The use of immunomodulatory medications is expanding across all fields of medicine. The selective immune deficiencies that arise with their use generate an increased incidence of infections caused by previously lesser-known or generally harmless micro-organisms. Physicians will therefore increasingly encounter patients presenting with unusual infections or their unusual manifestations. Here we present three patients who were treated with various forms of B-cell depleting medication for three very different conditions (granulomatosis with polyangiitis, multiple sclerosis, and tuberous sclerosis complex in their unborn child). In all three cases there was a significant doctor's delay - the diagnosis of a Ureaplasma infection was only made once this was specifically considered, as PCR testing had to be employed. Through this case series we demonstrate that in culture-negative infections in patients receiving therapy that affects the humoral immune response, Ureaplasma infection should be considered and specific diagnostic testing should be used.
A 52 year old male, without medical history, had painful shins for several months. X-ray showed lytic bone reaction and blood results showed a primary hyperparathyroidism. The diagnosis was osteitis fibrosa cystica, a rare, benign bone lesion. Increased parathyroid hormone leads to high osteoclastic bone turnover causes osseous deformities and fractures.
Regular engagement in physical activity reduces the risk for chronic diseases and mortality. Nevertheless, more than half of the Dutch population does not adhere to contemporary physical activity guidelines. We provide insight into the dose-response relationship between physical activity and health benefits, and present novel approaches to enhance the uptake of a physically active lifestyle. Important take-aways are as follows: 1) Due to the curvilinear association, risk reductions with increases in physical activity volumes strongly depend on baseline activity levels. 2) High intensity activities produce similar health benefits in relatively less time compared to activities atmoderate- or low intensity. 3) Novel metrics, such as daily steps or exercise snacks expand the physical activity toolbox and could allow more personalized activity prescriptions.
A 26-year-old, healthy man develops complaints of his right hand, consisting of pain, paresthesia and a white discolouration. Accessory cervical ribs were detected and the patient was referred to a specialised centre for thoracic outlet syndrome, where he was successfully treated.
OBJECTIVE:To investigate the role of racial/ethnic bias in the assessment, management and treatment of pain among maternal and newborn care professionals in the Netherlands. DESIGN:Mixed methods study. METHOD:Quantitative: retrospective assessment of a prospective cohort of uterine ruptures in the Netherlands (NethOSS, 2016-2018) examining associations between race/ethnicity categories and language barrier, and the response time to pain and maternal/perinatal outcomes. Qualitative: thematic analysis of semi-structured interviews with professionals about racial and ethnic bias in pain assessment, management and treatment. RESULTS:Caesarean section was significantly more frequently performed >180 minutes after the first pain complaint in the non-Western category compared to the Western category (8/15 (53.3%)) vs (1/12 (8.3%))) (OR 12.57, 95% CI 1.28- 123.48). Professionals expressed implicit racial and ethnic bias and stereotypes about pain experience and expression, while mostly perceiving their own practice as unbiased. CONCLUSION:Racial thinking and notions of ethnic differences in pain assessment, management, and treatment were largely unrecognized.
Revascularization remains the cornerstone of treatment for CLTI. Conservative treatment represents an underexposed yet potentially appropriate alternative for selected elderly and frail patients. This population is characterized by high mortality rates, substantial perioperative risks, prolonged hospital stays, increased healthcare costs, and deterioration in functional status and quality of life following invasive interventions. Conservative treatment - including wound care, pain management, and when necessary, minor amputations - may offer an alternative for frail, elderly patients with CLTI. Emerging evidence suggests that, for selected patients, conservative treatment can result in acceptable wound healing rates and survival comparable to invasive strategies, without an increase in major amputation rates. Within the context of appropriate and value-based care, conservative treatment may better balance functional outcomes, healthcare utilization and patient preferences. Future research on prediction models to guide patient selection, cost-effectiveness analyses, and qualitative studies exploring patient-reported outcomes and experiences, should support evidence-based implementation of conservative treatment.
In 25-40% of patients with thromboembolic stroke, current diagnostics fail to identify a cause. It has been shown that prolonged heart rhythm monitoring can detect atrial fibrillation (AF) as the underlying cause in one-third of these patients. Even though an implantable loop recorder detects AF in 37% of cases up to four years after stroke, several studies show no reduction in the number of recurrent strokes with anticoagulation treatment. It seems that a high degree of AF around the stroke, so-called high burden, has a more likely causal link, than AF detected months or years after stroke. Anticoagulation treatment may be more effective in high AF burden stroke patients. A less expensive, non-invasive detection method, applicable immediately after stroke, may be more suitable in practice. Furthermore, recent research shows promising results in the importance of determining electrocardiographic, anatomical and blood biomarkers indicative for an atrial myopathy and better detection AF.
