Current Trends and Future Directions in Urban Social Prescribing.

PURPOSE OF REVIEW: Social prescribing (SP) is defined as a non-medical community referral program to support well-being and health. This review explores the current evidence about the effectiveness of SP. RECENT FINDINGS: This review examined existing SP models that have been or are being tested to connect people to these opportunities through direct and indirect referral schemes. The review identified a fifth model that facilitates a group-based approach used to mental well-being and resilience. While the development of SP largely originates from the UK, the global interest in SP has increased, with over 31 nations reporting elements of SP. The main goal of SP is to better integrate care between the traditional medical setting and resources available in the community and voluntary sectors. Although this review found widespread optimism around SP, there remain concerns about its effectiveness and demands for high-quality evaluations to strengthen the evidence base for SP.

Modulus of Elasticity of Two Ceramic Materials and Stress-Inducing Mechanical Deformation following Fabrication Techniques and Adhesive Cementation Procedures of a Dental Ceramic.

STATEMENT OF PROBLEM: Fabrication technique, precementation, and cementation operative procedures can induce significant modification of the stressing patterns throughout the thickness of some classes of dental ceramic materials. OBJECTIVES: To estimate, by means of the deflection test, residual stress in restorative dental ceramic following fabrication technique, precementation, and resin cement coating procedures and to relate it to the elastic property of the ceramic material tested. MATERIALS AND METHODS: From IPS e.max® Press, lithium disilicate heat-pressed glass-ceramic (elastic modulus of 95 ± 5 GPa) disc-shaped specimens (n = 10) were made according to the manufacturer's instructions. One surface of the specimens was polished to provide accurate baseline profilometric measurements (reference surface). Deflection measurements were performed after polishing and annealing alumina air-particle abrasion of the unpolished surface followed by resin cement coating of the alumina air-particle abraded surface. The specimens were reprofiled at 24, 48, and 168 hrs after coating. The Friedman test followed by Dunn's multiple comparison test was employed to identify significant differences (p < 0.05). To compare the difference in mean of maximum mechanical deflection, after cement coating at 0 hr, between two different ceramic materials (IPS e.max Press and Vitadur Alpha (result from another study)), Student's t-test for unpaired data was performed. RESULTS: Baseline profilometric measurements identified a convex form on the polished surface of the ceramic discs with a mean of maximum mechanical deflection of 4.45 ± 0.87 µm. A significant reduction in convexity of the polished specimens was characterized after alumina air-particle abrasion of the unpolished surface. The mean deflection significantly increased after resin cement coating and did not change over the time investigated. CONCLUSIONS: The precementation treatment, namely, alumina air-particle abrasion and cementation procedure of IPS e.max® Press glass-ceramic disc-shaped specimens generates stress that induced mechanical deformation. However, a dental ceramic material with higher elastic modulus (stiffer) would minimize stress-inducing mechanical deformation.

Management of community-acquired pneumonia in adults: 2016 guideline update from the Dutch Working Party on Antibiotic Policy (SWAB) and Dutch Association of Chest Physicians (NVALT).

The Dutch Working Party on Antibiotic Policy in collaboration with the Dutch Association of Chest Physicians, the Dutch Society for Intensive Care and the Dutch College of General Practitioners have updated their evidence-based guidelines on the diagnosis and treatment of community-acquired pneumonia (CAP) in adults who present to the hospital. This 2016 update focuses on new data on the aetiological and radiological diagnosis of CAP, severity classification methods, initial antibiotic treatment in patients with severe CAP and the role of adjunctive corticosteroids. Other parts overlap with the 2011 guideline. Apart from the Q fever outbreak in the Netherlands (2007-2010) no other shifts in the most common causative agents of CAP or in their resistance patterns were observed in the last five years. Low-dose CT scanning may ultimately replace the conventional chest X-ray; however, at present, there is insufficient evidence to advocate the use of CT scanning as the new standard in patients evaluated for CAP. A pneumococcal urine antigen test is now recommended for all patients presenting with severe CAP; a positive test result can help streamline therapy once clinical stability has been reached and no other pathogens have been detected. Coverage for atypical microorganisms is no longer recommended in empirical treatment of severe CAP in the non-intensive care setting. For these patients (with CURB-65 score >2 or Pneumonia Severity Index score of 5) empirical therapy with a 2nd/3rd generation cephalosporin is recommended, because of the relatively high incidence of Gram-negative bacteria, and to a lesser extent S. aureus. Corticosteroids are not recommended as adjunctive therapy for CAP.

