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Changing Perspectives: Save your breath

Save your breath

Burping baby? A 4-year-old with a chronic stomachache? Thinking of lactose-intolerance? The lactose hydrogen breath test (HBT) is an inventive, non-invasive way to detect a low lactase. All your patient needs to do is take a deep breath and allow you to collect some exhaled air. The test seems reliable too. It showed high sensitivity and specificity in previous research.¹

The lactose HBT measures hydrogen in exhaled breath, produced by metabolization of lactose in the so-called process of ‘colonic fermentation’. In the presence of sufficient lactase, lactose is absorbed in the duodenum. However, if there is little lactase in the duodenum (hypolactasia), lactose will be metabolized, or fermented, by the colon. A side product of this process is hydrogen, which is excreted via the lungs and detected by the lactose HBT. Colonic fermentation may be accompanied by stomach ache, flatulence and osmotic diarrhea. Despite promising test parameters, the relation between clinical signs of lactose-intolerance and test results proves poor. This mismatch arises because hypolactasia in children is rare. All babies are born with the capability to metabolize lactose in breast
milk. Above the age of 2, this capability decreases, but only slowly. If hypolactasia does occur, this will only cause symptoms in a small group of patients with excessive lactose intake or comorbid gastro-intestinal disease. Thus, hydrogen breath testing has a very limited clinical use. Rather try if it is helpful to limit lactose intake, or search for another explanation for the gastro-intestinal symptoms.²

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Changing Perspectives: Restrictive use of blood transfusion in critical care: the dawn of a new age?

Restrictive use of blood transfusion in critical care: the dawn of a new age?

Haemoglobin transports oxygen from the pulmonary capillaries to vital organs and other tissues. Acute anaemia, for example as a consequence of surgical blood loss, can lead to tissue hypoxia and organ damage. When haemoglobin concentration drops below critical levels, red blood cell (RBC) transfusion may be indicated and even lifesaving. However, RBC transfusion has also been associated with many complications, for instance transfusion reaction, infection transmission, and acute lung injury. Therefore, determining adequate transfusion triggers is of utmost importance.1 The prevailing Dutch transfusion guideline endorses the ‘4-5-6’ strategy, in which patient characteristics and clinical status influence the decision to apply RBC transfusion.2 In short, RBC transfusion is triggered by haemoglobin concentrations below 4 mmol/L in healthy adults, whereas this trigger is 6 mmol/L in cardiopulmonary restricted patients. Despite its simplicity, recent evidence suggests that the ‘4-5-6’ strategy does not benefit patient outcomes and that a more restrictive use of RBC transfusion might be beneficial. A recent, multicenter, randomized study comprising of more than five thousand cardiac surgery patients found no difference in clinical outcomes (stroke, renal failure, myocardial infarction and death) between a transfusion trigger of 4.5 and 6 mmol/L , respectively.3 Furthermore, a randomized study comprising of almost one thousand patients with acute upper gastrointestinal bleeding found an higher survival rate with a transfusion trigger of 4.3 compared to 5.5 mmol/L.1-4 Therefore, we expect that future guidelines will recommend restrictive use of RBC transfusion in critical care settings.

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Changing Perspectives: Tonsillectomy and its implications for anesthetic management

Tonsillectomy and its implications for anesthetic management

Many children with complaints of upper airway obstruction undergo a tonsillectomy. Dr. Sluder (1865-1928) first described this procedure in 1911, which includes the use of a blunt guillotine.1 He was able to remove both tonsils in less than 10 seconds. General anesthesia was extremely dangerous at the time. Therefore, this technique was performed in non-intubated children, mostly with the use of local anesthetics, and sometimes without any anesthetics.

Over many years, Sluder’s method made way for a nowadays daily used dissection technique in which intubation is necessary. In this procedure, a free airway is guaranteed throughout the whole operation. Moreover, the surgeon is able to perform the tonsillectomy more carefully, and as a result the hemostasis of the operational area can be monitored more precisely. However, this technique is more cumbersome and has an increased procedural time.

