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Biomedical subjects

J B L Hoekstra

Publications and source records attributed to J B L Hoekstra.

17 recordsLinked to original sources
PubMed2006

[The practice guideline 'Diabetes mellitus type 2' (second revision) from the Dutch College of General Practitioners; a response from the perspective of internal medicine].

The revised guideline 'Diabetes mellitus type 2' contains several improvements. The HbA1C target level has been lowered to 7% or less. The universal first step in oral therapy has become metformin. The target level for the treatment of hypertension is now a systolic pressure below 140 mmHg. Statins should be prescribed to almost every patient. Finally, ACE-inhibitors are now suggested for all patients with microalbuminuria and hypertension. Some choices made in the present guideline are not evidence-based, e.g. the advice to prescribe pioglitazone to patients with both a body mass index above 27 kg/m2 and cardiovascular disease, but without heart failure. Still, in general, the updated guideline is an important document which has been greatly improved in comparison to the former one.

Diabetes Mellitus, Type 2↗
PubMed2006

[Melatonin: physiological and pathophysiological aspects and possible applications].

The number of indications for the medical use of melatonin is slowly increasing. Melatonin is produced by the pineal gland and is a key signal in the circadian rhythm of the body. Melatonin plays an obvious role in the pathophysiology and treatment of sleep disorders and jetlag. Recent research has also demonstrated its favourable effect on blood-pressure regulation. By analogy, melatonin may play a role in a variety of other circadian processes. However, research into the precise effects is still insufficient.

Blood Pressure↗
PubMed2006

[Trial of pioglitazone for the secondary prevention of cardiovascular events in patients with diabetes mellitus type 2: insufficient evidence].

The PROactive study was a multicentre, multinational, double-blind, placebo-controlled randomised trial that was intended to show a benefit of pioglitazone in the secondary prevention of cardiovascular disease in patients with diabetes. However, the result for the primary composite endpoint was not significant. The most important secondary endpoint (time to death, myocardial infarction or cerebrovascular accident) did show a significant reduction of 16%, but any potential benefit was outweighed by a major increase in the incidence ofhospitalisation for heart failure in the pioglitazone-treated group. Moreover, in this secondary prevention trial, there was marked undertreatment with statins while no effect of pioglitazone was observed in those who did receive a statin. Finally, no adjustment was made for the poorer glycaemic control in the placebo group. Based on these data, broadening the indication for pioglitazone in patients with diabetes cannot be recommended.

Cardiovascular Diseases↗
PubMed2006

Infection induced inflammation is associated with erectile dysfunction in men with diabetes.

BACKGROUND: In diabetic patients with erectile dysfunction, endothelial dysfunction is a major underlying cause. Infection-induced inflammation may be associated with endothelial dysfunction. The goal of this study was to determine whether erectile dysfunction in patients with diabetes is associated with infections of Chlamydia pneumoniae or cytomegalovirus and/or with low-grade inflammation. MATERIALS AND METHODS: Diabetic patients, 57 with and 33 without erectile dysfunction, were enrolled in a case-control study. Both groups of patients consists of type 1 and type 2 diabetics. Serum antibodies against cytomegalovirus and C. pneumoniae and markers of inflammation, including high-sensitivity C-reactive protein and fibrinogen, were measured. RESULTS: Adjusted odds ratios for erectile dysfunction in cytomegalovirus IgG, C. pneumoniae IgG and C. pneumoniae IgA seropositive men were 2.4 (95%CI; 1.0-6.0), 3.0 (95%CI; 1.2-8.1) and 1.8 (95%CI; 0.7-4.6), respectively. Odds ratios for the highest tertiles of high-sensitivity C-reactive protein and fibrinogen concentrations compared to the lowest tertile were 4.3 (95%CI; 1.4-13.1) and 6.6 (95%CI; 2.1-21.2), respectively. CONCLUSION: Elevated high-sensitivity C-reactive protein or fibrinogen serum levels and infection with cytomegalovirus or C. pneumoniae were associated with erectile dysfunction in diabetes. The relation between cytomegalovirus and erectile dysfunction is markedly present in patients with elevated high-sensitivity C-reactive protein and fibrinogen levels, suggesting a modifying effect by the inflammation.

Antibodies, Bacterial↗
PubMed2005

[Diagnosis of vitamin B12 deficiency revised].

