[Guidelines in historical perspective]. / Richtlijnen in historisch perspectief.

The role of clinical practice guidelines has changed dramatically the past 50 years. Both beneficial, as also having some disadvantageous effects. Considering the international developments, such as a growing body of evidence and evolving methodologies, some limits might be in reach or already been reached. The solution thereof is part nationally and part internationally. Internationally because of new methodologies and technologies, such as use of artificial intelligence, and nationally in a more coherent approach. Coherent not only in medical disciplines, but also in policies of government, regulators, and health insurers. This calls for a renewed, integral and an all-encompassing vision.

Carotid Artery Calcification on Orthopantomograms (CACO Study) - is it indicative of carotid stenosis?

It is unclear whether incidental carotid artery calcification (CAC) on radiographs has a defined relationship to clinically significant carotid artery stenosis, and therefore risk of stroke. The primary objective of this study was to ascertain the relationship between dental radiograph detected carotid calcification and carotid artery stenoses ≥50% on carotid duplex ultrasound. We carried out an observational study of patients undergoing routine dental orthopantomogram (OPG) examinations. Consecutive patients with CAC on OPG were prospectively matched to those without CAC based on age and gender. Ultrasound of the carotid arteries was performed to determine the presence of stenosis (≥50%) in either vessel. Of 5780 consecutive OPG examinations with suitable images for analysis, CAC was detected in 10.8%. A total of 233 patients underwent carotid ultrasound (130 with and 103 without CAC on OPG). The prevalence of a clinically significant (≥50%) carotid stenosis on ultrasound was 15.4% (20/130) in those with CAC and 5.8% (6/103) for those without CAC on OPG. Incidental CAC detected on routine OPG requires both radiological reporting and clinical follow-up since 1 in 7 patients will have a clinically significant carotid artery stenosis as compared with 1 in 20 patients who do not have CAC. Trial Registration: Australian and New Zealand Clinical Trials Registry website (U1111-1148-1066). http://www.ANZCTR.org.au/ACTRN12613001038785.aspx.

[The future of guidelines: an exploration based on the four perspectives of the PHSF-2014]. / De toekomst van richtlijnen: een verkenning aan de hand van de vier perspectieven van de VTV-2014.

In the Dutch Public Health Status and Foresight report (PHSF), the Dutch National Institute for Public Health and the Environment explores the future of public health and health care in the Netherlands up to 2040. In the first article of a short series on the PHSF 2014, we briefly explained the study and four normative perspectives on public health. In the second article, we described the most important future trends up to 2030. In this, the final article on the PHSF 2014, we use the four normative perspectives as a foresight of future guidelines. We make some recommendations in which normative diversity is taken into account. Our ultimate goal is to see our results and analyses also being put to use in other strategic discussions and determinations.

A patient with anaphylaxis after alteplase infusion.

Anaphylaxis to alteplase is a rare but reported complication of intravenous thrombolysis. We report a patient with a documented episode of anaphylaxis that occurred following an initial bolus and a subsequent delayed infusion of alteplase for thrombolysis of acute ischaemic stroke. The patient was treated with hydrocortisone, adrenaline, prochlorperazine and ranitidine, as per the hospital anaphylaxis protocol, intubation and admission to the intensive care unit. Serum tryptase levels performed during the anaphylactic event (at the end of the infusion) and 1.5 hours later showed an increase of 2 µg/L, suggestive of an anaphylactic reaction. Anaphylaxis remains largely a clinical diagnosis even in the absence of an elevated serum tryptase. The patient would benefit from further allergen testing given the severity of the reaction to alteplase. We report this patient to indicate that although rare, anaphylaxis is a recognised adverse event following alteplase. In the case of any symptoms suggestive of a minor anaphylactic reaction to alteplase, further infusion should be ceased to avoid a dose dependent major reaction.

Rescue therapy with local intra-arterial urokinase after poor clinical response with intravenous recombinant tissue plasminogen activator in acute ischaemic stroke.