Early pregnancy immune biomarkers in peripheral blood may predict preeclampsia.

We performed a prospective cohort study in 197 pregnant women. Peripheral blood was collected between 5 and 16 weeks of gestation. Intracellular cytokine analysis and immunophenotype were performed by flow-cytometry. Serum levels of cytokines and chemokines were analyzed by multiplex assay. 86 patients were eligible for the analysis and 10.5% (n=9) developed preeclampsia. Patients with preeclampsia had significantly higher percentage of CD3+CD4+TNFα+ T helper (Th) 1 cells (45.4±10.3 vs 37.1±8.5, P=0.032) and CD3+CD4+IL17+ Th 17 cells (2.4±1.3 vs 1.6±1.1, P=0.029) when compared to those of patients without preeclampsia. CD3+CD4+CD25+CD127dim/- T regulatory cells (Treg) cells (5.7±1.2% vs 7.0±1.6%, P=0.015) were significantly lower in patients with preeclampsia when compared to those without preeclampsia. Patients with preeclampsia had significantly higher TNFα/IL-10 cell ratio (43.8±10.3 vs 34.3±7.9, P=0.005) and Th17/Treg cell ratio (0.5±0.3 vs 0.2±0.2, P=0.011) when compared to those of patients without preeclampsia. IL-8 and Macrophage inflammatory protein (MIP)-1α serum levels were significantly higher in patients with preeclampsia when compared with patients without preeclampsia (Median=341.0 vs 87.6, U=152, P=0.020 and Median=35.7 vs 17.7, U=120, P=0.029 respectively). Serum MCP-1 levels were significantly lower in patients with preeclampsia when compared with patients without preeclampsia (Median=233.8 vs 390.9, U=183, P=0.021). The logistic regression predictive model combining TNFα/IL-10 ratios, IL-8 and MCP-1 serum levels had the best performance (AUC=0.886, 95%CI 0.8-0.9). We concluded that elevated Th1 and Th17 cell percentages, elevated TNFα/IL-10 and Th17/Treg cell ratios and decreased Treg cell percentages in early pregnancy are associated with preeclampsia.

Cessation of oral anticoagulants in antiphospholipid syndrome.

Objective To study the outcome of patients with antiphospholipid syndrome (APS) after oral anticoagulant treatment cessation. Methods We performed a retrospective study of patients with APS experiencing cessation of oral anticoagulant and enrolled in a French multicentre observational cohort between January 2014 and January 2016. The main outcome was the occurrence of recurrent thrombotic event after oral anticoagulation cessation. Results Forty four APS patients interrupted oral anticoagulation. The median age was 43 (27-56) years. The median duration of anticoagulation was 21 (9-118) months. Main causes of oral anticoagulant treatment cessation were switch from vitamin K antagonists to aspirin in 15 patients, prolonged disappearance of antiphospholipid antibodies in ten, bleeding complications in nine and a poor therapeutic adherence in six. Eleven (25%) patients developed a recurrent thrombotic event after oral anticoagulation cessation, including three catastrophic APS and one death due to lower limb ischemia. Antihypertensive treatment required at time of oral anticoagulants cessation seems to be an important factor associated with recurrent thrombosis after oral anticoagulant cessation (15.2% in patients with no relapse versus 45.5% in patients with recurrent thrombosis, p = 0.038). Oral anticoagulant treatment was re-started in 18 (40.9%) patients. Conclusion The risk of a new thrombotic event in APS patients who stopped their anticoagulation is high, even in those who showed a long lasting disappearance of antiphospholipid antibodies. Except for the presence of treated hypertension, this study did not find a particular clinical or biological phenotype for APS patients who relapsed after anticoagulation cessation. Any stopping of anticoagulant in such patients should be done with caution.

