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van Schie P, Rijksen BLT, Bot M, Wiersma T, Merckel LG, Brandsma D, Compter A, de Witt Hamer PC, Post R, Borst GR. Optimizing treatment of brain metastases in an era of novel systemic treatments: a single center consecutive series. J Neurooncol 2023:10.1007/s11060-023-04343-1. [PMID: 37266846 PMCID: PMC10322956 DOI: 10.1007/s11060-023-04343-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND The multidisciplinary management of patients with brain metastases consists of surgical resection, radiation treatment and systemic treatment. Tailoring and timing these treatment modalities is challenging. This study presents real-world data from consecutively treated patients and assesses the impact of all treatment strategies and their relation with survival. The aim is to provide new insights to improve multidisciplinary decisions towards individualized treatment strategies in patients with brain metastases. METHODS A retrospective consecutive cohort study was performed. Patients with brain metastases were included between June 2018 and May 2020. Brain metastases of small cell lung carcinoma were excluded. Overall survival was analyzed in multivariable models. RESULTS 676 patients were included in the study, 596 (88%) received radiotherapy, 41 (6%) awaited the effect of newly started or switched systemic treatment and 39 (6%) received best supportive care. Overall survival in the stereotactic radiotherapy group was 14 months (IQR 5-32) and 32 months (IQR 11-43) in patients who started or switched systemic treatment and initially did not receive radiotherapy. In patients with brain metastases without options for local or systemic treatment best supportive care was provided, these patients had an overall survival of 0 months (IQR 0-1). Options for systemic treatment, Karnofsky Performance Score ≥ 70 and breast cancer were prognostic for a longer overall survival, while progressive extracranial metastases and whole-brain-radiotherapy were prognostic for shorter overall survival. CONCLUSIONS Assessing prognosis in light of systemic treatment options is crucial after the diagnosis of brain metastasis for the consideration of radiotherapy versus best supportive care.
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Affiliation(s)
- P van Schie
- Department of Neurosurgery, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - B L T Rijksen
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - M Bot
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - T Wiersma
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - L G Merckel
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - D Brandsma
- Department of Neurology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - A Compter
- Department of Neurology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - P C de Witt Hamer
- Department of Neurosurgery, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - R Post
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Neuroscience, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Department of Neurosurgery, Amsterdam University Medical Centres, Location AMC, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - G R Borst
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
- Division of Cancer Sciences, School of Medical Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health & Manchester Cancer Research Centre, Manchester Academic Health Science Centre (MAHSC), University of Manchester, Manchester, UK.
- Departments of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK.
- Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Dept 58, Floor 2a, Room 21-2-13, Wilmslow Road, Manchester, M20 4BX, UK.
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van Hemert A, van Duijnhoven F, van Loevezijn A, Loo C, Wiersma T, Sonke G, Groen E, Vrancken Peeters M. 110P An in-depth analysis of pathology results of surgical specimen and biopsies performed after NST in an attempt to identify patients with pCR: Time to reconsider the omission of surgery? Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.03.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Stam J, Lim G, Wiersma T, Koetsveld F. PO-1893: Average body diameter as a predictive factor for the usability of inline CBCT for spine SBRT. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01911-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Van Loevezijn A, van der Noordaa M, van Werkhoven E, Loo C, Winter-Warnars G, Wiersma T, van de Vijver K, Groen E, Sonke G, Blanken C, Zonneveld B, Duijnhoven F, Vrancken-Peeters M. Minimally Invasive Complete Response Assessment of the breast after neoadjuvant systemic therapy (MICRA trial): Interim analysis of a multicenter observational cohort study. Eur J Cancer 2020. [DOI: 10.1016/s0959-8049(20)30549-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Peeters MJTV, van Loevezijn A, van der Noordaa MEM, van Duijnhoven FH, Loo CE, van Werkhoven E, van de Vijver KK, Wiersma T, Winter-Warnars HAO, Sonke GS, Blanken C, Zonnevels B. Abstract GS5-06: Towards omitting breast surgery in patients with a pathologic complete response after neoadjuvant systemic treatment: interim analysis of the MICRA trial (Minimally Invasive Complete Response Assessment). Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-gs5-06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background and Objectives: Improvements in neoadjuvant systemic therapy (NST) for breast cancer patients have led to increasing rates of pathologic complete response (pCR). In patients with an excellent response, imaging alone is not reliable enough to differentiate between patients with residual disease, who should be surgically treated or patients with pCR where surgery could be considered overtreatment. Several trials currently investigate the accuracy of minimal invasive biopsies to assess presence of pCR of the breast. We initiated the MICRA trial (Minimal Invasive Complete Response Assessment NTR6120) combining MRI and minimal invasive biopsies of the breast.