We report a case of combined intravenous and intra-arterial thrombolysis in a patient presenting with acute ischaemic stroke. Progression to intra-arterial thrombolysis in patients who fail to show clinical improvement within 6 h of symptom onset might be a safe treatment option at centres with access to stroke specialist and endovascular services. The purpose of this report is to demonstrate the efficacy and potential benefits of this rescue therapy.

Prospective comparison of three guideline development methods for treatment of actinic keratosis.

OBJECTIVE: To compare three methods of guideline development, to see whether using alternative evidence-based methods resulted in variation of recommendations for treating actinic keratosis. METHODS: Method 1 followed a standard multiple session evidence-based approach with a working group. In method 2 recommendations were formulated by a working group during a 2-day conference. Method 3 used one epidemiologist to summarise the evidence and one dermatologist to make clinical recommendations afterwards. Graded recommendations and levels of evidence were compared per therapy across three draft guidelines. The primary outcome was the extent of accordance or discordance. Secondary outcomes were total costs and time period necessary to make a draft guideline. RESULTS: Therapeutic recommendations and levels of evidence differed in some occasions. However, intraclass correlations between levels of evidence were significant (method 1 vs 2: p = 0.003; method 1 vs 3: p < 0.001). Regarding recommendation variation method 1 and method 2 correlated significant at 0.755 (p = 0.001). Method 1 versus 3 and method 2 versus 3 also showed significant, but lower, correlation coefficients (respectively, 0.493 (p = 0.026) and 0.673 (p = 0.007)). Method 3 was the cheapest and quickest (24,770 euro and 4 months) and method 1 was the most expensive and slowest method (€48,100 euro and 14 months). CONCLUSIONS: The value of a guideline using alternative evidence-based methods seems to at least equal that of a guideline composed in multiple sessions, that is, for topics with a monodisciplinary character and a relatively small number of conducted trials. In addition, the presented alternatives were more time- and cost-efficient.

Off-label use of azathioprine in dermatology: a systematic review.

OBJECTIVE: To summarize evidence regarding the effectiveness, efficacy, and safety of off-label azathioprine use in dermatology. DATA SOURCES: We searched the MEDLINE (1950-2009), EMBASE (1980-2009), and CENTRAL (1996-2009) databases on October 9, 2009. The main search terms were azathioprine and its synonyms. No restrictions were imposed regarding publication date. Only articles in English, French, German, or Dutch were included. STUDY SELECTION: Randomized controlled trials, cohorts, and case series concerning the use of azathioprine in an off-label dermatologic setting were independently assessed for eligibility by 2 coauthors. The search retrieved 3870 articles, and 148 articles were selected for detailed review. DATA EXTRACTION: Forty-three articles matching the inclusion and exclusion criteria were reviewed for methodologic quality by 2 reviewers independently, including an evaluation of components associated with biased estimates of treatment effect. DATA SYNTHESIS: High-quality evidence (level A) was found for a moderate therapeutic effect in severe atopic dermatitis. Evidence of moderate quality (level B) was found for efficacy in parthenium dermatitis (an airborne plant allergen contact dermatitis), bullous pemphigoid, chronic actinic dermatitis, and leprosy type 1 reaction. Furthermore, favorable therapeutic effects existed for erythema multiforme, lichen planus, and pityriasis rubra pilaris, although the quality of evidence was low (level C). CONCLUSIONS: A strong clinical recommendation was given for azathioprine in atopic dermatitis. Conclusions regarding safety in an off-label setting could not be reached because of scarce and incomplete data (level C evidence). Long-term registries and prospective studies could add to the existing evidence and provide legal support for off-label drug use in dermatology.

[Guideline 'Diagnosis and treatment of inflammatory bowel disease in adults'. I. Diagnosis and treatment]. / Richtlijn 'Diagnostiek en behandeling van inflammatoire darmziekten bij volwassenen'. I. Diagnostiek en behandeling.