Deficiency in memory B cell compartment in a patient with infertility and recurrent pregnancy losses.

Alterations in normal balance of B cell subsets have been reported in various rheumatic diseases. In this study, we report a woman with a history of recurrent pregnancy losses (RPL) and infertility who had low levels of memory B cells. A 35-year-old woman with a history of RPL and infertility was demonstrated to have increased peripheral blood CD19+ B cells with persistently low levels of memory B cell subsets. Prior to the frozen donor egg transfer cycle, prednisone and intravenous immunoglobulin G (IVIg) treatment was initiated and patient achieved dichorionic diamniotic twin pregnancies. During pregnancy, proportion (%) of switched memory B cells CD27+IgD- increased, while percent of total CD19+ B cells and CD27-IgD+ naive B cells were gradually decreased with a high dose IVIg treatment. She developed cervical incompetence at 20 weeks of gestation, received a Cesarean section at 32 weeks of gestation due to preterm labor, and delivered twin babies. B cell subset abnormalities may be associated with infertility, RPL and preterm labor, and further investigation is needed.

Catheter failure rates and time course with epidural versus combined spinal-epidural analgesia in labor.

BACKGROUND: The combined spinal-epidural technique for labor analgesia has several advantages over the traditional epidural technique, including faster onset, greater maternal satisfaction, and decreased need for physician boluses. Proponents of the epidural technique criticize the combined spinal-epidural technique, arguing that the epidural catheter remains untested and thus may not be reliable if needed for surgical intervention. We compared failure rates and time of failure between techniques in our tertiary-care academic practice. METHODS: Data regarding failed catheters were collected from October 2012 to September 2014 as part of our Quality Assurance program. Failed catheters were defined as any catheter replaced after it was considered to be properly placed and then determined to be intravascular, one sided or resulting in poor maternal analgesia or anesthesia. RESULTS: A total of 5487 analgesics were performed (3980 combined spinal-epidural; 1507 epidural). Eighty-five combined spinal-epidural catheters (2.1%) and 59 epidural catheters (3.9%) were replaced during labor (P<0.001). Mean time to replacement was 512±422min and 354±300min for the combined spinal-epidural (n=80) and epidural (n=57) groups, respectively (P=0.02). Median time to replacement was 398 [IQR 131-578] min and 281 [IQR 186-767] min for combined spinal-epidural and epidural groups, respectively (P<0.0001). CONCLUSION: We were able to demonstrate that catheters placed using a combined spinal-epidural technique were less likely to fail during labor and that the time to detection of a failed catheter was significantly longer in the combined spinal-epidural group. Our findings validate the combined spinal-epidural technique as reliable for labor analgesia and tend to refute the theory of the untested catheter.

Inhibition of vacuolar ATPase subunit in tumor cells delays tumor growth by decreasing the essential macrophage population in the tumor microenvironment.

