[Prevention and control of infectious diseases from a disciplinary-law perspective]. / Preventie en bestrijding van infectieziekten in tuchtrechtelijk perspectief.

OBJECTIVE: To gain insight into the importance for medical disciplinary courts of the collective health interest in the prevention and control of infectious diseases. DESIGN: Descriptive retrospective study. METHOD: The electronic databases of the Dutch government gazette (Staatscourant) and the Netherlands' medical disciplinary courts were searched for disciplinary court rulings on actions and negligence in the prevention and control of infectious diseases. RESULTS: We found 67 verdicts relevant to our subject in the period 1995-2013. Of these 67 disciplinary hearings, 12 were filed by the Netherlands' health inspectorate, 29 by the patient and 26 by a representative or next of kin. The defendants included 31 medical specialists, 12 dentists and 11 general practitioners. The disciplinary tribunal imposed measures in 23 cases, including 5 suspensions. CONCLUSION: In the case of serious infectious diseases the disciplinary courts decide that the caregiver also has to take into account the interests of other parties than caregiver and the patient. Medical microbiologists in hospitals should even go so far as to surrender their responsibility for general patient safety, if they are unable to comply with the applicable medical guideline. It is also striking that in questions of vaccination the disciplinary court judge is inclined to put a child's health interests before parental authority. One final striking point is that the health inspectorate plays an important role as complainant in disciplinary cases concerning prevention of infection.

Lifestyle-Associated Risk Factors for Community-Acquired Methicillin-Resistant Staphylococcus aureus Carriage in the Netherlands: An Exploratory Hospital-Based Case-Control Study.

BACKGROUND: Community-acquired MRSA (CA-MRSA) is rapidly increasing. Currently, it is unknown which reservoirs are involved. An exploratory hospital-based case-control study was performed in sixteen Dutch hospitals to identify risk factors for CA-MRSA carriage in patients not belonging to established risk groups. METHODS: Cases were in- or outpatients from sixteen Dutch hospitals, colonised or infected with MRSA without healthcare- or livestock-associated risk factors for MRSA carriage. Control subjects were patients not carrying MRSA, and hospitalised on the same ward or visited the same outpatients' clinic as the case. The presence of potential risk factors for CA-MRSA carriage was determined using a standardised questionnaire. RESULTS: Regular consumption of poultry (OR 2⋅40; 95% CI 1⋅08-5⋅33), cattle density per municipality (OR 1⋅30; 95% CI 1⋅00-1⋅70), and sharing of scuba diving equipment (OR 2⋅93 95% CI 1⋅19-7⋅21) were found to be independently associated with CA-MRSA carriage. CA-MRSA carriage was not related to being of foreign origin. CONCLUSIONS: The observed association between the consumption of poultry and CA-MRSA carriage suggests that MRSA in the food chain may be a source for MRSA carriage in humans. Although sharing of scuba diving equipment was found to be associated with CA-MRSA carriage, the role played by skin abrasions in divers, the lack of decontamination of diving materials, or the favourable high salt content of sea water is currently unclear. The risk for MRSA MC398 carriage in areas with a high cattle density may be due to environmental contamination with MRSA MC398 or human-to-human transmission. Further studies are warranted to confirm our findings and to determine the absolute risks of MRSA acquisition associated with the factors identified.

Adolescent health screening and counseling.

Serious health problems, risky behavior, and poor health habits persist among adolescents despite access to medical care. Most adolescents do not seek advice about preventing leading causes of morbidity and mortality in their age group, and physicians often do not find ways to provide it. Although helping adolescents prevent unintended pregnancy, sexually transmitted infections, unintentional injuries, depression, suicide, and other problems is a community-wide effort, primary care physicians are well situated to discuss risks and offer interventions. Evidence supports routinely screening for obesity and depression, offering testing for human immunodeficiency virus infection, and screening for other sexually transmitted infections in some adolescents. Evidence validating the effectiveness of physician counseling about unintended pregnancy, gang violence, and substance abuse is scant. However, physicians should use empathic, personal messages to communicate with adolescents about these issues until studies prove the benefits of more specific methods. Effective communication with adolescents requires seeing the patient alone, tailoring the discussion to the individual patient, and understanding the role of the parents and of confidentiality.

Treatment of breast cancer.