The Dutch national practice guideline 'Diagnosis and treatment of inflammatory bowel diseases (IBD) in adults' describes the multidisciplinary approach for adult patients with (suspected) IBD, recommended following analysis of the literature according to the principles of evidence based guideline development. The symptoms on first presentation of a patient with IBD are mainly connected with the localisation and severity of the disease and less with the resulting diagnosis 'Crohn's disease' or 'ulcerative colitis'. There is no test by which the diseases can be distinguished with certainty. Clinical course, ileocolonoscopy and histopathological investigation following biopsy form the 'gold standard' for diagnosis of IBD. The final diagnostic step is disease assessment according to the Montreal classification in order to enable unambiguous communication with medical professionals. The first aim of treatment is to treat and stabilise active disease (induction therapy); at the same time maintenance therapy is initiated. A step-up approach is recommended for both treatment aims. Surgical intervention is indicated if the medical treatment is ineffective, in case of intractable gastrointestinal bleeding, in clinically significant gastrointestinal stenosis due to fibrotic scar tissue, or if complications of the inflammation occur such as abscess, peritonitis, or complicated fistula formation. Nutrition and diet do not play a primary therapeutic role in treatment of adult patients with IBD. However, supportive nutritional care is warranted. Probiotics have a demonstrable effect in preventing pouchitis, but not in the treatment of IBD. Alternative medicine has no role to play in the treatment of IBD. The risk of developing colorectal carcinoma is slightly elevated in IBD patients. Therefore, endoscopic surveillance strategies, aimed at early detection of dysplasia, is indicated according to a schedule in which the frequency increases according to the time elapsed since first clinical signs of IBD.

[Advice on guidelines: planning for guideline development in the Netherlands]. / Regie over richtlijnen: plannen voor richtlijnontwikkeling in Nederland.

There is a lack of shared responsibility and national steering in guideline development. The 'Regieraad' (advisory board on guideline development, established by the Dutch Health Secretary) hopes to facilitate the coordination of guideline development. Therefore, the board developed a shortlist of the 100 most important diseases and 25 important care processes, based on several accepted criteria. An inventory of already available guidelines and other instruments for quality improvement was also made. The board thinks that guidelines should become more uniform to improve accessibility and usefulness for daily practice. The board encourages the availability of guidelines for the most important topics. With the information available a long-term policy for guideline development and maintenance can be determined.

The guideline "consultation psychiatry" of the Netherlands Psychiatric Association.

BACKGROUND: In 2008, the Netherlands Psychiatric Association authorized a guideline "consultation psychiatry." AIM: To set a standard for psychiatric consultations in nonpsychiatric settings. The main objective of the guideline is to answer three questions: Is psychiatric consultation effective and, if so, which forms are most effective? How should a psychiatric consultations be performed? What increases adherence to recommendations given by the consulting psychiatrist? METHOD: Systematic literature review. RESULTS: Both in general practice and in hospital settings psychiatric consultation is effective. In primary care, the effectiveness of psychiatric consultation is almost exclusively studied in the setting of "collaborative care." Procedural guidance is given on how to perform a psychiatric consultation. In this guidance, psychiatric consultation is explicitly looked upon as a complex activity that requires a broad frame of reference and adequate medical and pharmacological expertise and experience and one that should be performed by doctors. Investing in a good relation with the general practitioner, and the use of a "consultation letter" increased efficacy in general practice. In the hospital setting, investing in liaison activities and an active psychiatric follow-up of consultations increased adherence to advice. CONCLUSION: Psychiatric consultations are effective and constitute a useful contribution to the patients' treatment. With setting a standard consultations will become more transparent and checkable. It is hoped that this will increase the quality of consultation psychiatry.

[Guideline 'Medicinal care for drug addicts in penal institutions']. / Richtlijn 'Medicamenteuze zorg aan gedetineerde verslaafden'.

