[A 14-year-old Syrian refugee with neurobrucellosis]. / Een 14-jarige Syrische vluchteling met neurobrucellose.

BACKGROUND: Neurobrucellosis is a rare complication of brucellosis, a bacterial zoonotic disease endemic in regions such as the Middle East. It is important to be alert for this imported disease in the Netherlands as well, especially among migrants. CASE DESCRIPTION: A 14-year-old boy from Syria presented with headache, vomiting and weight loss. Brucella melitensis was identified in the cerebrospinal fluid. The patient's condition deteriorated despite antibiotic treatment, particularly neurologically, and imaging revealed a newly developed hydrocephalus. The symptoms disappeared after placement of a temporary external ventricular drain. The patient made a complete recovery following 8 months of continual antibiotic therapy. CONCLUSION: Diagnosis and treatment were delayed, partly because there were no medical records available, previous treatment had been interrupted when the patient fled the country, and the language barrier. Knowledge of previous medical history and of the epidemiology of infectious diseases in the land of origin is particularly important when treating migrants. Treating brucellosis with antibiotics can lead to clinical deterioration due to a Jarisch-Herxheimer-like phenomenon.

[Pharmacogenetics in the treatment of tobacco addiction]. / Farmacogenetica bij de behandeling van tabaksverslaving.

BACKGROUND: Smokers vary in their genetic susceptibility to become addicted to smoking and probably also in their reaction to smoking cessation pharmacotherapies. AIM: To provide an overview of the developments on the pharmacogenetics of the treatment of tobacco addiction. METHOD: Review article describing the biological processes associated with tobacco addiction, and the influence of genetic variants on smoking behavior and the efficacy of smoking cessation therapies. RESULTS: Several (combinations of) genetic variants in smoking-related genes influence nicotine dependence. Moreover, several genetic variants in smoking- and treatment-related genes seem to influence the efficacy of smoking cessation therapies which are distinctive for the different forms of pharmacotherapy, especially when they have a different mechanism-of-action. CONCLUSION: Much progress has been made in unraveling the (pharmaco)genetics of tobacco addiction, but much still remains to be done before genetically tailored smoking cessation therapy can be implemented in clinical practice.

Genetic variation as a predictor of smoking cessation success. A promising preventive and intervention tool for chronic respiratory diseases?

Tobacco smoking continues to be the largest preventable cause of premature morbidity and mortality throughout the world, including chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease. Although most smokers are highly motivated to quit and many smoking cessation therapies are available, cessation rates remain very low. Recent research strongly suggests that variation in genetic background is an important determinant of smoking behaviour and addiction. Since these genetic variants might also influence the response to smoking cessation pharmacotherapies, it is likely that assessment of genetic background could be a promising tool to guide selection of the most effective cessation treatment for an individual smoker. Recently, it has been shown that genetic variants in the dopaminergic system, opioid receptors, the bupropion-metabolising enzyme CYP2B6 and the nicotine-metabolising enzyme CYP2A6 may play an important role in predicting smoking cessation responses to nicotine replacement therapy and bupropion treatment. Despite the progress that has been made, several challenges will still have to be overcome before genetically tailored smoking cessation therapy can be implemented in standard clinical practice.

Automation of the patient history--evaluation of ergonomic aspects.

In this study it was investigated in quantitative terms how patient reactions were on automated history-taking. The study is part of a comprehensive project, in which also physicians participated in the validation of such computerized medical records. In total 99 patients, visiting the outpatient clinic of Internal Medicine for the first time, took part in this in-depth study, in which they could express themselves via an interactive and modified terminal and keyboard. The questionnaire that was used in the system contains 28 different screens. Patient complaints are entered together with data on frequency, severity, onset, and duration. The patient may indicate his physical complaints on a stylized picture of the human body. Of the 99 patients, 67 answered the full questionnaire, and another 16 the main part. On the average, 66 min were needed. Younger patients do complete the history in a significantly shorter time than older patients, resulting in relatively more completed histories for the younger group. Quick patients answered on the average 3.5 questions per minute, the slow patients only 2.5. This was strongly correlated with patient familiarization, that has also been investigated: patients who had a quick familiarization were able to finish within 50 min. Patients who needed no help at all in using the system had even answering rates of 3.9/min.

AIDA for the automation of the patient history.

This article describes the application of a fourth-generation programming package (AIDA) for the construction of an interactive system for history-taking. It is shown that this system has been made very flexible and user-friendly, and that patients can easily answer all questions themselves. Parts of the system, that are supported by AIDA, are an interactive terminal with special, illuminated function keys, a screen driver for the generation and maintenance of 28 different screens, extensive help texts (with 260 help messages), and a report generator. The screens contain altogether 402 questions, through which 434 different answers can be given on 179 different items. The system has been evaluated extensively.

Comparisons between written and computerised patient histories.