Vitamin B12 (cobalamin) deficiency is a common disorder with potential irreversible haematological and neurological consequences. Currently used diagnostic tests such as the evaluation of serum vitamin B12 and the Schilling test are insufficient, e.g. the positive predictive value of a low serum vitamin B12 level for actual vitamin B12 deficiency (i.e. tissue deficiency) is low. Insufficient availability of vitamin B12 will lead to the accumulation of methylmalonic acid and homocysteine in the body. Nearly all patients with vitamin B12 deficiency also have substantially increased levels of methylmalonic acid and homocysteine. New tests of serum methylmalonic acid and homocysteine are highly sensitive for vitamin B12 deficiency and may obviate the need for the somewhat cumbersome Schilling test.

Homocysteine↗
PubMed2005

[Continuous subcutaneous insulin infusion is sometimes a good choice in case of poorly regulated diabetes mellitus type I].

Continuous subcutaneous insulin infusion (CSII) was initiated in 3 patients with diabetes mellitus type I who experienced difficulties with their glucose regulation: a woman aged 26 years and two men aged 56 and 41 years. 2 patients responded very well, while the third, the youngest man, did not benefit. Although interest in CSII has been growing in recent years, considerable uncertainty exists about which patients will benefit from it. In most studies, patients have attained a lower HbA,, and fewer blood glucose fluctuations. Recently, the advantages of CSII have been confirmed in 2 large studies in patients with diabetes mellitus type I. Motivated patients in poor glycaemic control seem to benefit most from CSII. Some questions remain, especially whether these advantages can be confirmed in studies comparing CSII with injection regimens using the new long-acting insulin analogues. Motivated patients in poor control and those with an unpredictable daily life, needing a flexible mode of therapy, should not be denied a trial of CSII.

Adult↗
PubMed2005

Pendra goes Dutch: lessons for the CE mark in Europe.

The development of a truly non-invasive continuous glucose sensor is an elusive goal. We describe the rise and fall of the Pendra device. In 2000 the company Pendragon Medical introduced a truly non-invasive continuous glucose-monitoring device. This system was supposed to work through so-called impedance spectroscopy. Pendra was Conformité Européenne (CE) approved in May 2003. For a short time the Pendra was available on the Dutch direct-to-consumer market. A post-marketing reliability study was performed in six type 1 diabetes patients. Mean absolute difference between Pendra glucose values and values obtained through self-monitoring of blood glucose was 52%; the Pearson's correlation coefficient was 35.1%; and a Clarke error grid showed 4.3% of the Pendra readings in the potentially dangerous zone E. We argue that the CE certification process for continuous glucose sensors should be made more transparent, and that a consensus on specific requirements for continuous glucose sensors is needed to prevent patient exposure to potentially dangerous situations.

Blood Glucose↗
PubMed2005

Influence of old age on survival after prolonged mechanical ventilation.

BACKGROUND: While the proportion of elderly people in society is increasing, little is known about the influence of old age on survival after prolonged mechanical ventilation. METHODS: A retrospective follow-up study of 120 patients who had been mechanically ventilated for at least 10 days was performed with a follow-up of up to 5 years. In-hospital survival and post-hospital survival were documented. Also, the functional status of survivors was recorded. The predictive value of age and several other clinical and laboratory parameters for outcome was analyzed. RESULTS: The in-hospital survival of the 120 patients studied was 35%. While age below 50 years was associated with improved survival, age was not predictive of in-hospital survival for patients over 50 years of age. The post-hospital survival was 77% 1 year after discharge, with almost all survivors being functionally independent. Again, old age was not predictive of survival. CONCLUSIONS: For patients aged 50 years or older, patient age does not predict survival after prolonged mechanical ventilation. Even very old survivors have a reasonable life expectancy and regain full functional status.

Journal Article↗
PubMed2005

The use of two continuous glucose sensors during and after surgery.

BACKGROUND: Maintaining plasma glucose between 80 and 120 mg/dL is beneficial for patients admitted to a surgical intensive care unit, but requires frequent glucose monitoring to ensure adequacy of treatment and detection of hypoglycemia. We examined whether continuous glucose sensing is feasible and reliable during and after major surgical procedures using two commercially available sensors. METHODS: Eight patients undergoing abdominal surgery were studied. A CGMS device (Medtronic MiniMed, Northridge, CA) and a GlucoDay device (A. Menarini Diagnostics, Florence, Italy) were placed in the shoulder region, and a second GlucoDay device was placed in the upper leg. Blood glucose was measured every 15 min for a total duration of 12 h. RESULTS: Technical failure of the CGMS was observed peroperatively more frequently than postoperatively (66% of all time points vs. 18%, P < 0.001). Technical failure of the GlucoDay device occurred most frequently in the GlucoDay placed in the upper leg (64% vs. 17%, P < 0.001). Accuracy of all three sensors was comparable peroperatively (74%, 76%, and 63% of values in Zone A of the Clarke error grid for the CGMS, GlucoDay shoulder, and GlucoDay upper leg, respectively, P = 0.2). Postoperatively, better accuracy was observed in both sensors placed in the shoulder compared with the GlucoDay placed in the upper leg (73%, 69%, and 51% of values in Zone A for the CGMS, GlucoDay shoulder, and GlucoDay upper leg, respectively, P < 0.001). CONCLUSIONS: Technical performance and accuracy of continuous glucose sensors need improvement before continuous glucose sensors can be used to monitor strict glycemic control during and after surgery.

