[The practice guideline 'Diagnosis and treatment of familial hypercholesterolaemia' of the Dutch Health Care Insurance Board]. / Richtlijn 'diagnostiek en behandeling van familiaire hypercholesterolemie' van het College voor zorgverzekeringen.

Until 2010, the Dutch ministry of Health, Welfare and Sport will fund a nationwide project to identify the approximately 40,000 patients with familial hypercholesterolaemia (FH) in the Netherlands. The Health Care Insurance Board will coordinate the project and safeguard its quality, while the 'Stichting Opsporing Erfelijke Hypercholesterolemie' [Foundation for the Detection of Hereditary Hypercholesterolaemia], with its national network of genetic fieldworkers, will search systematically within families with assessed FH-mutations. The referral of the first suspected case of FH in a family for DNA diagnosis remains a task for GPs, internists and other clinical professionals; these will also be expected to take the responsibility for treatment. The list of diagnostic criteria of the 'Dutch Lipid Clinic Network' has recently been validated and is recommended as a decision-tool for initiating DNA diagnosis. After confirmation of the DNA diagnosis, the plasma level of LDL-cholesterol remains the main criterion for pharmacotherapy; treatment with hypocholesterolaemic agents is recommended at levels above 2.5 mmol/l.

[Summary of the practice guideline 'Heart failure' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Hartfalen' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The guideline entitled 'Heart failure' from the Dutch College of General Practitioners has been revised. The general practitioner makes the diagnosis of heart failure in a patient with the core symptoms (dyspnoea, fatigue, oedema) in combination with paroxysmal nocturnal dyspnoea, orthopnoea, crepitations, elevated central-venous pressure, a third heart sound or ifictus cordis is visible outside the mid-clavicular line. Further investigations include a panel of laboratory investigations, an ECG and possibly echocardiography and radiographic chest investigations. One new recommendation is that on suspicion of heart failure the plasma concentrations of B-type natriuretic peptide (BNP) or N-terminal pro-BNP should be investigated. The step-by-step medication plan has been changed; beta-blockers have been introduced to the plan. In the treatment of acute heart failure, rapidly working sublingual nitrates should be given first and foremost.

[Summary of the practice guideline 'Hypertension' (third division) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Hypertensie' (derde herziening) van het Nederlands Huisartsen Genootschap.

The revised practice guideline on hypertension from the Dutch College of General Practitioners has been brought in agreement with the guideline on hypertension from the Dutch Institute for Health Care Improvement. The main changes with regard to the former edition are: The threshold values for the diagnosis 'hypertension' have been lowered to 140 mmHg and 90 mmHg for the systolic and diastolic blood pressures, respectively. Annual screening for hypertension in the elderly is no longer recommended. Henceforth, blood pressure measurement once every five years is considered sufficient, unless the blood pressure is known to be in a borderline area in which treatment is being considered. Often, the decision as to whether a patient should take antihypertensive drugs no longer depends on the presence of hypertension as such: to receive drug treatment, the patient should have at least a 20% risk of developing a cardiovascular disease in the next 10 years. To aid in estimating this risk for individual patients a risk table has been devised. Diuretics and beta-blockers are the drugs of first choice. If the blood pressure remains too high, angiotensin-converting-enzyme (ACE) inhibitors and calcium-channel blockers may be added.

Withdrawal of long-term diuretic medication in elderly patients: a double blind randomised trial.

OBJECTIVES: About 20% of elderly people use long-term diuretic medication, but there is doubt whether prolonged diuretic medication on such a large scale is necessary. We performed a study to assess what proportion may successfully be withdrawn from diuretic therapy. DESIGN: Double blind randomised controlled trial with six month follow up. SETTING: General practice. SUBJECTS: 202 patients taking long-term diuretics without manifest heart failure or hypertension. INTERVENTIONS: Patients were allocated to either placebo (withdrawal group, n = 102) or continuation of diuretic treatment (control group, n = 100). MAIN OUTCOME MEASURE: Occurrence of clinical conditions requiring diuretic therapy based on fixed criteria. RESULTS: During follow up diuretic therapy was required in 50 patients in the withdrawal group and 13 in the control group (risk difference 36%; 95% confidence interval 22% to 50%). Heart failure was the most frequent cause of prescribing diuretic therapy (n = 25). Cessation of diuretic therapy caused a mean increase in systolic blood pressure of 13.5 (9.2 to 17.8) mm Hg and in diastolic pressure of 4.6 (1.9 to 7.3) mm Hg. CONCLUSION: Withdrawal of long-term diuretic treatment in elderly patients leads to symptoms of heart failure or increase in blood pressure to hypertensive values in most cases. Any attempt to withdraw diuretic therapy requires careful monitoring conditions, notably during the initial four weeks.

