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Biomedical subjects

J J van Everdingen

Publications and source records attributed to J J van Everdingen.

At least 19 recordsLinked to original sources
PubMed2003

[Restructuring of subsidy policy: research and quality measures under pressure].

The Minister of Health, Welfare and Sport has announced his intention to cut subsidies. In order to keep the health service affordable and accessible to everyone, he wants to make all parties within the health service more accountable. This will result in a squeeze on research programmes, modernisation and quality measures and comes on top of last year's considerable reduction in the budget for the Netherlands Organisation for Health Research and Development. Another expected consequence is the loss of infrastructure as happened after the subsidy for the promotion of effective-care coordination was withdrawn. The stimulation of quality standards and measures by the government is of the greatest importance in retaining the goodwill of those physicians who--along with the Order of Medical Specialists, the Dutch College of General Practitioners and others--have designed a health service of a qualitatively very high standard.

Financing, Government↗
PubMed2001

[CBO guidelines 'Antiretroviral therapy in the Netherlands'].

In collaboration with the Dutch Institute for Health Care Improvement (CBO) and on the basis of recent developments, new guidelines have been developed for the diagnosis and treatment of HIV-infected patients. The most important recommendations are: Treatment of adult patients is indicated if HIV load > 30,000 RNA copies/ml, or when CD4+ cell count is < 350 x 10(6) cells/l. Treatment of children is indicated if HIV load > 5,000 copies/ml, even when CD4+ cell count is > 500 x 10(6) cells/l. Optimal antiretroviral treatment consists of a combination of two nucleoside reverse transcriptase inhibitors (NRTIs) and one protease inhibitor, or a combination of two NRTIs and one non-nucleoside reverse transcriptase inhibitor. Patients on antiretroviral treatment should be monitored every 3 months. Undetectable HIV load should be the target of first- or second-line antiretroviral treatment. In order to prevent HIV transmission from mother to child, prescription of antiretroviral drugs after the first three months of pregnancy is indicated in pregnant women with a detectable HIV load. Prophylaxis of opportunistic infections can be discontinued if CD4+ cell count recovers above 200 x 10(6)/l. In case of exposure to HIV due to a needle or other occupational accident or unsafe sexual contact, post-exposure prophylaxis should be offered after careful risk evaluation. Preferably, vaccination to prevent pneumococci infections, influenza, hepatitis A or hepatitis B should be given when CD4+ cell count is > 200 x 10(6)/l.

AIDS-Related Opportunistic Infections↗
PubMed2001

Decision support for patients with early-stage breast cancer: effects of an interactive breast cancer CDROM on treatment decision, satisfaction, and quality of life.

PURPOSE: To investigate the effects of the Interactive Breast Cancer CDROM as a decision aid for breast cancer patients with a choice between breast conserving therapy (BCT) and mastectomy (MT). PATIENTS AND METHODS: Consecutive patients with stage I and II breast cancer were enrolled. A quasi-experimental, longitudinal, and pretest/posttest design was used. Follow-up was scheduled 3 and 9 months after discharge from the hospital. Control patients (n = 88) received standard care (oral information and brochures). The CDROM was provided to patients in the experimental condition (n = 92) as a supplement to standard procedures. Outcome variables were treatment decision, satisfaction, and quality of life (QoL). RESULTS: No effect on treatment decision was found. CDROM patients expressed more general satisfaction with information at 3 and 9 months (95% confidence interval for the difference (d) between the means (d: 4.1 to 12.5 and 5.7 to 14.2 respectively). CDROM patients were also more satisfied with their treatment decision at 3 and at 9 months (d: 0.1 to 0.4; 0.2 to 0.5). Moreover, at 9 months, CDROM patients were more satisfied with breast cancer-specific information (d: 0.9 to 16.5), the decision-making process (d: 0.1 to 0.4), and communication (d: 0.2 to 11.0). At 3 and 9 months, a positive effect was found on general health (d: 0.2 to 14.5 and 0.3 to 15.0). Moreover, at 9 months, CDROM patients reported better physical functioning (d: 5.1 to 19.8), less pain (d: -17.9 to -4.5), and fewer arm symptoms (d: -14.1 to -0.5). CONCLUSION: The Interactive Breast Cancer CDROM improved decision making in patients with early-stage breast cancer with a choice between BCT and MT, as evaluated in terms of patients' satisfaction and QoL.

Aged↗
PubMed2000

[The "best" hospitals in the Netherlands; comments on results from the Elsevier survey].