Methods: Breast cancer patients treated with NST resulting in a radiologic complete (rCR) or partial response (rPR, > 30 % decrease and < 2 cm residual diameter) on MRI are eligible. Post-NST, eight ultrasound-guided 14G core biopsies of the pre-NST marked tumor area are obtained. Pathology results of biopsies and surgical specimens are compared. The primary endpoint is the false-negative rate (FNR) of the biopsy procedure i.e. the proportion of patients with non-pCR in the surgical specimen but with pCR in the biopsies. Here we report results of the interim analysis.
Results: 219 patients were enrolled in the trial. Biopsies were successfully obtained and analyzed in 167 patients. Main age was 49 yrs (range 24-74). Tumor subtype was 26% hormone receptor positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-), 14% HR-/HER2+, 36% triple negative and 24% HR+HER2+. 135 patients had a rCR and 32 patients a rPR on MRI. There were 89 patients (53%) with pCR in the surgical specimen, all correctly identified by post-NST biopsies (false-positive rate 0%). Post-NST biopsies however missed residual disease in 29/78 patients (FNR 37%). FNR was higher in patients with rCR (FNR 45%; 26/55 patients with residual disease missed on biopsies) than in patients with rPR (FNR 13 %; 3/23 patients with residual disease missed with biopsies). The conditional power estimating the probability of the FNR being ≤ 8% at final analysis was < 1%.
MICRA patients total n=167Specimen negSpecimen posBiopsy neg8929118FNR= 29/7837%Biopsy pos049498978167
Conclusions: Ultrasound-guided core biopsies of the breast in patients with excellent response on MRI after NST are not accurate enough to safely select patients with pCR for omission of surgery.
Citation Format: Marie-Jeanne T.F.D. Vrancken Peeters, A van Loevezijn, M EM van der Noordaa, F H van Duijnhoven, C E Loo, E van Werkhoven, K K van de Vijver, T Wiersma, H AO Winter-Warnars, G S Sonke, C. Blanken, B. Zonnevels. Towards omitting breast surgery in patients with a pathologic complete response after neoadjuvant systemic treatment: interim analysis of the MICRA trial (Minimally Invasive Complete Response Assessment) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr GS5-06.