Adult↗
PubMed2004

[Long-acting insulin analogs: progressing slowly].

In the last few years short-acting insulin analogs have become increasingly popular. Their introduction has unmasked serious deficiencies in the capacity of isophane insulin to provide a stable basal insulinaemia. The long-acting insulin analogs, insulin glargine and insulin detemir, have been developed as alternatives to isophane insulin. Insulin glargine has a long duration of action and has demonstrated its usefulness in diabetes type 2, specifically a lower incidence of (nocturnal) hypoglycaemia compared to isophane insulin, in clinical practice. Insulin detemir has a very low variability in absorption and also seems to reduce the risk of nocturnal hypoglycaemia in diabetes type 1. More studies are, however, needed. Because of the higher costs of these novel insulins, the decision to switch a patient from isophane insulin to an insulin analog has to be made on an individual basis.

Blood Glucose↗
PubMed2004

Early post-operative glucose levels are an independent risk factor for infection after peripheral vascular surgery. A retrospective study.

OBJECTIVE: To evaluate whether hyperglycaemia in the first 48 h after infrainguinal vascular surgery is a risk factor for post-operative infection, independent from factors associated with insulin resistance and surgical stress. DESIGN: Retrospective cohort study. PATIENTS AND METHODS: Patients who underwent infrainguinal vascular surgery in our hospital between March 1998 and March 2003 were included. Glucose values until 48 h after surgery were retrieved from laboratory reports. Post-operative infections, treated with antibiotics, during hospital stay were scored until 30 days after surgery. Data were analysed with univariate and multivariate logistic regression analyses. RESULTS: At least one post-operative glucose value was retrieved for 211/275 (77%) patients. The incidence of post-operative infections was 84/275 (31%). When corrected for factors associated with insulin resistance and surgical stress, post-operative glucose levels were found to be an independent risk factor for post-operative infections (odds ratio top quartile versus lowest quartile: 5.1; 95% confidence interval: 1.6-17.1; P=0.007). CONCLUSION: Post-operative glucose levels appear to be an independent risk factor for infections after infrainguinal vascular surgery. This finding requires confirmation in a prospective study.

Aged↗
PubMed2004

Metformin and lactic acidosis: cause or coincidence? A review of case reports.

OBJECTIVE: Metformin has been associated with the serious side-effect lactic acidosis. However, it remains unclear whether the use of metformin was a cause or a coincidence in lactic acidosis. DESIGN: A literature search of the Index Medicus (1959-66) and of the databases Embase, Medline, Medline Express (1966-99) was performed using the keywords metformin, biguanides and lactic acidosis. All articles of cases with metformin-induced lactic acidosis (MILA) were cross-referenced. SUBJECTS: Cases were included for analysis if they met the following criteria: serum pH < or =7.35, lactate concentration > or =5 mmol L(-1). INTERVENTION: A forum of six experts in intensive care medicine independently categorized the cases in MILA unlikely (score 0), possible MILA (score 1) or probable MILA (score 2). MAIN OUTCOME MEASURES: Statistical analysis included the paired interobserver agreement (kappa) and multivariate regression analysis. RESULTS: Of 80 reported cases, 33 were excluded because of insufficient quality. The forum scores of the remaining 47 cases were distributed normally with a mean score of 7 (range 2-10). The kappa-value was 0.041 (SD = 0.24, range -0.514, 0.427). Neither lactate concentration nor mortality correlated with serum metformin concentrations. CONCLUSIONS: Given the low interobserver agreement and the lack of any relationship between metformin levels and outcome parameters, the concept that there is a simple, causal relationship between metformin use and lactic acidosis in diabetic patients has to be reconsidered.

Acidosis, Lactic↗
PubMed2004

Quality of life and metabolic control in patients with diabetes mellitus type 1 treated by continuous subcutaneous insulin infusion or multiple daily insulin injections.

