. A descriptive analysis of data, obtained by literature search and consensus-meetings was used. All relevant professional associations participated in this project. The project resulted in profiles for the future dental professionals and for the future dental team. In this project the dental professionals come to an agreement about the future professional performance. However, the discussion has not yet been finished. Further collaboration between the professional associations is recommended.

Simultaneous detection of NOS-3 protein expression and nitric oxide production using a flow cytometer.

Nitric oxide (NO) is involved in the regulation of SMC proliferation during intimal hyperplasia as has been shown by the inhibitory effect on intimal hyperplasia of adenovirus-mediated ceNOS overexpression in injured arteries in pig. Good assays to quantify the NO-producing enzymes, i.e., NO synthases (NOS), are essential to analyze the mechanism of action of NO in this process. We have developed novel flow cytometric assays for the simultaneous detection of NOS-3 protein, using NOS-3 specific antibodies, and NO production using 4,5-diaminofluorescein-diacetate (DAF-2/DA). The presence of NOS-3 protein and NO production is demonstrated on human A549 and HepG2 cells infected with a NOS-3 adenovirus (Ad.NOS-3). A comparative study showed that the flow cytometric assays are equally sensitive as Western blot analysis, the citrulline assay, or the Sievers assay. On human endothelial and SMC, NOS-3 protein and NO production were simultaneously detected with the assays, both under basal conditions and after Ad.NOS-3transduction. Simultaneous analysis of NOS-3 protein and NO production, made possible by the here-described novel flow cytometric assays, is of significant value to those investigating NOS-3 and NO.