Establishing a differential diagnosis for polyuria and polydipsia during pregnancy can be challenging. We describe a pregnant woman with severe polyuria (urine output 9L/24h) and polydipsia without pre-existing symptoms. Gestational diabetes and electrolyte disturbances were excluded; HbA1c and daily glucose profiles were normal. Due to pregnancy, no water deprivation or arginine stimulation test was performed. Copeptin, a surrogate marker for AVP/ADH, was <2 pmol/L (reference: 0-9 pmol/L), ruling out AVP resistance. Because of disabling symptoms, a trial of oral desmopressin was initiated during admission, leading to complete normalization of diuresis without thirst. Weight, diuresis, plasma/urine sodium, and osmolality were closely monitored. After delivery of a healthy son, desmopressin was discontinued and symptoms resolved spontaneously, with copeptin remaining normal. These findings ruled out primary polydipsia. Conclusion: this was a case of pregnancy-induced AVP deficiency due to elevated placental vasopressinase activity, a rare condition (2-4 per 100,000 pregnancies).
The Dutch Healthcare Evaluation & Appropriate Use program aims to ensure that only proven effective care is provided. A protocol-based healthcare system is based on an ideal that leaves little room for an improvising healthcare practice with unique patient experiences. This essay articulates the contrast between a technological-rationalist approach to healthcare and the phenomena in healthcare that fall outside this framework. Phenomena that hardly fit within the political ideal of a healthy and productive society, such as suffering, misfortune, and death. Inspired by the philosopher of science Michel Serres, we refer to this as 'noise'. We argue that noise is not only an inconvenient interruption of effective care but, paradoxically, also its prerequisite. A well-functioning system is sensitive to the unprotocolled. In this way, noise undermines the problematic dichotomy between effective and ineffective. Medical practice must always address disruptive elements that do not fit within the discourse of proven effectiveness.
Epistaxis, also known as a nosebleed, is common and usually stops spontaneously. However, when a patient visits the general practitioner, various self-care advice can be provided and several treatment options are available. Underlying causes of nosebleeds should be considered. Referral to an otolaryngologist is necessary if nosebleeds are persistent or recurrent. This article discusses the incidence, etiology, treatment, and prevention of nosebleeds.
OBJECTIVE:To evaluate the implementation of home-administered intravenous rehydration for patients with hyperemesis gravidarum (HG) as an alternative to hospital admission. DESIGN:Prospective cohort study. METHOD:Between 11 July 2022 and 1 January 2025, patients with HG requiring intravenous fluids were treated at home. Patient satisfaction was assessed using a structured questionnaire. Primary outcomes were the number of avoided hospital admission days and patient satisfaction. RESULTS:A total of 167 patients received home-administered rehydration, covering 246 treatment episodes and 1,989 treatment days. In 89% of cases rehydration could be administered at home, either fully or partly, resulting in an estimated reduction of 566 inpatient days. In 66% of cases, a single treatment episode was sufficient. Patient satisfaction was high. CONCLUSION:Home-administered therapy for HG significantly reduced hospital admissions while maintaining high patient satisfaction. The organizational framework we developed may serve as a template for other low-complexity conditions requiring intravenous therapy in the home setting.
Refugee children and their parents face cumulative stressors before, during and after displacement. This renders them vulnerable to develop emotional and behavioral problems, often accompanied by strain on family functioning. Psychotrauma-related symptoms are not always readily identifiable in clinical practice and may present diffusely, including as somatic complaints. Awareness of possible psychotrauma symptoms and thorough screening are therefore essential. When indicated, effective treatment options are available, ranging from low-threshold psychosocial support to specialized mental health care, both individually (EMDR, TF-CBT, KID-NET, Veerkracht) and family-focused (parent-child therapy, systemic therapy, MFT).
A 62-year-old woman presented with chronic dyspnea since childhood and progressive hypercapnic respiratory failure. Imaging revealed right diaphragmatic elevation, left lung hypoplasia, and absence of left pectoral muscles. Poland syndrome was diagnosed. This case highlights the importance of thorough physical examination and imaging interpretation in identifying rare congenital conditions.
Randomized controlled trials (RCTs) often assume an unchanging control condition. When blinding is not feasible, waitlist or standard-care conditions can evoke negative expectations and nocebo effects. Differences between the intervention and control conditions are therefore determined not only therapeutically, but also contextually. Psychopathology and various somatic conditions are increasingly understood as disturbances of a complex dynamic system, in which small changes can trigger large shifts. Effects that may appear to be of little significance, such as the impact that assignment to a control condition has on people's expectations, may have major effects on the outcome.