In cancer cells, vacuolar ATPase (V-ATPase), a multi-subunit enzyme, is expressed on the plasma as well as vesicular membranes and critically influences metastatic behavior. The soluble, cleaved N-terminal domain of V-ATPase a2 isoform is associated with in vitro induction of tumorigenic characteristics in macrophages. This activity led us to further investigate its in vivo role in cancer progression by inhibition of a2 isoform (a2V) in tumor cells and the concomitant effect on tumor microenvironment in the mouse 4T-1 breast cancer model. Results showed that macrophages cocultivated with a2V knockdown (sh-a2) 4T-1 cells produce lower amounts of tumorigenic factors in vitro and have reduced ability to suppress T-cell activation and proliferation compared with control 4T-1 cells. Data analysis showed a delayed mammary tumor growth in Balb/c mice inoculated with sh-a2 4T-1 cells compared with control. The purified CD11b(+) macrophages from sh-a2 tumors showed a reduced expression of mannose receptor-1 (CD206), interleukin-10, transforming growth factor-ß, arginase-1, matrix metalloproteinase and vascular endothelial growth factor. Flow cytometric analysis of tumor-infiltrated macrophages showed a significantly low number of F4/80(+)CD11c(+)CD206(+) macrophages in sh-a2 tumors compared with control. In sh-a2 tumors, most of the macrophages were F4/80(+)CD11c(+) (antitumor M1 macrophages) suggesting it to be the reason behind delayed tumor growth. Additionally, tumor-infiltrating macrophages from sh-a2 tumors showed a reduced expression of CD206 compared with control whereas CD11c expression was unaffected. These findings demonstrate that in the absence of a2V in tumor cells, the resident macrophage population in the tumor microenvironment is altered which affects in vivo tumor growth. We suggest that by involving the host immune system, tumor growth can be controlled through targeting of a2V on tumor cells.

[Radiological media and modern supporting tools in radiology]. / Radiological Media und moderne Tools zur Unterstützung in der Radiologie.

Radiology is a field with a high demand on information. Nowadays, a huge variety of electronic media and tools exists in addition to the classical media. Asynchronous and synchronous e-learning are constantly growing and support radiology with case collections, webinars and online textbooks. Various internet resources, social media and online courses have been established. Dynamic websites show a variety of interactive elements and it is easier and faster to access large amounts of data. Social media have an exponentially growing number of users and enable an efficient collaboration as well as forming professional networks. Massive open online courses (MOOCs) complete the offer of education and increase the opportunity to take part in educational activities. Apart from the existing variety of resources it is essential to focus on a critical selection for using these radiological media. It is reasonable to combine classical and electronic media instead of a one-sided use. As dynamic as the progress in the field of radiological media and its tools may be, the personal contact remains and should be maintained.

Tumor-associated vacuolar ATPase subunit promotes tumorigenic characteristics in macrophages.

Macrophage polarization contributes to distinct human pathologies. In tumors, a polarized M2 phenotype called tumor-associated macrophages (TAMs) are associated with promotion of invasion and angiogenesis. In cancer cells, vacuolar ATPase (V-ATPase), a multi-subunit enzyme, is expressed on the plasma/vesicular membranes and critically influences the metastatic behavior. In addition, the soluble, cleaved N-terminal domain of a2 isoform of V-ATPase (a2NTD) is associated with in vitro induction of pro-tumorigenic properties in monocytes. This activity of a2 isoform of V-ATPase (a2V) caused us to investigate its role in cancer progression through the evaluation of the immunomodulatory properties of a2NTD. Here, we present direct evidence that surface expression of V-ATPase is associated with macrophage polarization in tumor tissue. Macrophages from BALB/c mice (peritoneal/bone marrow derived) were stimulated with recombinant a2NTD in both ex vivo and in vivo systems and evaluated for TAM characteristics. a2V was highly expressed in tumor tissues (breast and skin) as well as on the surface of tumor cell lines. The a2NTD-stimulated macrophages (a2MΦ) acquired TAM phenotype, which was characterized by elevated expression of mannose receptor-1, Arginase-1, interleukin-10 and transforming growth factor-ß. a2MΦ also exhibited increased production of other tumorigenic factors including matrix metalloproteinase-9 and vascular endothelial growth factor. Further, a2MΦ were cocultured with mouse B-16F0 melanoma cells for their functional characterization. The coculture of these a2MΦ subsequently increased the invasion and angiogenesis of less invasive B-16F0 cells. When cocultured with naive T cells, a2MΦ significantly inhibited T-cell activation. The present data establish the role of V-ATPase in modulating a macrophage phenotype towards TAMs through the action of a2NTD, suggesting it to be a potential therapeutic target in cancer.