Health care workers are increasingly asked to disclose the achievements and failures of their medical interventions. Comparative evaluation of hospitals seems to be inevitable. In July 2000 about 6000 health care workers in the Netherlands received a questionnaire from the general lay weekly Elsevier asking them to grade the hospitals in their area: specialists, general practitioners, heads of departments in hospitals, nursing staff and hospital directors. The questionnaire has serious methodological flaws, e.g. regarding the items included (such as 'press sensitivity' and 'waiting lists'), the way in which the score was determined (hospitals that were scored by less than 14 respondents were excluded), the way the questions were formulated (there was no way respondents could indicate their level of experience with the hospitals involved) and the very low response rate (13%). In addition there were no data to determine the accuracy of the questionnaire, the distribution of the respondents, or whether the answers had been adjusted. The questionnaire appears to be primarily aimed at creating sensation. It received little attention in the health care sector, probably because the results were contrary to the expectations. Hospital care will undoubtedly benefit from surveys applying a limited number of well-designed indicators for quality of service, but a questionable public qualification based on a competitive model such as the Elsevier questionnaire will probably do more harm than good.

Adult↗
PubMed2000

[CBO guidelines on diagnosis, treatment, and prevention of complication in diabetes mellitus: retinopathy, foot ulcers, nephropathy and cardiovascular diseases. Dutch Institute for Quality Assurance].

Early detection and adequate treatment of complications of diabetes mellitus (DM) are important for many patients in maintaining independence and ability to work. Diabetic retinopathy cannot be prevented. Limitation of damage is possible by aiming for normoglycaemia and normotension. While exudative as well as proliferative retinopathy can occur without any visual symptom, regular ophthalmological examination is necessary for timely laser coagulation. Fundus photography for screening is applicable under certain conditions; fluorescence angiography can be useful in patients with understood deterioration of visual acuity or diabetic maculopathy. In many patients foot disease can be prevented by simple measures: examining the foot at least once a year, recognition of the foot with a high level of risk, education of patient and family, adapted shoes and preventive foot care. Treatment of a foot ulcus consists of relief of mechanical pressure, repair of disturbed skin circulation, treatment of infection and oedema, optimal metabolic control, frequent local wound care and education. Patients with a diabetic foot have to be thoroughly followed up for the rest of their lives. For patients with diabetic nephropathy cardiovascular complications are the main causes of morbidity and mortality. Of all patient with DM older than 10 years urine has to be examined for loss of albumin at least once a year. Treatment of nephropathy consists of non-smoking, sufficient physical exercise, reduction of overweight, well-composed nutrition and particularly treatment of hypertension. Diagnosing cardiovascular diseases in patients with DM is in principle the same as for other patients. Treatment of hypercholesterolaemia has to be based on an absolute risk of 20% for cardiovascular disease in the following 10 years. The limit for treatment will be reached earlier in the presence of microalbuminuria, persistent high HbA1c > 8.5%, triglyceride concentration > 2.0 mmol/l, or a positive family history with myocardial infarction < 60 years. In proven cardiovascular disease one needs to strive for optimalization of the glucose metabolism, non-smoking and if necessary drug therapy.

Cardiovascular Diseases↗
PubMed1999

['Urinary tract infections'--revised CBO guideline. Dutch Institute for Quality Assurance].

Recently the 'Kwaliteitsinstituut voor de gezondheidszorg CBO' (Dutch Institute++ for Health Care Improvement) published revised guidelines on urinary tract infections. In children less than one year old clinical signs of urinary tract infection are non-specific and the diagnosis should be ruled out by laboratory investigations: a nitrite test, followed by inspection of the urinary sediment for leucocytes and bacteria if the test is negative. If one of the investigations is positive an urinary culture is made and antimicrobial therapy is started as for pyelonephritis. The child should be referred to a paediatrician to examine the urinary tract for anatomical abnormalities with a view to possible preventive measures regarding renal function loss. Boys older than one year with urinary tract infections should be managed in the same way as younger children. In older girls examination of the urinary tract is indicated after recurrent infection. In adult women with complaints of urinary tract infection causes like vaginitis, pyelonephritis and genital herpes should be excluded. Urine is examined (nitrite test, if negative followed by urinary sediment) to confirm the diagnosis. A urine culture is not indicated. First-choice treatment for uncomplicated infection is trimethoprim or nitrofurantoin. Persistent infection may be treated blind with a second antimicrobial drug. Recurrent infection can be prevented by changing behaviour, antimicrobial prophylaxis or oestrogen cream in postmenopausal women. If a man with micturition complaints also suffers from pain in the perineum, the lower back or the lower abdomen or during ejaculation, a distinction should be made between bacterial prostatitis, non-bacterial prostatitis and prostatodynia. Uncomplicated urinary infections can be treated with trimethoprim or nitrofurantoin. Urinary catheters are a risk for infection and their use should be restricted in number and duration. Catheter care should follow the guidelines of the Workgroup Infection Prevention. Urinary cultures should only be made in the presence of signs of infection if there is an indication for antimicrobial therapy.