In the Netherlands, the policy on care for prisoners who are addicted to opiates is still heterogeneous. The recent guidelines entitled 'Medicinal care for drug addicts in penal institutions' should contribute towards unambiguous and more evidence-based treatment for this group. In addition, it should improve and bring the care pathways within judicial institutions and mainstream healthcare more into line with one another. Each rational course of medicinal treatment will initially be continued in the penal institution. In penal institutions the help on offer is mainly focused on abstinence from illegal drugs while at the same time limiting the damage caused to the health of the individual user. Methadone is regarded at the first choice for maintenance therapy. For patient safety, this is best given in liquid form in sealed cups of 5 mg/ml once daily in the morning. Recently a combination preparation containing buprenorphine and naloxone - a complete opiate antagonist - has become available. On discontinuation of opiate maintenance treatment intensive follow-up care is necessary. During this period there is considerable risk of a potentially lethal overdose. Detoxification should be coupled with psychosocial or medicinal intervention aimed at preventing relapse. Naltrexone is currently the only available opiate antagonist for preventing relapse. In those addicted to opiates, who also take benzodiazepines without any indication, it is strongly recommended that these be reduced and discontinued. This can be achieved by converting the regular dosage into the equivalent in diazepam and then reducing this dosage by a maximum of 25% a week.

Factors that influence the stroke care team's effectiveness in reducing the length of hospital stay.

BACKGROUND AND PURPOSE: The purpose of this study was to explore the effects of a quality improvement program for improving stroke care and the determinants of success at the team and hospital levels. Method- For 16 months, 23 multidisciplinary stroke service teams participated in a quality improvement collaborative designed to set up stroke services and reduce the length of hospital stay (LOHS). We monitored the LOHS and the discharge delay during the project and measured indicators of well organized stroke services at baseline and after the intervention. A multiple and multilevel regression model was used to relate the outcome variables to the team and hospital characteristics. National LOHS figures served as reference data. RESULTS: Data regarding 4549 stroke patients were included in the analyses. The LOHS decreased significantly from 18.3 to 13.3 days. The mean LOHS varied substantially (9.2 to 20.9 days) after the intervention. Teams with higher team functioning scores showed lower LOHS scores and higher scores for the indicators of well organized stroke services. Team characteristics explain almost 40% of the variance in LOHS and 53% in the indicators of well organized stroke care. CONCLUSIONS: Participation in a national quality improvement collaborative effected a significant decrease of the LOHS and a significant increase in the presence of key features of stroke services. Variation in ability to reduce the LOHS and increase key features of stroke services were related to team functioning. The data suggest that the composite of team functioning is pivotal in quality-of-care improvement and may need specific attention in any quality improvement program.

Evidence for the impact of quality improvement collaboratives: systematic review.

OBJECTIVE: To evaluate the effectiveness of quality improvement collaboratives in improving the quality of care. DATA SOURCES: Relevant studies through Medline, Embase, PsycINFO, CINAHL, and Cochrane databases. STUDY SELECTION: Two reviewers independently extracted data on topics, participants, setting, study design, and outcomes. DATA SYNTHESIS: Of 1104 articles identified, 72 were included in the study. Twelve reports representing nine studies (including two randomised controlled trials) used a controlled design to measure the effects of the quality improvement collaborative intervention on care processes or outcomes of care. Systematic review of these nine studies showed moderate positive results. Seven studies (including one randomised controlled trial) reported an effect on some of the selected outcome measures. Two studies (including one randomised controlled trial) did not show any significant effect. CONCLUSIONS: The evidence underlying quality improvement collaboratives is positive but limited and the effects cannot be predicted with great certainty. Considering that quality improvement collaboratives seem to play a key part in current strategies focused on accelerating improvement, but may have only modest effects on outcomes at best, further knowledge of the basic components effectiveness, cost effectiveness, and success factors is crucial to determine the value of quality improvement collaboratives.