[The neurosurgical therapy of trigeminal neuralgia]. / Die neurochirurgische Therapie der Trigeminusneuralgie.

The Trigeminal Neuralgie (TN) is he most common cause of facial pain with an incidence of 27 per 100'000 patients per year. The symptoms are paroxysmal stabbing, tearing, and burning pain usually in the area of the second and third trigeminal nerve, that can be provoked by drinking, shaving, chewing or talking. If the classical drug therapy with anticonvulsants is not sufficient or must be discontinued due to side effects, then the retrosigmoidal craniotomy and micro-vascular decompression in vascular-nerve-contact ot partial rhizotomy are good pain-free procedures. Such operations are of low risk in the hands of experienced neurosurgeons and possible to be carried out even in elderly patients. A high percentage of free of complaints postoperative and low recurrence rate legitimate this method.

SWAB/NVALT (Dutch Working Party on Antibiotic Policy and Dutch Association of Chest Physicians) guidelines on the management of community-acquired pneumonia in adults.

The Dutch Working Party on Antibiotic Policy (SWAB) and the Dutch Association of Chest Physicians (NVALT) convened a joint committee to develop evidence-based guidelines on the diagnosis and treatment of community acquired pneumonia (CAP). The guidelines are intended for adult patients with CAP who present at the hospital and are treated as outpatients as well as for hospitalised patients up to 72 hours after admission. Areas covered include current patterns of epidemiology and antibiotic resistance of causative agents of CAP in the Netherlands, the possibility to predict the causative agent of CAP on the basis of clinical data at first presentation, risk factors associated with specific pathogens, the importance of the severity of disease upon presentation for choice of initial treatment, the role of rapid diagnostic tests in treatment decisions, the optimal initial empiric treatment and treatment when a specific pathogen has been identified, the timeframe in which the first dose of antibiotics should be given, optimal duration of antibiotic treatment and antibiotic switch from the intravenous to the oral route. Additional recommendations are made on the role of radiological investigations in the diagnostic work-up of patients with a clinical suspicion of CAP, on the potential benefit of adjunctive immunotherapy, and on the policy for patients with parapneumonic effusions.

Diagnostic management of chronic obstructive pulmonary disease.

Detection of early chronic obstructive pulmonary disease (COPD) in patients presenting with respiratory symptoms is recommended; however, diagnosing COPD is difficult because a single gold standard is not available. The aim of this article is to review and interpret the existing evidence, theories and consensus on the individual parts of the diagnostic work-up for COPD. Relevant articles are discussed under the subheadings: history taking, physical examination, spirometry and additional lung function assessment. Wheezing, cough, phlegm and breathlessness on exertion are suggestive signs for COPD. The diagnostic value of the physical examination is limited, except for auscultated pulmonary wheezing or reduced breath sounds, increasing the probability of COPD. Spirometric airflow obstruction after bronchodilation, defined as a lowered ratio of the forced volume in one second to the forced vital capacity (FEV1/FVC ratio), is a prerequisite, but can only confirm COPD in combination with suggestive symptoms. Different thresholds are being recommended to define low FEV1/FVC, including a fixed threshold, and one varying with gender and age; however, the way physicians interpret these thresholds in their assessment is not well known. Body plethysmography allows a more complete assessment of pulmonary function, providing results on the total lung capacity and the residual volume and is indicated when conventional spirometry results are inconclusive. Chest radiography has no diagnostic value for COPD but is useful to exclude alternative diagnoses such as heart failure or lung cancer. Extensive history taking is of key importance in diagnosing COPD.