Accuracy of an oscillometric automatic blood pressure device: the Omron HEM403C.

The purpose of this study was to assess the accuracy of the Omron HEM403C blood pressure (BP) device and to study whether this accuracy was affected by subject-related factors such as BP level and age. A comparison was made with a Hawksley random zero sphygmomanometer. BP was measured with both meters connected to one arm-cuff by means of a T-connector. To assess the level of agreement of the Omron HEM403C with the random zero meter, BP was measured in 212 subjects. Systolic and diastolic readings with the Omron HEM403C were on average 1 mmHg (s.d. 9, 95% CI 0.4-2.2) and 4 mm Hg (s.d. 8, 95% CI 3.6-5.1) respectively, higher than those with the random zero meter. The Omron HEM403C underestimated SBP compared with the random zero at higher SBP levels and overestimated SBP at lower SBP levels. The Omron meter overestimated the diastolic pressure at all DBP levels and the diastolic difference was not related to the DBP level. A multiple linear regression analysis demonstrated that the SBP level and not age was the factor that independently influenced the systolic difference between the meters. According to the criteria of the British Hypertension Society the Omron HEM403C is accurate enough to be recommended for those clinical and research purposes that are in need of automatic measurements.

Withdrawing long-term diuretic therapy in the elderly: a study in general practice in The Netherlands.

BACKGROUND: About 20% of all men and women age 65 or older are on maintenance therapy with diuretics. Multiple drug use and side effects increase with age whereas a clear indication for long-term diuretic therapy is not always present. The aim of the present study was to assess whether in some patients long-term diuretic therapy could be withdrawn in general practice. METHODS: This study is a pilot-study for a large multicentered randomized controlled trial in general practice. In one general practice in The Netherlands, 15 diuretic-using patients were selected from a total population of 52. All had been using diuretics for more than six months, were not hypertensive, and did not show overt symptoms of heart failure. In these 15 patients, diuretic medication was withdrawn under careful medical monitoring conditions. RESULTS: After six months, six patients were still without diuretic therapy. Diuretic therapy had to be resumed in nine cases, because of congestive heart failure (one), hypertension (three), bronchial asthma (one), increased ankle edema (two) and subjective complaints (two). The withdrawal of diuretic therapy caused an increase in mean systolic blood pressure, heart failure score, body weight and ankle edema. CONCLUSIONS: Long-term maintenance diuretic therapy in patients age 65 or older in general practice may be successfully withdrawn in selected cases. Careful medical surveillance during and after withdrawal is warranted.

Engraftment of stem-cell-enriched bone marrow fractions in MHC-identical dogs after fractionated total-body irradiation.

Discontinuous albumin density gradients were used to obtain enrichment of hemopoietic stem cells and depletion of T lymphocytes in aspirated dog bone marrow. Colony forming units in agar (CFU-C) were determined to evaluate the degree of enrichment achieved. An average CFU-C concentration factor of 12.4 was obtained. All transplantations in the study were carried out between DLA-identical sibling combinations. The number of CFU-C administered varied from 0.2 to 5.5 X 10(5)/kg and the number of nucleated cells transfused varied from 0.1 to 1.0 X 10(8)/kg. Stem cell concentrates were found more difficult to engraft than unmodified bone marrow following standard conditioning with a single total-body irradiation (TBI) dose of 7.5 Gy. The efficacy of different TBI-fractionation schedules for obtaining sustained engraftment of CFU-C-enriched grafts in identical bone marrow transplantation (BMT) was determined. A total dose of 12 Gy TBI delivered in two equal fractions of 6.0 Gy (72-hr interval) resulted in sustained engraftment of stem cell grafts in 7 of 7 evaluable dogs. A TBI dose of 9 Gy in two fractions of 4.5 Gy (72-hr interval) resulted in sustained engraftment in 5 of 7 evaluable dogs. The two dogs with engraftment failure received low total cell numbers (10(7) cells/kg) and low CFU-C numbers. 9 Gy of TBI in two fractions of 4.5 Gy (24-hr interval) resulted in sustained engraftment in 11 of 12 evaluable dogs. A significant improvement of engraftment was obtained by increasing the total dose of TBI, which necessitates fractionation into two fractions of TBI. The lower-total-dose TBI (9 Gy) produced less early and late toxicity than the total high-dose (12 Gy) TBI. The incidence of engraftment was similar for the two dosages, however the recovery of peripheral leukocyte counts was slower after 9 Gy TBI. In the dog, optimal conditioning for lymphocyte-depleted hemopoietic stem cell grafts can be obtained by increasing the dose of TBI and concomitant fractionation.