Hospital referral of detainees during police custody in Amsterdam, The Netherlands.

This study describes how many detainees have been referred to emergency departments for further evaluation or emergency care while in police custody in Amsterdam (years 2012/2013). It provides insights into the diagnoses assigned by forensic doctors and hospital specialists and the appropriateness of the referrals. We made use of the electronic registration system of the Forensic Medicine Department of the Public Health Service Amsterdam. This department is in charge of the medical care for detainees in the Amsterdam region. Hospital diagnoses were obtained through collaboration with several Amsterdam-based hospitals. According to our results, in 1.5% of all consultations performed, the detainee was referred to hospital. The most frequent reasons for referral were injuries (66%), intoxication/withdrawal (11%) and cardiac problems (7%). In 18% of all referrals, hospital admission (defined as at least one night in the hospital) was the consequence. After review of hospital files, the indication for referral as stated by the forensic physician was confirmed in 77% of all cases. A minority of referrals was considered unnecessary (7%). The identified cases allow for a discussion of cases of over-referral. Future research should focus on the problem of under-referral and associated health risks.

[A woman with severe abdominal pain and endometriosis in the past]. / Een vrouw met hevige buikpijn en eerdere endometriose.

A 44-year-old woman came to the emergency department with severe pain in the right upper abdomen. Her medical history mentioned a low anterior resection 8 years ago because of severe endometriosis. The CT scan showed a ruptured right hemidiaphragm with herniation of the small intestine.

Definition of hemodynamic stability in blunt trauma patients: a systematic review and assessment amongst Dutch trauma team members.

INTRODUCTION: Trauma is a great contributor to mortality worldwide. One of the challenges in trauma care is early identification and management of bleeding. The circulatory status of blunt trauma patients in the emergency room is evaluated using hemodynamic (HD) parameters. However, there is no consensus on which parameters to use. In this study, we evaluate the used terms and definitions in the literature for HD stability and compare those to the opinion of Dutch trauma team members. METHOD: A systematic review was performed to collect the definitions used for HD stability. Studies describing the assessment and/or treatment of blunt trauma patients in the emergency room were included. In addition, an online survey was conducted amongst Dutch trauma team members. RESULTS: Out of a total of 222, 67 articles were found to be eligible for inclusion. HD stability was defined in 70% of these articles. The most used parameters were systolic blood pressure and heart rate. Besides the variety of parameters, a broad range of corresponding cut-off points is noted. Despite some common ground, high inter- and intra-variability is seen for the physicians that are part of the Dutch trauma teams. CONCLUSION: All authors acknowledge HD stability as the most important factor in the assessment and management of blunt trauma patients. There is, however, no consensus in the literature as well as none-to-fair consensus amongst Dutch trauma team members in the definition of HD stability. A trauma team ready to co-operate with consensus-based opinions together with a valid scoring system is in our opinion the best method to assess and treat seriously injured trauma patients.

Long term IOP lowering efficacy of bimatoprost/timolol fixed combination: a 12 month prospective study.

PURPOSE: To evaluate the long-term IOP-lowering effect of an initially successful switch from prostaglandine-analog (PGA) monotherapy to bimatoprosttimolol fixed combination (BTFC) METHODS: Prospective, monocentric, open-labeled clinical trial. 30 patients with insufficient intraocular pressure (lOP) control under PGA monotherapy were screened. Following a one month run-in period of BTFC, patients who presented an effective IOP-lowering response were prospectively studied for an additional 11-month period. IOP, tolerability and safety (adverse reactions, slit lamp biomicroscopy) were further assessed at month 6 and month 12 after initiating BTFC. RESULTS: BTFC therapy significantly decreased IOP when compared to PGA monotherapy (PGA monotherapy: 17.3+/-3.8 mmHg; BTFC 1 month 13.2+/-3.3mmHg; p<0.05). This decrease from PGA-monotherapy IOP was sustained throughout the time-frame (6-month: 13.5+/-3.6mmHg; 12-month: 13.9+/-2.4mmHg; p<0.05 in pairwise comparison). There was no statistical difference in IOP between BTFC study visits (p>0.05). Of the 27 patients who had a satisfactory lOP-lowering response to BTFC after one month, 18 (66.7%) still had sufficient IOP control at the 12 month study visit. Therapy was discontinued at 1 month in 3 patients (2 due to intolerance to medication and 1 failing to achieve IOP control). No intolerability was reported beyond the 1 month of BTFC therapy. CONCLUSION: In the majority of patients, the initial lOP lowering effect of replacing PGA monotherapy by BTFC seems to predict a long term response to the new treatment strategy.