An imbalance in interleukin-17-producing T and Foxp3⁺ regulatory T cells in women with idiopathic recurrent pregnancy loss.

BACKGROUND: T cells which produce interleukin (IL)-17 are involved in chronic inflammatory processes and regulatory T (Treg) cells are possibly the most important immune regulators. We aimed to investigate peripheral blood IL-17(+) T and Foxp3(+) Treg cells in women with idiopathic recurrent pregnancy loss (RPL). METHODS: The study design is a cross-sectional evaluation of Th1, Th2, IL-17(+) T and Treg cells in women with idiopathic RPL (n = 42) and age-matched parous controls (n = 24). Flow cytometric analysis was performed to measure IL-17(+) T and Foxp3(+) Treg cells, and ratios of Th1/Th2 cells using anti-IL-17A and anti-Foxp3 antibodies, and monoclonal antibodies to tumor necrosis factor (TNF)-α, interferon (IFN)-γ and IL-10. Student's t-test and partial correlations were applied for statistical analysis. RESULTS: TNF-α-/IL-10-producing CD3(+)CD4(+) T cell ratio was higher in women with RPL than controls (P = 0.048). Levels of IL-17(+) T cells (P = 0.021) and the IL-17(+) T/CD4(+)Foxp3(+) Treg cell ratio (P = 0.001) were increased, whereas Foxp3(+) (P = 0.035), Foxp3(low) (P = 0.032) and CD4(+)Foxp3(+) T cell (P = 0.037) levels were decreased in women with RPL, compared with controls. Levels of IL-17(+) T cells were correlated with TNF-α-producing CD3(+)CD4(+) T cells (r = 0.269, P = 0.033), and with ratios of TNF-α/IL-10 (r = 0.276, P = 0.027) and IFN-γ/IL-10 (r = 0.266, P = 0.035)-producing CD3(+)CD4(+) cells. Furthermore, the ratio of IL-17(+) T cells to CD4(+)Foxp3(+) Treg cells showed a positive correlation with TNF-α-producing CD3(+)CD4(+) T cells (P = 0.047) and IFN-γ-producing CD3(+)CD4(+) T cells (P = 0.048) as well as a ratio of IFN-γ/IL-10-producing CD3(+)CD4(+) T cells (P = 0.037). CONCLUSIONS: Enhanced pro-inflammatory immune responses with suppressed immune regulation may be an important immune mechanism involved in RPL.

Lipid profile and cardiovascular risk factors among first-year Brazilian university students in São Paulo.

BACKGROUND/AIMS: The surveillance of cardiovascular risk factors has been recommended worldwide. The current study is aimed to estimate the prevalence of cardiovascular risk factors among first-year students from a public university in the city of Sao Paulo, Brazil. METHODS: A cross-sectional study of 56 first-year students, of both genders, was performed. Information about demographic characteristics, family history of chronic diseases, smoking, and physical activity was obtained by means of a standardised questionnaire. Anthropometrical parameters (BMI, waist circumference, body fat percentage), metabolic parameters (glycaemia, serum lipid profile), and dietary data (total energy intake, percentage of total energy from macronutrients, cholesterol and dietary fiber) were assessed. RESULTS: The risk of cardiovascular diseases was characterised by family history of cardiovascular diseases (44.6%), smoking (10.7%), physical inactivity (35.7%), borderline high total cholesterol and LDL-c levels (16.1% and 5.4, respectively), decreased HDL-c levels (8.9%), increased triglyceride levels (8.9%), and overweight and obesity (17.8% and 7.1%, respectively). The diet of the students was inadequate: it was high in fat and protein, and low in carbohydrate and dietary fibre. CONCLUSIONS: The prevalence of risk factors for cardiovascular diseases in young adults draws attention to the need to adopt preventive plans in the university setting.

[How does the German DRG system differentiate and reimburse vitreoretinal surgery in diabetic patients?]. / Wie differenziert und vergütet das G-DRG-System bei vitreoretinalen Eingriffen an Diabetikern?