OBJECTIVE: To assess the quality of life and metabolic control in patients with diabetes mellitus type 1 on continuous subcutaneous insulin infusion (CSII) in comparison with patients on multiple daily insulin injections (MDII). RESEARCH DESIGN AND METHODS: The study included 49 patients (13 males, 36 females), aged 41.4+/-11.3 years (mean+/-SD) on CSII for >1 year and 79 patients (43 males, 36 females), aged 43.1+/-14.8 years on MDII for >1 year, from three Dutch diabetic clinics. There were no statistically significant differences in duration of diabetes, social class, level of education, marital status, smoking or recent admissions to hospital. The questionnaires used were a Diabetes Quality of Life scale adapted from the DCCT, the Diabetes Satisfaction Questionnaire (DTSQ), and the WHO Well-Being Questionnaire. HbA1c was measured with an HPLC method (reference range 4.3 to 6.1 %). RESULTS: Using two-sided t-tests no statiscally significant differences were found between the patients on CSII and MDII with respect to quality of life (version A (<30 years) 4.32+/-0.22 vs 4.20+/-0.30; version B (> or =30 years) 4.18+/-0.25 vs 4.29+/-0.28), well-being (48.59+/-9.23 vs 50.99 +/-8.70), satisfaction with treatment (5.10+/-0.69 vs 5.15+/-0.71) and HbA1c (8.14+/-1.51 vs 8.47+/-1.40). Frequency of daily blood glucose monitoring was slightly higher in CSII than in MDII patients (4.52+/-1.19 vs 3.60+/-1.47; p<0.0001). CONCLUSION: The present data indicate that patients on CSII have similar QoL based on questionnaires when compared with patients on MDII. These data suggest that in patients with less optimal control on MDII, converting the treatment strategy to CSII is not associated with decreased quality of life.

Adult↗
PubMed2002

[Dyspnoea and dysphagia in an adult caused by a tracheo-esophageal fistula].

In a 64-year-old man who was suffering from chronic obstructive pulmonary disease, recurrent airway infections, dysphagia, and weight loss, achalasia was diagnosed on the basis of endoscopic and radiological examinations. Afterwards he underwent flexible bronchoscopy, which revealed a benign looking fistula between trachea and oesophagus. This appeared to be a congenital tracheo-oesophageal fistula. The fistula was closed surgically. Three months later breathlessness and a sputum-producing cough were the only remaining symptoms. This rare anomaly is mostly diagnosed during childhood, but can also manifest itself in adulthood. If a tracheo-oesophageal fistula is suspected, the diagnostic procedures of choice are a barium oesophagogram in a forward-sitting or supine position or endoscopy of the trachea. Treatment consists of division and closure of the fistula. The prognosis is good.

Bronchoscopy↗
PubMed2002

[The last breath. The decision to ventilate patients with severe chronic obstructive pulmonary disease or not].

Three patients, a 74-year-old man and 2 women aged 40 and 58 years, were admitted to the hospital on a number of occasions due to respiratory insufficiency as a result of progressive debilitating COPD. Weaning from mechanical ventilation became increasingly difficult. Therefore, in two patients it was eventually decided not to apply mechanical ventilation again; they died after the next COPD exacerbation. The 40-year-old woman was eligible for a lung transplant and was placed on the waiting list for this procedure. The decision to mechanically ventilate patients with severe COPD and respiratory insufficiency is fraught with therapeutical, emotional and ethical dilemma. Objective criteria indicating a poor outcome in mechanically ventilated patients with severe COPD are: a forced expiratory volume in one second lower than 700 ml, being housebound, advanced age, cardiac comorbidity, and a low serum albumin concentration prior to mechanical ventilation. Since subjective criteria such as the patient's own wishes should also be considered, a policy is advocated in which the consultant pulmonologist regularly evaluates the available data and communicates the feasibility of mechanical ventilation.

Adult↗
PubMed2002

Glucose and cardiovascular risk.

The American Diabetes Association and the World Health Organisation have recently redefined the spectrum of abnormal glucose tolerance. The criteria for diabetes mellitus were sharpened and impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) were classified as intermediate stages between normal glucose homeostasis and diabetes, based on fasting and challenged glucose levels, respectively. Criteria were established for 'the metabolic syndrome', as a cluster of cardiovascular risk factors that frequently coincides with the abnormal glucose tolerance state. The extent to which the glucose level itself should be regarded as a cardiovascular risk factor is the subject of ongoing debate. Recent research suggests that cardiovascular risk is related to the plasma glucose level even in the normal range of glucose concentrations. The impact of glucose in relation to cardiovascular events is discussed in this review.

Blood Glucose↗