Oximetry: recent insights into retinal vasopathies and glaucoma.

This review will highlight a new technology and recent insights into measuring retinal oxygen saturation in several ophthalmic diseases. A growing body of evidence suggests that disturbances in retinal blood flow and oxygenation are related to several retinopathies and glaucoma, which can severely impair vision. The retinal oximeter may allow researchers and physicians to gain deeper insights into retinal physiology and clarify the impact of ischemia on retinal health and function. There are two commercially available systems to measure retinal oxygen saturation: the Oxymap retinal oximeter (Reykjavik, Iceland) and the Imedos Systems UG (Jena, Germany). In this review we will focus on the results obtained with Oxymap. Direct and non-invasive measurement of retinal oxygen saturation have potentially useful diagnostic and therapeutic indications in various eye diseases such as diabetic retinopathy, age-related macular degeneration, central retinal vein and artery occlusion, anterior ischemic optic neuropathy and retinopathy of prematurity. Despite several limitations, oxygen saturation assessment in the retinal vessels is a significant advancement in the understanding of ocular diseases. Nevertheless, further studies are needed to validate the use of oximetry in retinal vasopathies and glaucoma.

Hyperfibrinolysis in out of hospital cardiac arrest is associated with markers of hypoperfusion.

AIM OF THE STUDY: This study investigated the incidence of hyperfibrinolysis upon emergency department (ED) admission in patients with out of hospital cardiac arrest (OHCA), and the association of the degree of hyperfibrinolysis with markers of hypoperfusion. METHODS: From 30 OHCA patients, cardiopulmonary resuscitation (CPR) time, pH, base excess (BE), and serum lactate were measured upon ED admission. A 20% decrease of rotational thromboelastometry maximum clot firmness (MCF) was defined as hyperfibrinolysis. Lysis parameters included maximum lysis (ML), lysis onset time (LOT) and lysis index at 30 and 45 min (LI30/LI45). The study was approved by the Human Subjects Committee. RESULTS: Hyperfibrinolysis was present in 53% of patients. Patients with hyperfibrinolysis had longer median CPR times (36 (15-55) vs. 10 (7-18)min; P=0.001), a prolonged activated partial thromboplastin time (54 ± 16 vs. 38 ± 10s; P=0.006) and elevated D-dimers (6.1 ± 2.1 vs. 2.3 ± 2.0 µg/ml; P=0.02) when compared to patients without hyperfibrinolysis. Hypoperfusion markers, including pH (6.96 ± 0.11 vs. 7.17 ± 0.15; P<0.001), base excess (-20.01 ± 3.53 vs. -11.91 ± 6.44; P<0.001) and lactate (13.1 ± 3.7 vs. 8.0 ± 3.7 mmol/l) were more disturbed in patients with hyperfibrinolysis than in non-hyperfibrinolytic subjects, respectively. The LOT showed a good association with CPR time (r=-0.76; P=0.003) and lactate (r=-0.68; P=0.01), and was longer in survivors (3222 ± 34s) than in non-survivors (1,356 ± 833; P=0.044). CONCLUSION: A substantial part of OHCA patients develop hyperfibrinolysis in association with markers for hypoperfusion. Our data further suggest that the time to the onset of clot lysis may be an important marker for the severity of hyperfibrinolysis and patient outcome.