Adult↗
PubMed1999

[From consensus to CBO guideline].

From the start of the consensus development programme by the Dutch Institute for Health Care Improvement CBO in 1981 the primary goal for the institute as an independent non-profit organization was to develop scientific guidelines for care that not only represented the state of the art, but also were acceptable to the medical community. The programme is run for and by the medical profession itself (scientific associations), but finds recognition among government authorities, financiers and patients' organizations. Since in this era of evidence-based medicine guidelines are considered necessary tools to face the complexity of medicine, and since there are so many institutions that offer guidelines of inconsistent format and style, carefully constructed guidelines are needed with standardization of the way the outcome data of the scientific literature is disclosed, analysed and weighed. CBO has adopted a transparent approach to provide such evidence-based guidelines.

Academies and Institutes↗
PubMed1999

[Guideline for administration of sedatives and analgesics by physicians who are not anesthesiologists. National Organization for Quality Assurance in Hospitals].

A consensus text for sedation or analgesia in diagnostic or therapeutic procedures has been developed for application by non-anaesthetist physicians. The final consensus text has the support of 17 scientific societies in the Netherlands. There is not enough medical manpower for direct, personal, specialist-based supervision of level 3 sedation procedures (the patient is relaxed, with eyes closed, but promptly reacts to verbal commands) for significant number of patients in the Netherlands. Sedation and analgesia may be administered by other health care personnel than anaesthesiologists when a number of conditions are met. These concern risk management, information to the patient, patient's consent, requirements for medical and supporting personnel, equipment, sedation procedures, monitoring, data management, recovery and aftercare. The consensus party favours titrated administration of small doses of short acting sedative or analgetic drugs. Combining sedative and analgesic drugs increases risk. Sedation and analgesia in children and patients with mental handicaps is acceptable in terms of quality, but requires special expertise, because of the greater psychic and physical vulnerability of these categories of patients.

Adult↗
PubMed1998

[National guidelines for clinical decisions, a methodological view].

Medical guidelines used to be based mostly on expertise and experience. Since the eighties they are increasingly scientifically founded. In recent years results of possible treatments have been estimated quantitatively and compared. In drawing up the consensus text 'Antithrombotic prophylaxis of vascular events in patients with manifest atherosclerotic vasculopathy' the preparatory committee, after systematic arrangement of the relevant literature, made maximal use of the results of randomized prospective clinical trials of good quality and sufficient magnitude, published in peer-reviewed journals. For most indications, the pathophysiological reasoning and the study results were in agreement. A demonstrated effect of a treatment was evaluated on the basis of its magnitude and related to the associated costs and efforts. For the consensus 'Treatment and prevention of coronary heart disease by lowering the serum cholesterol level' use was made of estimates of effects of treatment with statins versus placebo. For prevention of total mortality and non-fatal myocardial infarctions and strokes, the relative risk reduction was 30-35%. The decrease of the absolute risk depended on the initial risk. The committee was of the opinion that treatment would be useful given an absolute risk of 25% of a (subsequent) manifestation of cardiovascular disease within 10 years. This would cost Dfl. 40,000.-per year of life gained, which the committee considered acceptable. In the argumentation of guidelines there is a trend to systematic evaluation and quantitative application of the research data. Subjective assessments remain necessary, particularly the evaluation of clinical relevance of observed or assumed effects of treatments.

Cardiovascular Diseases↗
PubMed1998

[2nd revision consensus on blood transfusion. Central Guidance Organization for Peer Review].

Since 1982 several consensus conferences regarding the transfusion practice in hospitals have been organized in the Netherlands. Repeated updating of the consensus text such as described in this article is required to keep abreast of new developments and changes in clinical practice. Guidelines concerning compatibility testing (the result of compatibility testing is valid for three days at most), the organization of responsibilities and the clinical use of red cell concentrates, including a protocol for transfusion in patients with massive bleeding, were changed. No consensus was reached concerning the need to use only red cells that are antigen c, E and K compatible in women younger than 45 years of age and in patients with abnormal erythropoiesis. Although the need of systematic reviews to support guidelines was recognized, literature reviews revealed that only few studies were designed well enough to allow definitive conclusions regarding the benefits and risks of red cell transfusion.

Adult↗
PubMed1998

The development of practice guidelines for the treatment of severe plaque form psoriasis.