Understanding breast cancer treatment options can help family physicians care for their patients during and after cancer treatment. This article reviews typical treatments based on stage, histology, and biomarkers. Lobular carcinoma in situ does not require treatment. Ductal carcinoma in situ can progress to invasive cancer and is treated with breast-conserving surgery and radiation therapy without further lymph node exploration or systemic therapy. Stages I and II breast cancers are usually treated with breast-conserving surgery and radiation therapy. Radiation therapy following breast-conserving surgery decreases mortality and recurrence. Sentinel lymph node biopsy is considered for most breast cancers with clinically negative axillary lymph nodes, and it does not have the adverse effects of arm swelling and pain that are associated with axillary lymph node dissection. Choice of adjuvant systemic therapy depends on lymph node involvement, hormone receptor status, ERBB2 (formerly HER2 or HER2/neu) overexpression, and patient age and menopausal status. In general, node-positive breast cancer is treated systemically with chemotherapy, endocrine therapy (for hormone receptor-positive cancer), and trastuzumab (for cancer overexpressing ERBB2). Anthracycline- and taxane-containing chemotherapeutic regimens are active against breast cancer. Stage III breast cancer typically requires induction chemotherapy to downsize the tumor to facilitate breast-conserving surgery. Inflammatory breast cancer, although considered stage III, is aggressive and requires induction chemotherapy followed by mastectomy, rather than breastconserving surgery, as well as axillary lymph node dissection and chest wall radiation. Prognosis is poor in women with recurrent or metastatic (stage IV) breast cancer, and treatment options must balance benefits in length of life and reduced pain against harms from treatment.

Newborn skin: Part I. Common rashes.

Rashes are extremely common in newborns and can be a significant source of parental concern. Although most rashes are transient and benign, some require additional work-up. Erythema toxicum neonatorum, acne neonatorum, and transient neonatal pustular melanosis are transient vesiculopustular rashes that can be diagnosed clinically based on their distinctive appearances. Infants with unusual presentations or signs of systemic illness should be evaluated for Candida, viral, and bacterial infections. Milia and miliaria result from immaturity of skin structures. Miliaria rubra (also known as heat rash) usually improves after cooling measures are taken. Seborrheic dermatitis is extremely common and should be distinguished from atopic dermatitis. Parental reassurance and observation is usually sufficient, but tar-containing shampoo, topical ketoconazole, or mild topical steroids may be needed to treat severe or persistent cases.

Newborn skin: Part II. Birthmarks.

Birthmarks in newborns are common sources of parental concern. Although most treatment recommendations are based on expert opinion, limited evidence exists to guide management of these conditions. Large congenital melanocytic nevi require evaluation for removal, whereas smaller nevi may be observed for malignant changes. With few exceptions, benign birthmarks (e.g., dermal melanosis, hemangioma of infancy, port-wine stain, nevus simplex) do not require treatment; however, effective cosmetic laser treatments exist. Supernumerary nipples are common and benign; they are occasionally mistaken for congenital melanocytic nevi. High- and intermediate-risk skin markers of spinal dysraphism (e.g., dermal sinuses, tails, atypical dimples, multiple lesions of any type) require evaluation with magnetic resonance imaging or ultrasonography. Family physicians should be familiar with various birthmarks and comfortable discussing disease prevention and cosmetic strategies.

Treatment of panic disorder.

Panic disorder with or without agoraphobia occurs commonly in patients in primary care settings. This article assesses multiple evidence-based reviews of effective treatments for panic disorder. Antidepressant medications successfully reduce the severity of panic symptoms and eliminate panic attacks. Selective serotonin reuptake inhibitors and tricyclic antidepressants are equally effective in the treatment of panic disorder. The choice of medication is based on side effect profiles and patient preferences. Strong evidence supports the effectiveness of cognitive behavior therapy in treating panic disorder. Family physicians who are not trained in cognitive behavior therapy may refer patients with panic disorder to therapists with such training. Cognitive behavior therapy can be used alone or in combination with antidepressants to treat patients with panic disorder. Benzodiazepines are effective in treating panic disorder symptoms, but they are less effective than antidepressants and cognitive behavior therapy.

Suicide risk not increased with SSRI antidepressants.

Depressed adult patients are no more likely to commit suicide while taking selective serotonin reuptake inhibitors (SSRIs) than any other class of antidepressants. The low suicide rate in the non-SSRI category, which included tricyclic antidepressants (TCAs), reminds us that no evidence exists to consider tricyclics more dangerous than other antidepressants, despite what is commonly believed. Thus, clinicians who avoid prescribing any antidepressant because of risk of suicide may change their clinical practice. It is important to remember that these patients are adults and had mild to moderate depression without any significant comorbid conditions.

Shock wave therapy ineffective for plantar fasciitis.

Extracorporeal shock wave therapy (ESWT) cannot be recommended to improve pain and function in patients with plantar fasciitis based on the results of this study. Although previous studies do report a benefit from ESWT, this study appears to represent a higher level of evidence than was previously available for evaluating the efficacy of this therapy. An updated meta-analysis combining all the studies on ESWT will be useful.