Sluder’s operation is still performed in some Dutch hospitals. Current guidelines recommend that his technique should only be performed in non-intubated children by competent anesthesiologists and ENT specialists.2  The airway is considered unsafe due to the possibility of aspiration of tissue and blood. Moreover, this very painful stimulus is performed during sub-anesthetic threshold values of volatile anesthetics, which may lead to acute laryngospasm, resulting in a ‘cannot ventilate’ situation in a patient without intravenous access. In addition, anesthesiologists lose their competence as this method disappears in their education. Thus, in our opinion, the classic dissection technique is ought to replace Sluder’s operation in non-intubated children.

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Changing Perspectives: MRI and arthroscopy of the knee in patients over 50 years of age

MRI and arthroscopy of the knee in patients over 50 years of age

In the Netherlands knee injuries occur approximately 300,000 times a year.1 Meniscal tears are among the most common knee injuries with an incidence of 2 per 1,000 patients a year.2 As a result arthroscopic meniscectomy is performed nearly 30,000 times a year in patients over 50 years of age.3 In over half of these patients magnetic resonance imaging (MRI) was performed prior to surgery.  However, multiple randomized controlled trial observed no significant difference between knee function, pain relief and patient satisfaction when comparing arthroscopy to conservative treatment.4,5 In addition, the amount of knee arthroscopies where no therapeutic intervention was conducted during surgery ranges from 27 to 61%.1

Consequently, it is questioned whether these procedures benefit healthcare efficacy. Especially when taking into account that patients over 50 years of age are at risk of having existing osteoarthritis (OA) of the knee.6 This is accompanied by degenerative meniscal tears in up to 80%.7 Therefore, differentiating whether the symptoms are caused by the meniscal tear or developing OA is quite challenging. As a result, there is no indication to perform MRI in patients over 50 years of age according to the Netherlands Orthopedic Association (NOV). On that account, it is advised only to perform knee arthroscopy in case of locking of the knee caused by mechanical obstruction in these patients. This is without performing MRI prior to surgery.1

Therefore a substantial reduction of MRI and knee arthroscopies in patients over 50 years of age is warranted, especially in these times of increasing awareness of cost-effectiveness.6

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Changing Perspectives: DSM-IV: make way for DSM-5

DSM-IV: make way for DSM-5

As of 2017 the fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) will be the leading classification system for psychiatry in the Netherlands. It succeeds its predecessor DSM-IV, which has been around since the ‘90s and was known for adding the required ‘clinically significant impairment in functioning’ criterion to many disorders.

One of the biggest changes is the removal of the multiaxial system. Sixteen new classifications have been added and some disorder groups have changed radically. Most notably, the diagnosis ‘Autism Spectrum Disorder’ now encompasses autism, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified and it is categorized in severity. Another notable change is the reorganization of the former anxiety disorders into separate anxiety, obsessive-compulsive-related and trauma- and stressor-related disorders.

Not all changes have been met with enthusiasm. For example, there has been much debate about the removal of the bereavement exclusion in major depressive disorder. This criterion was used to exclude the possibility of diagnosing someone with a depression in the first two months of grief. Some fear that this removal may lead to unnecessarily medicalizing normal grief.

According to Edith Schippers, Minister of Health, Welfare and Sport, the change to DSM-5 will not have any noticeable effect, insurance-wise. It will be interesting to see how much impact this DSM update will have in the everyday clinical setting.

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Changing Perspective: The use of 24-hour urine collections to estimate sodium intake: lessons from space

The use of 24-hour urine collections to estimate sodium intake: lessons from space

The relation between sodium intake and cardiovascular health is a subject of an ongoing, sometimes overheated, discussion. An important issue contributing to this discussion is the way by which sodium intake is assessed, e.g. by the use of morning urine samples or dietary questionnaires. Generally, measurement of sodium content in 24-hour urine collection is considered to be the best reflection of daily sodium intake. Recent data indicate that the latter may not be true, not only because of daily variation in sodium intake, sampling errors or urinary bladder retention. The recent discovery by Rakova et al in subjects that underwent training for a long-term space flight to Mars (!) importantly influences the interpretation of sodium excretion using 24-hour collections.1 At a perfectly stable sodium intake for months, 24-hour sodium excretion into the urine has been demonstrated to display huge day-to-day fluctuations. The finding of rhythmic sodium excretory and retention patterns by the kidney may contribute to variations exceeding 50-100 mmol/d when subjects are put on a fixed diet containing 200 mmol/d of sodium. In light of the discussion on health outcomes related to sodium intake, alternatives to reliably assess an individual’s dietary sodium intake are highly needed, but yet unknown.
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Changing Perspectives: Putting bedrest to rest

Putting bedrest to rest

In the previous century, bedrest was often used as a therapy by itself.1 The ancient Greeks prescribed it, as did clinicians in the late 19th century until the Second World War. Back then, a myocardial infarction required patients to lie down for four weeks.