INTRODUCTION: The German DRG system (G-DRG system) is required to assign medical cases with similar costs correctly into a particular group, each case within the group receiving the same amount of reimbursement. At the same time the system should allow all-inclusive reimbursement, not necessarily reflecting the exact costs of each case. These opposite goals and the so far limited calculation basis raise the question of how the G-DRG system actually processes and reimburses empirically collected in-hospital treatment data. PATIENTS AND METHODS: In 2005, 112 patients were admitted to the University Eye Hospital, University of the Saarland. All patients had diabetic retinopathy and required at least one vitreoretinal procedure. Demographic and clinical data were collected by using the hospital information system and the coding software KODIP. For statistic evaluation, principal diagnoses, ancillary diagnoses and procedures were each reassigned to particular groups. Reimbursement was calculated based on the case data of the year 2005. Also, the case data were reassigned with respect to calculation of reimbursement for the years 2006 and 2007. The results were compared with federal G-DRG calculation data. RESULTS: Mean age of the patients was 65.8 +/- 11.1 years, length of stay in-hospital was 9.3 +/- 3.2 days. In the 66 patients requiring general anaesthesia the cumulative length of stay in the operation room was 148.4 +/- 39.5 minutes, the cumulative duration of surgery was 86.3 +/- 34.1 minutes. In the 50 patients requiring local anaesthesia the cumulative length of stay in the operation room was 137.8 +/- 51.8 minutes, the cumulative duration of surgery was 81.6 +/- 43.6 minutes. The patients had 1.9 +/- 0.8 principal diagnoses, 14.4 +/- 5.8 ancillary diagnoses and 3.4 +/- 1.6 procedures. Twenty-five of 112 patients (22.3 %) were assigned to DRG C 03Z (1), 82 of 112 patients (73.2 %) were assigned to DRG C 17Z (2). Five patients were assigned to other DRG. Compared with the federal calculation data, our own data for 2005, 2006 and 2007 showed more high primary clinical complexity levels and a longer duration of in-hospital stay. For each of the three years the amount of reimbursement was equal in about two thirds of the own patients. Reimbursement was only differentiated for outliers beyond the trim point of the duration of in-hospital stay. CONCLUSIONS: The demographic and clinical G-DRG data of the included patients showed substantial cost-effective inhomogeneities. These inhomogeneities were not sufficiently considered for reimbursement based upon Z-DRG. Specialised departments with higher numbers of difficult cases may be discriminated. Wrong incentives may result in the selection of "low-risk cases".

[Summary of the practice guideline 'allergic and non-allergic rhinitis' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Allergische en niet-allergische rhinitis' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The practice guideline 'Allergic and non-allergic rhinitis' of the Dutch College ofGeneral Practitioners has been revised based on developments that have occurred in recent years. The most important modifications are: Impermeable covers for beddings are advised only for patients with serious complaints despite the use of medication and other mite-avoidance measures, and patients with allergic rhinitis with asthma. The indication for the use ofa corticosteroid nasal spray is broadened. There is more evidence for the efficacy ofa nasal spray with antihistamines. The indication for cromoglycate has been restricted. Two major unsolved points of discussion concerned the effectiveness of sublingual immunotherapy and the link between asthma and allergic rhinitis.

Chest radiography and pneumonia in primary care: diagnostic yield and consequences for patient management.