Analysing completion times in an academic emergency department: coordination of care is the weakest link.

Congestion with prolonged stay in the emergency department (ED) is associated with poor health outcomes. Many factors contribute to ED congestion. This study investigates the length of time spent in the ED (time to completion) and the factors contributing to prolonged stay in an academic ED. Data of ED patients were prospectively collected during four weeks in February 2010. Presentation time, referrer, discharge destination, and medical specialities involved were registered in 2510 patients. Additional detailed data about relevant time steps were collected from 66 patients in the triage category Emergency Severity Index (ESI) 3. The Pearson's chi-square test and the Mann-Whitney test were used for statistical analysis. Time to completion was longer than four hours in 13% of patients (average in total population 2:23 hours). In ESI 3 patients, 24% stayed longer than four hours in the ED (p<0.001). Internal medicine had most patients exceeding the four-hour target (37%), followed by neurology (29%). Undergoing a CT scan, treatment by multiple specialities, age above 65 years and hospital admission were associated with exceeding the four-hour target (p<0.001). The elapsed time between receiving test results and admission/discharge also influenced the completion time (p<0.001). A significant percentage of vulnerable and ill patients with triage category ESI 3 exceeded the four-hour completion time in our ED. Absence of coordination of care when multiple specialists were involved and delay in the process of decision-making after completion of all diagnostics on the ED were among other factors responsible for this prolonged stay. Improving the coordination of care will, in our opinion, speed up the decision-making process and lead to shortening of completion times in many patients.

[Vascular endothelial growth factor (VEGF) and modulation of wound healing after glaucoma surgery]. / Vasculaire endotheliale groeifactor (VEGF) en modulatie van wondheling na glaucoomheelkunde.

Glaucoma is an important cause of blindness. Therefore, the optimalisation of glaucoma surgery might have an important impact on the visual prognosis and the quality of life of glaucoma patients. This project focuses on the development of antifibrotic strategies that would inhibit the scarring of the created fistula, and thus improve the outcome after glaucoma surgery. We found that the vascular growth factor VEGF that is mostly known for its role in blood vessel formation also plays a role in postoperative wound healing. Furthermore, we studied the potential of anti-VEGF therapy to inhibit excessive wound healing (scar formation) after glaucoma surgery. Indeed, both in vitro and in vivo, VEGF prove to be efficacious to reduce scar formation, and thus improve the prognosis after glaucoma surgery. This fundamental research translated into a prospective clinical study, in which anti-VEGF is administered during glaucoma surgery, to improve the outcome after the surgery. We therefore hope that this translational research will indeed result in a better prognosis and quality of life for our glaucoma patients.

The iStent trabecular micro-bypass stent: a case series.

PURPOSE: To evaluate the safety and effectiveness of a trabecular micro-bypass stent, the iStent (Glaukos, USA), for reduction of intraocular pressure in patients with open angle glaucoma. METHODS: In this prospective case series, ten eyes of eight patients underwent a gonioscopically-guided implantation of an iStent. Six eyes underwent combined surgery: cataract surgery followed by iStent implantation, and the remaining four eyes underwent iStent implantation only. The primary outcome measure was intraocular pressure and the secondary outcome measures were the reduction in number of glaucoma medications, and the number of complications. RESULTS: Mean intraocular pressure dropped from 19.6 mmHg preoperatively to 16.3 mmHg (range 12-27) after one month (p = 0.04), to 15.4 mmHg (range 8-23) after six months (p = 0.03) and 15.8 mmHg (range 9-25 mmHg) after one year (p = 0.03). There was a significant reduction in number of hypotensive medications between baseline and 12 months postoperatively from 2.7 to 1.7 medications. No vision-threatening complications were observed. CONCLUSIONS: The Glaukos iStent trabecular micro-bypass implantation is a safe procedure that is not associated with complications traditionally associated with filtering surgery. This trabecular bypass results in significant mid-term reduction of intraocular pressure as well as the number of medications.