[Nephrogenic systemic fibrosis possibly caused by gadolinium-containing contrast agent]. / Nefrogene systemische fibrose, mogelijk veroorzaakt door gadoliniumhoudend contrastmiddel.

A 34-year-old woman with terminal renal insufficiency presented with thickening and hardening of the skin of the extremities, resulting in contractures of the joints and severe disability. Serology revealed no signs of autoimmune disease, apart from a positive result for antinuclear antibodies. Histological evaluation of a skin biopsy showed marked fibrosis of the entire dermis, extending into the subcutaneous fat, with CD34-positive fibrocytes. The clinical features resembled a recently reported new disorder: nephrogenic systemic fibrosis (NSF). This disease causes fibrotic changes in the skin and other organs in patients with (pre)terminal renal insufficiency. The cause of the disease is still unknown, although there are strong indications that exposure to gadolinium-containing contrast agents plays a role in the pathogenesis. To prevent more patients from developing NSF, the Dutch Medicines Evaluation Board has changed the clinical indications for the use of gadolinium-containing contrast agents in patients with kidney disease: gadodiamide (Omniscan) and gadopentetate dimeglumine (Magnevist) may not be used in patients with severe renal failure or patients that will undergo or have already undergone liver transplantation. Caution is advised in patients with moderate renal insufficiency; this also applies to the other registered gadolinium-containing contrast agents.

Cardiac and hemodynamic effects of hemodialysis and ultrafiltration.

Imbalance between cardiac oxygen supply and demand may trigger cardiac events in already vulnerable hemodialysis (HD) patients. We studied the effect of ultrafiltration (UF) and HD in nine chronic HD patients by continuously measuring blood volume (BV; by Critline), blood pressure (BP; by Portapres), and changes in hemodynamics (Modelflow) during isolated UF (iUF) of 500 mL in 30 minutes and subsequent HD combined with UF (HD + UF). Aortic pressure was reconstructed from finger pressure. Changes in cardiac oxygen supply were assessed by calculating the area under the aortic pressure curve during diastole (diastolic pressure time index [DPTI]). Changes in cardiac oxygen demand were assessed by calculating systolic pressure time index (SPTI). BV decreased 4.0% +/- 1.8% during UF and 7.3% +/- 3.3% during HD + UF (both P < 0.01). Systolic BP did not change; diastolic and mean BP increased 11 +/- 7.4 and 11 +/- 8.4 mm Hg during iUF, respectively (both P < 0.01), and stabilized during HD + UF. Overall pulse pressure decreased 19 +/- 11.1 mm Hg (P < 0.01). Heart rate increased 13 +/- 11 beats/min (P < 0.01) and systemic vascular resistance increased 59% +/- 51% (P < 0. 01), whereas stroke volume and cardiac output (CO) decreased by 40% +/- 17% and 30% +/- 13%, respectively (both P < 0.01). Both cardiac oxygen supply (DPTI) and demand (SPTI) increased during iUF, and both decreased during HD + UF. By the end of the procedure, DPTI/SPTI ratio had increased 9% +/- 8% (P < 0.05). Changes in CO correlated closely to changes in BV. Despite large changes in hemodynamics during uncomplicated UF and HD, the balance between cardiac oxygen supply and demand (DPTI/SPTI ratio) did not decrease, but improved slightly.

Glomerulopathy as a paraneoplastic phenomenon.

A review is presented of the association between a glomerular disease and a malignancy. The incidence of Hodgkin's disease in patients with glomerulopathy is very low, but the incidence of a solid tumour in a patient with glomerulopathy varies between 3 and 13%, mean 7%, and may be as high as 22% in patients over 60 years of age with a membranous nephropathy. A solid tumour was found most frequently in patients with membranous nephropathy. On the other hand, minimal change nephropathy is often associated with Hodgkin's disease and membrano-proliferative glomerulopathy with chronic lymphatic leukaemia. In Hodgkin's disease-associated glomerulopathy, a defect in the function of T lymphocytes is probably important, but the precise pathogenesis has not yet been elucidated. The other glomerulopathies may be mediated by immune complexes, containing tumour-derived antigens and their antibodies, either formed in situ or deposited as complexes from the circulation.

Risk factors for HCV infection in two haemodialysis units in The Netherlands.

BACKGROUND: In order to assess risk factors for HCV infection during haemodialysis, all patients receiving haemodialysis for more than 6 months in two separate units in the Netherlands were studied retrospectively. METHODS: Antibodies to HCV, HCV-RNA and HCV genotypes were determined. Risk factors were identified by analysis of an extensive collection of clinical data. RESULTS: In unit A, 8 out of 75 (11%) patients and in unit B 4 out of 122 (3%) patients had antibodies to HCV. Eleven out of the 12 anti-HCV-positive patients had detectable HCV-RNA. Genotyping showed the presence of 4 different genotypes in unit A (1, 1a, 2b, and 3a). Three patients in unit B were infected with the same genotype (1b), where one of these patients was also infected with genotype 1a. One patient in unit B did not have detectable HCV-RNA. The risk of acquiring a HCV infection in unit A was associated with the number of blood transfusions. However, in unit B this risk was associated with the duration of dialysis. Other factors such as the number of surgical procedures were not associated with HCV infection. CONCLUSIONS: Blood transfusions and the dialysis process itself are important and independent risk factors for HCV transmission in dialysis patients. Surgical events do not appear to be important risk factors. However, relative risks may vary considerably between different dialysis centres.