The current prospective cohort study assessed the diagnostic yield of chest radiography (CXR) in primary-care patients suspected of pneumonia. In total, 192 patients with a clinical suspicion of pneumonia aged >/=18 yrs were referred by their general practitioner (GP) for CXR to one of the three participating hospitals in the Netherlands. All GPs were asked to complete a standardised form before and after CXR. Pneumonia was diagnosed by GPs in 35 (18%) patients, of whom 27 (14%) patients had a positive CXR, and eight (4%) patients a negative CXR, but with an assumed high probability of pneumonia by the GP. CXR clearly influenced the diagnosis of pneumonia by the GP in 53% of the patients. CXR ruled out pneumonia in 47% and the probability of pneumonia substantially increased in 6% of the patients. Patient management changed after CXR in 69% of the patients, mainly caused by a reduction in medication prescription (from 43 to 17%) and more frequent reassurance of the patient (from 8 to 35%). In conclusion, pneumonia was frequently over diagnosed clinically by general practitioners. Chest radiography is a valuable diagnostic tool to substantially reduce the number of patients misdiagnosed and is particularly important for the exclusion of pneumonia in general practice.

Body composition in patients with chronic obstructive pulmonary disease: which method to use in clinical practice?

The objective of the present study was to compare anthropometry with bioelectrical impedance (BIA) in relation to densitometry (dual-energy X-ray absorptiometry; DEXA) as methods of nutritional assessment and body composition in out-patients with chronic pulmonary obstructive disease (COPD). We conducted a cross-sectional clinical study with sixty-one patients with COPD (forty-two men and nineteen women), mean age of 66.5 (sd 7.9) years and forced expiratory volume in 1 s of 1.3 (sd 0.6) litres (52.2 (sd 19.8) % predicted), referred to the Pulmonary Rehabilitation Center. The patients were evaluated regarding nutrition status and body composition as determined by anthropometry, BIA and DEXA. In the results, 34.4 % showed mild obstruction, 31.2 %, moderate and 34.4 %, severe obstruction. According to the BMI (mean 24.5 (sd 4.5) kg/m2), 45.9 % of the patients exhibited normal weight, while 27.9 % were underweight and 26.2 % were obese. Related to fat-free mass (FFM), anthropometry and BIA compared with DEXA presented high correlations (r 0.96 and 0.95 respectively; P < 0.001) and high reliability between the methods (alpha 0.98; P < 0.001). Agreement analysis between the methods shows that anthropometry overestimates (0.62 (sd of the difference 2.89) kg) while BIA underestimates FFM (0.61 (sd of the difference 2.82) kg) compared with DEXA. We concluded that according to the nutritional diagnosis, half of our population of patients with COPD showed normal weight, while the other half comprised equal parts obese and underweight patients. Body composition estimated by BIA and anthropometry presented good reliability and correlation with DEXA; the three methods presented satisfactory clinical accuracy despite the great disparity of the limits of agreement.

[Optimizing the antibiotics policy in The Netherlands. VIII. Revised SWAB guidelines for antimicrobial therapy in adults with community-acquired pneumonia]. / Optimaliseren van het antibioticabeleid in Nederland. VIII. Herziene SWAB-richtlijnen voor antimicrobiële therapie bij thuis opgelopen pneumonie.

The Dutch Working Party on Antibiotic Policy (SWAB) has revised the 1998 guideline for community-acquired pneumonia (CAP) in light of changing resistance patterns for common pathogens and new developments in epidemiology, diagnostic testing and treatment strategies. The current guideline is applicable to both primary and inpatient care, and has been developed by delegates of all professional organisations involved in the treatment of CAP, following recommendations for evidence-based guideline development. Assessment of a patient's 'severity of illness' at presentation is considered important when choosing an optimal empirical antibiotic regimen for CAP. Severely-ill patients should be treated with antibiotics covering the most important expected pathogens, including Legionella. Assessment of the severity of illness may be facilitated by the use of validated scoring systems like the pneumonia severity index and the 'confusion, urea, respiratory-rate, blood-pressure, 65-years-of-age' (CURB-65) score. Patients can also be stratified based on their location during treatment: in the community, a normal ward or an intensive-care unit. Legionella urine antigen testing is considered an important tool in the process of deciding on an optimal antibiotic regimen for CAP. Empirical therapy should be replaced with pathogen-directed therapy if the causative agent is identified.