The logistic challenges of the Second World War changed the paradigm. Hospitals full of wounded soldiers had to make room for the most wounded, thus mobilising patients earlier than usual. Clinicians noted that this improved outcomes. Additionally, studies carried out in preparation for space missions demonstrated muscle loss and functional decline in immobile subjects. Since then, detrimental health effects of immobilisation have been reported for almost any organ in the human body.2-4 Myocardial damage, postural hypotension, atelectasis, higher rate of pulmonary and urinary tract infections, thrombosis, sarcopenia, reflux disease, constipation, diverticulitis and numerous other effects are associated with prolonged bedrest.

This insight has shaped current practice: the use of physiotherapists and enhanced ambulatory care are examples of measures implemented throughout modern medicine. However, while the importance of mobilisation is undeniable, health institutions are still designed primarily around the bed. Further measures, for example altered ward designs, may be introduced to promote patient mobility and further reduce adverse health effects in an increasingly sedentary, obese and aging society.

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Changing Perspectives: Plain radiography in acute abdominal pain; ancient history?

Plain radiography in acute abdominal pain; ancient history?

In the not so distant past, plain radiography of the abdomen was one of the diagnostic tools in the management of patients with acute abdominal pain. It is quick, cheap and yields less radiation exposure than a CT-scan. However, multiple large studies showed that plain radiography of the abdomen has no additional value on top of clinical assessment in the evaluation of patients with acute abdominal pain (1-3). Furthermore, plain radiography gives the false reassurance of being able to exclude major pathology, for example, free air due to a bowel perforation. Moreover, if free air is seen on plain radiography mostly an additional CT-scan of the abdomen will be obtained to decide what type of operation has to be performed.

Multiple studies showed that the highest sensitivity and lowest radiation exposure, in patients with acute abdominal pain, can be achieved by first performing an abdominal ultrasound followed by, if the ultrasound is inconclusive, a CT scan (1). Therefore, in the Dutch guidelines for acute abdominal pain, there is no room for conventional imaging of the abdomen (4). Nevertheless, many doctors are still attributing great diagnostic value to plain radiography of the abdomen in the acute setting although scientific evidence is lacking. The future will show whether plain radiography in acute abdominal pain will definitely belong to ancient history.

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Changing Perspectives: Third time‘s a charm

Third time‘s a charm

(Psychosurgery: from lesion to insertion)

In the first half of the 1900’s the first real steps into psychosurgery were made. Tens of thousands prefrontal leucotomies (lobotomies) were performed on patients with different psychiatric disorders. Even though this rather crude brain lesioning procedure was already regarded unethical, risky and unscientific, the neurologist Egas Moniz still received a Noble Prize for his work on lobotomies in 1949.

After the introduction of the stereotactic frame the selectivity of subcortical lesioning strongly improved and lobotomies were quickly replaced by stereotactic psychosurgery. However, with the introduction of psychoactive medication in the 1950’s and 1960’s the interest in the invasive and irreversible treatment of psychosurgery subsided strongly.

Since the emergence of deep brain stimulation (DBS) in the 1990’s, the returning interest in the field of neurosurgery has been remarkable. DBS involves the insertion of electrodes that deliver electrical impulses to targeted areas of the brain. Opposed to ablative surgery, DBS is an adjustable and reversible intervention. For several psychiatric disorders the results are promising and the number of psychiatric patients treated with DBS is growing steadily (±300 DBS for obsessive-compulsive disorder patients). Today, DBS is considered a promising treatment for psychiatric disorders and for psychosurgery it seems, third time‘s a charm.

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Changing Perspectives: Bed rest

Bed rest

The lumbosacral radicular syndrome is associated with radiating pain in one or more lumbar or sacral dermatomes. Patients are treated mostly with conservative treatment first and for decades the mainstay of this conservative treatment was strict bed rest for 14 days. Clinical trials back in the 90’s already showed that bed rest in patients with a lumbosacral radicular syndrome is not more effective than ‘watchful waiting’ and ‘watchful exercise’.

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