Notes

Principal outflow problematic vein closure within the management of organic side-line arteriovenous anomalies in pets.
Inflammatory bowel disease affects many women of childbearing potential. Women who wish to conceive face many uncertainties. Effects of their medications and their disease may interfere with normal pregnancy and development of the child.

A 30 year old woman with Crohn's disease has a wish to conceive. Her disease has been in remission for 2 years with infliximab use. She is concerned about effects of the medication on her pregnancy and child. An individual risk assessment was made and infliximab was continued until week 22 of gestation. Her pregnancy was monitored, a healthy neonate was born at 38 weeks.

For women on chronic medication an individual preconceptional risk assessmentis needed. The influence of the disease on pregnancy and fetushas to be weighed against possible risks of the drug(s). Crohn's disease is preferably in remission well before and during pregnancy.
For women on chronic medication an individual preconceptional risk assessmentis needed. Ivacaftor order The influence of the disease on pregnancy and fetushas to be weighed against possible risks of the drug(s). Crohn's disease is preferably in remission well before and during pregnancy.Compliance to pediatric guidelines is low, highlighting the gap between the evidence-based and current clinical practice. This leads to considerable variation in practice, both between hospitals, but also even within one department, and to higher costs. Low compliance can be attributed to the guideline itself, if it results in overtreatment, even if it is based on sufficient scientific evidence, or if the guideline contains a large number of subjective criteria. In both cases it is desirable to modify the guideline. Low compliance can also be the result of the user's attitude. Behavioural interventions can be meaningful and effective measure to increase guideline compliance. Guideline implementation and evaluation research is necessary to improve compliance to guidelines.A 40-year-old man presented with acute respiratory distress and a productive cough in the past three days with 'currant jelly' sputum. X-ray showed a right upper lobe infiltrate. Culture of sputum showed Klebsiella pneumoniae, consistent with 'Friedländer' pneumonia. The patient was treated with antibiotics but died after a complicated course.Influenza immunisation during pregnancy is recommended by the WHO since 2010 and implemented in the majority of the Western countries. Finally, the Dutch government follows this recommendation and will be offering vaccination to pregnant women starting upcoming influenza season. Remarkably, this new guideline mainly focuses on the benefits for infants. In this article we want to make healthcare workers aware of the fact that the maternal influenza vaccination has substantial benefits for both mothers and their infants. Vaccination will reduce the risk of infection and influenza-associated hospitalizations. Potentially, the vaccination has positive effects on pregnancy outcomes like birth weight and premature delivery, but further research is needed. Offering the vaccination requires a solid campaign, in which all involved healthcare workers should advocate for vaccination. In addition, the vaccination should not only be available for pregnant women above 22 weeks of gestational age, but throughout the entire pregnancy if necessary.A 74-year-old woman presented with progressive dyspnoea which started a few days after developing a unilateral dermatomal rash characteristic for herpes zoster at dermatome C4-C5. X-ray of the thorax showed an elevated hemidiaphragm ipsilateral of the skin abnormalities. Cervical herpes zoster is a rare cause of a unilateral elevated hemidiaphragm.The coronacrisis was a serious threat for health care and society. By its complexity and deep uncertainty the pandemic showed that patients, physicians and health care need more resilience and flexibility to manage similar future stressors. Moreover, the pandemic uncovered growing disparities in health among citizens, the close links between health care and other societal domains and the fact that we still have only limited power to manage complex new challenges for our global health. We have to adopt another way of managing health care and society to get grip on similar complex medical problems, which we will probably have to face in the future as well. Physicians cannot manage these by themselves. Governments also have to act to diminish social inequality, and create incentives for interdisciplinary collaboration, which together may make citizens and professionals experience coherent and resilient health care management.This case concerns an 81-year-old man with weight loss and erythematosquamous plaques, with central clearing and atrophy. Due to a CT scan and blood test the diagnosis necrolytic migratory erythema as a paraneoplastic manifestation of glucagonoma was made. The pathogenesis is not completely elucidated. Early recognition of symptoms is important.Supervised exercise therapy with lifestyle counseling by a specialized physical therapist has replaced endovascular or open revascularization as primary treatment for intermittent claudication for most patients in the Netherlands. Succesful implementation of this guideline-recommended treatment strategy was achieved by warranting availability and quality of care by organizing care around a national network. Further reductions in unnecessary interventions in this population may be achieved when general practitioners and medical specialists collaborate, for instance by making in-hospital vascular diagnostic laboratories accessible for primary care. The implementation of similar interventions for other non-communicable chronic diseases such as chronic obstructive pulmonary disease or coronary heart disease in standard care is lacking, despite a solid evidence base and guideline recommendations.
A very early medical abortion (VEMA) is an abortion early in pregnancy before the pregnancy is visible on an ultrasound. This treatment has been offered in several countries for many years. Our objective was to investigate whether VEMA is also desirable and can be carried out safely, in the Netherlands.