[Medical accidents in the dental practice. Survey of 471 dentists in the Netherlands]. / Medische accidenten in de tandartspraktijk. Rapportage door 471 tandartsen in Nederland.

OBJECTIVE: To determine frequency and nature of medical accidents in Dutch dental practice in relation to type and time of treatment, with and without the use of the MRRH; frequency and nature of the professional assistance. METHOD: Dentists MRRH-users (n = 51) and control dentists (n = 420) recorded medical accidents by name, using a registration form, followed by an anonymous survey. RESULTS: 91 accidents were reported by name by 471 dentists. This contrasted with 300 accidents recorded by 380 dentists in an anonymous survey. No life threatening accidents were reported. Syncope and hyperventilation were frequent. Most of the accidents occurred during local anaesthesia or during treatment, as the procedure became more stressful. Two-third of the accidents could possibly have been prevented by means of a medical history. Medical assistance was requested in 6% of the cases. CONCLUSION: Life threatening disorders were not reported, possible because in the Netherlands no intravenous sedation or general anaesthetic is used in general dental practice.

Salivary flow rate and acute-phase proteins in Bell's palsy.

The flow rate of extra-parotid and parotid saliva was compared in patients with Bell's palsy and in healthy volunteers. Samples were analysed for the concentration of total protein and seven acute-phase proteins. There was no difference between younger and older patients with regard to oral status, salivary flow rate, total protein or acute-phase proteins, in either extra-parotid or parotid saliva. No significant difference in flow rate for both extra-parotid and parotid saliva was found in the Bell's palsy patients in comparison with the controls. In the patients the salivary flow rate from the parotid gland on the paralysed side was slightly lower than on the healthy side, but not to a significant extent. The quantity of total protein was lower in the extra-parotid saliva in the patient group; there were no differences between the two groups with regard to parotid saliva. We were able to demonstrate small amounts of various acute-phase proteins in the control group. In the patients we found higher quantities per minute of acute-phase proteins in both extra-parotid saliva and parotid saliva than in the controls. In extra-parotid saliva there were significant differences in haptoglobulin, alpha 2-macroglobulin, C3-complement factor and ceruloplasmin; in parotid saliva the differences in haptoglobulin and ceruloplasmin were significant. However, there was a large inter individual variation in both groups studied. In the patient group no significant difference in the secretion of acute-phase proteins from the parotid gland could be demonstrated between the paralysed side and the healthy side.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute medical complications in 277 general dental practices.

BACKGROUND: Due to the aging of the population on one hand and both medical and dental innovations on the other, the number of medical complications which occur during dental treatment is expected to rise. In order to prevent such complications, dental practitioners have used a medical risk-related history which includes risk determination and preventive measures (together the MRRH system). In this study, the medical complications which occurred in their practice have been compared with those recorded by a control group. METHODS: First, a tested registration form was used. In addition, the group using the MRRH system had previously attended a 1-day introductory course de voted to the MRRH system. Furthermore, a power analysis was used to determine the group sizes. The registration period was set at 1 year, during which the dentists sent in monthly reports. Only patients over the age of 18 were included, after having given their oral consent. An independent diagnosis was given of all registered medical complications by two different internists. RESULTS: A total of 208 medical complications were reported: 45 complications were reported by the 62 dentists who used the MRRH system (reference group) and 163 by the 215 dentists of the control group. First, it should be noted that some reports did not register vital signs; this is reflected in categories such as "no diagnosis," "collapse eci," and "others." Second, the study has revealed that the reference group has registered the heart rate and the frequency of breathing of patients more frequently than the control group. Also, a relatively lower percentage of complications was recorded within the reference group due to the intravenous injection of local anesthetics. CONCLUSIONS: The number of medical complications recorded in the two groups shows little variation. There is a considerable difference, however, in the nature of these complications.

Infection control of hepatitis C in Dutch dialysis centres.