OBJECTIVE: To develop and introduce evidence-based guidelines for the selection of 5 commonly used treatment modalities--UV-B, photochemotherapy, methotrexate, acitretin, and cyclosporine--for adult patients with severe plaque form psoriasis. PATIENTS AND SETTING: Patients, residents, and dermatologists from the Department of Dermatology of the Academic Medical Center of the University of Amsterdam, Amsterdam, the Netherlands, were involved in this process. DESIGN: The development process started with a questionnaire to evaluate how patients with severe psoriasis were treated. A systematic literature review was set up to provide evidence-based estimates of effectiveness, adverse effects, and dropout rates. In 2 meetings, the opinion leaders and intended users discussed the results of the questionnaire and systematic review as well as the clinical considerations in the treatment choices. Guidelines were then made regarding the sequence of selection of 5 modalities in the concept of rotational therapy. These guidelines were introduced. Their use was analyzed for 6 months. RESULTS: Before the guidelines, there was no uniform approach. In the systematic review, 665 studies concerning the treatments were found. Exclusion rates were high. No studies of methotrexate therapy could be included. Photochemotherapy showed the highest average proportion of patients with clearance (70% [6947/9925]) and good response (83% [8238/9925]), followed by UV-B (67.9% [620/913]) and cyclosporine (64% [1030/1609]) therapy. In the second internal meeting, the following sequence for the treatments was defined: UV-B, photochemotherapy, methotrexate, acitretin, and cyclosporine. In 78% (69/88) of patients treated after the introduction, the guidelines were followed to determine the treatment choice. CONCLUSIONS: Guidelines for treating severe plaque form psoriasis can be successfully developed, introduced, and implemented and were considered to improve clinical care.

Evidence-Based Medicine↗
PubMed1993

Neonatal herpes policy in The Netherlands. Five years after a consensus conference.

In order to establish whether the recommendations of an in 1987 organized consensus conference about neonatal herpes policy in the Netherlands had been followed, an inquiry was held in January 1992 among gynecologists, pediatricians and microbiologists. Compared with the results of an inquiry that was held five years before, it was found that the incidence of neonatal herpes had not increased in the last ten years (approximately five cases annually or one per 35,000 neonates) despite the lower frequency of caesarean sections (more than 50 sections a year before 1987 and less than 10 sections a year after 1987). It is concluded that the consensus statements not only have been followed, but that they also proved to be sound.

Cesarean Section↗
PubMed1992

[Diagnostic management in suspicion of pulmonary embolism: results of a survey among Dutch internists and pulmonologists].

To gain insight into the incidence of suspected pulmonary embolism in the Netherlands and to evaluate the diagnostic strategy and therapeutic consequences in this patient population, a questionnaire was sent to all practising medical and pulmonary specialists (members of the respective associations). The number of patients admitted with suspected pulmonary embolism in the previous month and the diagnostic and therapeutic management in the last patient were requested. A reply was received from 698 internists and 272 pulmonologists (total response 73%). The management by the two specialist groups was not different. In the previous month 970 respondents treated 2245 patients for suspected pulmonary embolism. Extrapolated this means that 2.6 patients per 1000 inhabitants in the Netherlands are suspected of pulmonary embolism each year. Of the respondents, 95% had facilities to obtain a perfusion-ventilation scan. Of this group, 97% performed a perfusion scan when pulmonary embolism was suspected. A normal scan was found in 16% of the patients. A ventilation scan was performed in 71% of the patients with an abnormal perfusion scan result. Of all patients with an abnormal perfusion scan, 87% were treated with anticoagulants. The ventilation scan had little influence on this decision. The clinical suspicion of pulmonary embolism is a frequent clinical problem. The fact that of all patients with an abnormal perfusion scan 87% are treated, indicates overtreatment. The diagnosis of pulmonary embolism needs to be improved.

Angiography↗
PubMed1992

Liver biopsy versus ultrasound in methotrexate-treated psoriasis: a decision analysis.

Before starting methotrexate therapy for cases of recalcitrant psoriasis, a liver biopsy has been usual in order to exclude cirrhosis and moderate or severe fibrosis, which are contraindications for methotrexate treatment. As mortality and morbidity of liver biopsy are not negligible, and as this invasive procedure is unpleasant for the patient and urges clinical admission, we evaluated the possibility of ruling out severe liver pathology by means of ultrasonography, which we compared to liver biopsy. We made this comparison by means of a decision tree. The advantages of this analysis are the clear definition of the decision problem and its alternatives, and the possibility of calculating the risk of each alternative, thus being able to choose the best diagnostic method. In this study, the results of various research groups are discussed, in which liver biopsy and liver ultrasound were compared. In our decision tree we used some of these results and other assumptions, based on comparable studies. We varied the biopsy mortality and the sensitivity of ultrasound to show the change in the risk of each alternative. Our analysis shows that the differences of expected values between the liver biopsy branch and the ultrasonography branch are relatively small. Therefore, we advise each center, which has at its disposal a specialist in liver ultrasonography, to re-evaluate its guidelines with regard to the detection of severe liver pathology before starting methotrexate for the treatment of psoriasis.

Algorithms↗