Patient histories were obtained from 99 patients in three different ways: by a computerised patient interview (patient record), by the usual written interview (medical record), and by the transcribed record, which was a computerised version of the medical record. Patient complaints, diagnostic hypotheses, observer and record variations, and patients' and doctors' opinions were analysed for each record, and records were compared with the final diagnosis. About 40% of the data in the patient record were not present in the medical record. Two thirds of the patients said that they could express all or most of their complaints in the patient record. The doctors found that the medical record expressed the main complaints better (52%) than the patient record (15%) but that diagnostic hypotheses were more certain in the patient record (38%) than in the medical one (26%). The number of diagnostic hypotheses in the patient record was about 20% higher than that in the medical record. Intraobserver agreement (51%) was better than interobserver agreement (32%), while the inter-record agreement varied from 25% (between the medical and patient records) to 35% (between the transcribed and patient records). One third of final diagnoses were seen in the medical record, with 29% and 22% for the transcribed and patient records, respectively. Interobserver agreement in the final diagnosis was 35%. The results of the study suggest that computerised history taking is suitable for certain patients in addition to, and not as a substitute for, the oral interview with a doctor.

Appraisal of computerized medical histories: comparisons between computerized and conventional records.

Automated patient histories in internal medicine have been compared with written medical records by investigating the diagnostic statements that were generated for both types of records by three internists. Also the intra and interobserver variability was evaluated. In addition, the opinion of the internists about the usability of the different records was investigated. To have a fair comparison, the written record was transcribed to a computerized form and also offered to the internists. Each internist evaluated in total 72 records (from 18 patients) and altogether 529 diagnostic hypotheses were generated. The intraobserver agreement was for the written record 55%, for the automated history 46% and for the transcribed record 38%. Interobserver agreement was 23.5%, the agreement between the automated patient history and the written record was 24%, between the former and the transcribed record it was 36%.

Patient appreciations of computerized medical interviews.

In a research project on the automation of patient histories, 99 patients in internal medicine were questioned about their opinions on computerized medical records, after having answered an automated questionnaire. Patients were very positive on being able to express their medical complaints and the large majority found it useful (94%); 68% could express all or most of their complaints, but some of their physical complaints could not be entered (47% women against 25% men). Of the male patients 74% found the range of answers from which to choose sufficient, against 52% of the women. The printed report was positively rated, with a higher appreciation by men.

Predictive value of a positive endocervical curettage in diagnosis and treatment of CIN.

Predictive values of endocervical curettage (ECC) in the investigation of patients with abnormal Pap-smears were calculated with regard to a second histological diagnosis and with regard to results of conservative treatment of CIN. By using the combined follow up data of all 290 patients with colposcopically directed biopsies and ECC, the predictive value of a positive ECC for invasive cancer in patients with satisfactory colposcopy was 2%, and for unsatisfactory colposcopy 15%. Predictive value of a negative ECC was 100% in patients with satisfactory colposcopy, and 98% for unsatisfactory colposcopy. It is concluded that ECC should be used routinely in the investigation of patients with abnormal Pap smears. However, a positive ECC is not considered an absolute contraindication to conservative treatment, provided that colposcopy is satisfactory, that there is no suspicion of invasive cancer, and that a strict follow-up scheme can be maintained during the first year.

Predictive value of the abnormal PAP smear: a retrospective analysis of error rates.

The validity and performance of the Papanicolaou (PAP) smear, as a diagnostic test, was retrospectively analysed in 806 patients who presented with at least one abnormal smear. Histological tissue examination was available in 620 of these patients. It is shown that the definition of errors, selection criteria of smears, time intervals between examinations, definition of 'disease' and the values separating 'positive' and negative' test results must be clearly defined before comparison with other published error rates is possible. Consequently, a standardized method of reporting is recommended. Exact agreement between the results of cytology and histology was poor. The use of sensitivity, specificity and predictive values is preferred, but it is shown that precise definitions are still necessary. The optimal choice of the value separating positive and negative test results, i.e., the choice between an expectant and an active management of patients, must be tailored to the anticipated prevalence of the disease.

Laser or cryotherapy for cervical intraepithelial neoplasia: a randomized study to compare efficacy and side effects.

A randomized study was performed to compare efficacy and side effects of laser and cryotherapy: 51 patients were treated with laser vaporization and 50 patients with cryotherapy. Success rates for laser and cryotherapy were not significantly different. Success rates were significantly related to lesion size. Grade of CIN, positive endocervical curettage, parity, and age at treatment were not found to be related. Vaginal discharge, both in duration and amount, was significantly less in patients treated with laser vaporization, compared with cryotherapy, but pain and bleeding occurred more often in patients treated with laser vaporization. A brief review of possible sources of bias in comparative studies on laser and cryotherapy is given, indicating the preference for a randomized study. It is concluded that widespread introduction of laser facilities in smaller centers is not justified, because the success rates are not better than those of cryotherapy, and because the advantages of less discharge are outweighed by the high cost.