Some researchers in clinical medicine are firmly convinced about the benefits and the superiority of the treatments that they are evaluating. This may lead to conscious or unconscious decisions that affect the design, conduct, analysis, and reporting of trials. While human, and understandable, this practice should be balanced. This can be done by assigning professional skeptics in multidisciplinary research teams, aiming for adversarial collaboration in science, as advocated by Kahneman, and by installing Red Teams in complex analyses. Passion is what drives many, if not most, scientists. In clinical trials, the enthusiast should be surrounded by like-minded spirits, who can assemble the energy to finish the project. Yet there should also be at least one professional skeptic in the team.
BACKGROUND:Treatment with glucagon-like peptide-1 receptor agonists such as semaglutide is generally subject to strict reimbursement criteria. This leads to a growing off-label market outside of the regular healthcare system without strict quality controls, which may jeopardize patient safety. CLINICAL CONTEXT:Two cases are reported of patients without diabetes or obesity, who had injected semaglutide subcutaneously that was obtained without a prescription. Both presented in a coma with severe hypoglycemia, hypokalemia and hypothermia, which was caused by an intoxication with synthetic insulin. Monotherapy with semaglutide is not associated with significant hypoglycemia in healthy individuals. Up to two days of continuous glucose infusion was required to keep patients euglykemic. CONCLUSION:The use of illegally obtained semaglutide may lead to life-threatening intoxications, due to insufficient safety precautions for the provided medication. Timely notification of cases to the national health regulatory authority is essential to mitigate further distribution of falsified drugs.
OBJECTIVE:To evaluate the effectiveness and costs of the Back At work After Surgery (BAAS) integrated care pathway for workers receiving knee arthroplasty in the Netherlands. DESIGN:Comparative cohort study of the BAAS cohort versus two usual-care cohorts. METHODS:BAAS included explicit discussion of RTW in orthopedic consultations, workplace assessment, Goal Attainment Scaling, activity monitoring and an interdisciplinary online consult at 4-5 weeks postoperatively. Cohorts shared similar inclusion criteria and return-to-work and cost outcomes. Time to (full) RTW was analyzed with IPTW/Cox regression and costs with propensity score matching. RESULTS:Median time to first RTW was 27 days in BAAS versus 52 and 43 days in controls (HR 2.7 and 1.95). Full RTW took 183 versus 210 days (HR 1.4). Non-RTW within 12 months was 2% versus 16% and 13%. Intervention cost €845 with cost reductions of €4,493 per worker from employer perspective. CONCLUSION:BAAS accelerates return-to-work and delivers substantial economic benefits.
The incidence of osteoarthritis of the knee, hip, and shoulder is rising in the Netherlands due to aging and leads to a high disease burden. In addition to rising healthcare costs, reduced work participation and limitations in independent living in this patient group are problematic. The treatment algorithm for osteoarthritis starts with conservative treatment, including analgesics. If the effect is insufficient, a joint replacement surgery follows. Some patients are not operated on due to age and/or comorbidity or disease stage. Sometimes there is a long waiting time or the surgery does not yield the desired result. When analgesics also do not work in these cases, pose too much risk, or cause side effects, these patients continue to experience pain and a reduced quality of life. A peri-articular denervation treatment can reduce pain in osteoarthritis and get the patient moving again. The treatment algorithm for pain in osteoarthritis needs to be further developed in the coming years.
A 27-year-old Indonesian man, presented to the ED with a non-healing wound on his left elbow and unintentional weight loss of 6 kg. Further investigation revealed the unexpected cause: An inadequate treated disseminated tuberculosis. This case highlights the importance of considering extrapulmonary TB in persistent soft tissue infections.
Genetic therapies offer long-awaited hope for patients with rare genetic diseases and are emerging as cancer treatment as well. While these innovations appear promising, they are also extremely expensive and raise concerns about how they fit into an already overburdened healthcare system. What are the societal implications when these treatments become available? And how can we guide their adoption in the Dutch healthcare system in an ethically responsible manner? We describe the emerging landscape of genetic therapies, and specifically examine the ethical concerns surrounding their implementation within the Dutch healthcare system. From this reflection, we seek to offer direction on how to approach these new biomedical developments in a way that preserves the fundamental values of solidarity and justice. This is particularly important, given how rapidly developments in this field are progressing.