Descriptive study.

From August 2019 to February 2020 VEMA was offered to women who met the inclusion criteria. A fixed protocol for diagnostic examinations and follow up was used. Ultrasounds and serial human chorionic gonadotrophin assays were used to ensure safety and effectiveness. Satisfaction survey was conducted among clients and employees. The costs of different treatments, including VEMA, were compared.

During the study period 693 women received an abortion treatment in our clinic. 69 women met the inclusion criteria for VEMA. Three of them were referred to the local hospital because of an (suspected) ectopic pregnancy. No ectopic pregnancy was missed later in the process. VEMA was effective in 64 women. Two women needed a second treatment. Eight women did not appear for follow-up without an extra reminder. Women and healthcare providers were very satisfied with the offer of VEMA. VEMA was more expensive than other forms of treatment.

Our study showed that very early medical abortion is safe and achievable in the Netherlands and highly appreciated. When introducing this treatment, a strict protocol is necessary. We advise to offer this treatment to women who prefer a very early abortion.
Our study showed that very early medical abortion is safe and achievable in the Netherlands and highly appreciated. When introducing this treatment, a strict protocol is necessary. We advise to offer this treatment to women who prefer a very early abortion.Negative life events in childhood can have tremendous sequalae in adulthood. Parental death in childhood is associated with reaching lower socioeconomic status, delinquency, and premature death as an adult. Exposure to four or more adverse childhood experiences, (i.e. child abuse, exposure to domestic violence, parental drug addiction, mental disorder or imprisonment) is associated with an increased risk on chronic disease in adulthood, including diabetes, mental illness, alcoholism, cancer, and cardiovascular disease. Identification of children exposed to ongoing adverse experiences is important to offer them support or help them escape. It could be helpful to ask adults if they were exposed to these experiences. link2 If so, this could provide the possibility to offer them help when they still are hampered by these experiences. Maybe intervention could benefit them by preventing lifelong sequalae with chronic use of health care, incapacity for work, and use of medication.1,5 years into the pandemic, SARS-CoV-2 remains a dynamic and evolving disease. Growing proportions of the population have been vaccinated, but what degree of protection does vaccination actually offer, particularly in the face of an evolving virus and the emergence of viral variants? Here we explore the limits of vaccine protection -providing an overview of emerging data on how well vaccines protect against mild and asymptomatic disease, vaccine effectiveness against the backdrop of variants such as the Delta, and the implications for SARS-CoV-2 transmission. We assess the continued risks for our vulnerable elderly and immune-compromised patient populations, and whether emerging literature should impact our diagnostic strategies.In The Netherlands, since 2012, the movement 'DappereDokters' ('Brave Doctors') is trying to change maximum medical care into optimal medical care. Which means only to provide care that improves individual health. General practioners (GPs) and medical specialists (MSs) together form the base. From each point of view and experience, they want to realize this goal. Ending nonsensical care in hospitals, improving collaboration between GPs and MSs, shared decision making by patients and his or her doctors, combined with an open mind and critical attitude towards one's own professional way of treating patients are important aspects in the philosophy of this movement. Many initiatives and ideas have been raised during these years, including reduction of outpatient care. (Nationwide) protocols between GPs and MSs have been implemented. New (digital) technology will strengthen optimal treatment. link3 Financial obstacles should be demolished. The movement 'DappereDokters' is really alive and kicking.Lentigo maligna is an in situ melanoma which usually affects sun-damaged skin on the head and neck. In patients with lentigo maligna, the clinically visible demarcation often correlates poorly with the histopathologically confirmed demarcation. Micrograhic surgery of lentigo maligna offers certainty of the presence of clear histological margins and is at the same time tissue sparing. Because of the clear margins after micrographic surgery, this technique leads to fewer recurrences than standard excision.Femoral neck stress fractures are relatively rare and caused by repetitive high pressure on the bone with insufficient time to recover. These fractures are often seen in fanatic runners or military personnel, who cover great distances. Patients with a femoral neck stress fracture present with mild pain at the front of the thigh or groin. Radiological imaging includes a plain X-ray and/or MRI-scan. Differentiation between a tension- and compression type stress fracture is important, since their treatment strategies differ. Generally, tension type fractures are unstable and demand operative fixation. Compression type fractures can be treated non-operatively if the fracture is smaller than 50% circumferential of the femoral neck.
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