BACKGROUND: In dialysis patients, blood transfusions and long-term dialysis are well-known risk factors for transmission of hepatitis C virus (HCV). Transmission of HCV by transfusions has become extremely rare since the introduction of antibody screening. However, nosocomial transmission of HCV within dialysis units still occurs. We performed a survey of current infection control measures against HCV in Dutch dialysis centres that had participated in a national HCV prevalence study. METHODS: All twenty-seven Dutch dialysis centres where HCV-positive patients had been identified (HCV prevalence 1-8%), participated. With the use of a questionnaire we evaluated screening procedures for resident patients and guest patients, routine hygienic measures in HCV-positive and -negative patients, and cleaning procedures of dialysis equipment. RESULTS: All centres except one screened new patients for HCV antibodies, but the frequency of periodic follow-up screening varied. Most centres requested HCV antibody screening of guest patients in advance, but in daily practice 55% of the centres dialysed guest patients even when HCV antibody status was not available. The majority of centres had not implemented special precautions for patients with unknown HCV antibody status. In most centres the use of protective glasses, masks and aprons depended on the HCV antibody status of the patients. Surprisingly, 85% of the centres allowed their nurses to operate dialysis machines with gloves possibly blood contaminated. All centres sterilized their machines at the end of the day, but only 77% sterilized their machines between all dialysis sessions. Traces of blood were removed with alcohol in 63% of the centres. CONCLUSION: Dutch dialysis centres have not yet implemented an optimal policy for prevention of HCV. Especially, operating dialysis machines with gloves might be a potential source for nosocomial transmission of HCV, not yet covered by the issued guidelines. Because dialysis patients probably have a prolonged serological window phase after a recent HCV infection, it does not suffice to implement a preventive strategy against nosocomial transmission based on the results of HCV antibody screening. Universal, rigorous implementation of adequate infection control measures irrespective of HCV antibody status should be the cornerstone for prevention of nosocomial transmission of HCV and other blood borne pathogens.

Hepatitis C virus infections in dialysis centers in The Netherlands: a national survey by serological and molecular methods.

A national survey of hepatitis C virus (HCV) infections among dialysis patients in The Netherlands was performed. The study involved 2,653 patients (2,108 hemodialysis patients and 545 chronic ambulatory peritoneal dialysis [CAPD] patients) from 39 of the 49 dialysis centers in the country. Patient sera were analyzed by both serological and molecular methods. Screening by a third-generation enzyme immunoassay (EIA) yielded 79 reactive sera. The presence of anti-HCV antibodies was confirmed in 70 patients by a line immunoassay. All seropositive samples were tested by reverse transcriptase PCR, and 57 samples were found to contain HCV RNA. Of the nine EIA-positive and line immunoassay-negative or indeterminate samples, four were HCV RNA positive. All seronegative samples were screened for the presence of HCV RNA in pools of five sera. Of 2,576 antibody-negative samples, 6 contained HCV RNA. All antibody-positive and RNA-positive samples were also tested by a second serological assay. The prevalence of HCV infections among Dutch dialysis patients as determined by serology or the presence of HCV RNA was 3% (80 of 2,653), i.e., 3.5% (73 of 2,108) in patients treated on hemodialysis and 1.3% (7 of 545) in patients on CAPD. Of these 80 HCV-infected dialysis patients, 67 (84%) were HCV RNA positive. Serological screening alone would have diagnosed only 70 infected patients. Therefore, antibody screening combined with detection of HCV RNA should be considered as the "gold standard" for diagnosing HCV infection in dialysis patients. The prevalence of HCV-infected patients in Dutch dialysis centers ranged from 0 to 8%, suggesting the existence of local risk factors for acquiring HCV infection. Genotyping analysis by reverse hybridization line probe assay revealed the presence of genotypes la (23%), 1b (46%), 2 (3%), 2a (13%), 2b (1%), 3a (7%), and 4a (4%). In four (6%) samples multiple genotypes were detected. The genotype distribution of HCV isolates among Dutch dialysis patients was similar to the distribution among nondialysis patients from the Benelux, except for subtype 1a, which was significantly more prevalent among dialysis patients. In only one center, a high prevalence of an uncommon genotype was suggestive of infection from a common source.

The prevalence and incidence of hepatitis C virus infections among dialysis patients in the Netherlands: a nationwide prospective study.

A nationwide prospective survey on hepatitis C virus (HCV) infections among dialysis patients in The Netherlands was performed. Patients were recruited from 34 dialysis centers and were tested for antibodies and HCV RNA in 1995 and 1997. Seronegative serum samples were analyzed by reverse-transcriptase polymerase chain reaction in pools. HCV-RNA-positive serum samples were genotyped and were partly sequenced. In the first and second rounds, 67 (2.9%) of 2281 and 76 (3.4%) of 2286 patients were HCV positive, respectively. Of 960 patients with paired serum samples, 35 were HCV positive in both rounds, and 9 HCV-positive cases were newly identified in the second round. The incidence of HCV infection was 0.5 per 100 dialysis years. Phylogenetic analysis revealed clustered sequences that indicated nosocomial transmission. Sixty percent of HCV infections, however, can be attributed to 4 interdependent risk factors (i.e., hemodialysis before 1992, kidney transplantation before 1994, and birth or dialysis in a foreign country). In conclusion, the prevalence of HCV infections in The Netherlands does not decline, and transmission within dialysis units continues. Adequate screening of HCV infections and strict enforcement of universal infection control practices are required.