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Affiliation(s)
| | - A van Loevezijn
- 1Department of Surgical Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - M EM van der Noordaa
- 1Department of Surgical Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - F H van Duijnhoven
- 1Department of Surgical Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - C E Loo
- 2Department of Radiology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - E van Werkhoven
- 3Department of Medical Statistics, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - K K van de Vijver
- 4Department of Pathology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - T Wiersma
- 5Department of Radiation Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - H AO Winter-Warnars
- 2Department of Radiology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - G S Sonke
- 6Department of Medical Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - C. Blanken
- 7Department of Surgical Oncology, Rijnstate Hospital, Arnhem, Netherlands
| | - B. Zonnevels
- 8Department of Radiology, Deventer Hospital, Deventer, Netherlands
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Wiersema L, Stam J, Wiersma T, Belderbos J, Licup A, Koetsveld F, Remeijer P. EP-2175 No more Lines – Omitting skin marks, safe to align with tattoo only for lung cancer patients? Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)32595-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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van der Noordaa ME, van Duijnhoven FH, Loo CE, van Loevezijn A, van Werkhoven E, van de Vijver KK, Wiersma T, Winter-Warnars HA, Sonke GS, Vrancken Peeters MJT. Abstract OT2-01-04: Towards omitting breast cancer surgery in patients with pathologic complete response after neoadjuvant systemic therapy: The MICRA trial (minimally invasive complete response assessment). Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-ot2-01-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
Improvements in neoadjuvant systemic therapy (NST) for breast cancer patients have led to increasing rates of pathologic complete response (pCR). Breast-conserving surgery (BCS) after NST is considered safe, despite the fact that the original tumor bed is not entirely excised. It can therefore be hypothesized that breast surgery could be omitted in patients achieving pCR. However, since imaging modalities are insufficiently accurate to predict pCR after NST, the need for surgery is unchanged. The MICRA trial is designed to determine the value of ultrasound guided biopsy of the breast in identifying pCR after NST. The ultimate aim of our study is to eliminate surgery of the breast in patients achieving pCR, consequently improving quality of life of these patients.
Trial design
The MICRA trial is a multi-center observational prospective cohort study. Inclusion and exclusion criteria are presented in table 1. In all patients receiving NST, a marker is placed in the center of the tumor area pre-NST. Magnetic resonance imaging (MRI) is performed pre-NST and just before or after the last course of NST. Patients with radiologic complete response (rCR; complete absence of pathologic contrast enhancement) or partial response (rPR, 0.1-2.0 cm residual contrast enhancement, ≥30% decrease in tumour size) are eligible for participation. In these patients, 8 ultrasound guided biopsies are obtained in the region surrounding the marker: 4 central (<0.5 cm) and 4 peripheral biopsies (0.5-1.5cm). Hereafter, conventional surgery is performed (BCS or mastectomy) and pathology results of the biopsies and resected specimen are compared. Pathology findings are scored using Miller-Payne criteria. To evaluate the quality and representativeness of the biopsies, biopsies are categorized according to length and pathology results.
Statistical analysis and accrual
The primary endpoint of the trial is the false-negative rate (FNR) of the biopsy procedure. If the true FNR is 3%, 130 patients without pCR in specimen are sufficient to show that the FNR does not exceed 8% using a one-sided binomial test with a significance α-level of 0.05. With an expected average pCR rate of 65%, 375 patients with rCR will be included. In the rPR-group the expected pCR rate is 12% and therefore 150 patients will be included. In total 525 patients will be included. Until now, 144 patients have been included.
Conclusion
The ultimate aim of the MICRA trial is to eliminate surgery of the breast in patients achieving pCR, by identifying pCR with use of ultrasound guided biopsy. In this scenario, local therapy in patients with pCR would be restricted to radiotherapy.
Table 1:Inclusion and exclusion criteriaInclusion criteriaExclusion criteriaWomen with invasive breast cancer >18 years (all histological subtypes and tumor subtypes)DCIS as shown by core biopsy prior to NSTTumor histology and receptor status established by pre-NST biopsyWomen with distant metastatic diseaseComplete or partial response on post-NST MRIHistory of ipsilateral breast cancerMarker placed in tumor prior to NST Correct position of marker confirmed by mammography or ultrasound
Citation Format: van der Noordaa ME, van Duijnhoven FH, Loo CE, van Loevezijn A, van Werkhoven E, van de Vijver KK, Wiersma T, Winter-Warnars HA, Sonke GS, Vrancken Peeters M-JT. Towards omitting breast cancer surgery in patients with pathologic complete response after neoadjuvant systemic therapy: The MICRA trial (minimally invasive complete response assessment) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-01-04.
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Affiliation(s)
- ME van der Noordaa
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; University of California San Francisco, San Francisco, San Francisco; Ghent University Hospital, Ghent, Belgium
| | - FH van Duijnhoven
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; University of California San Francisco, San Francisco, San Francisco; Ghent University Hospital, Ghent, Belgium
| | - CE Loo
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; University of California San Francisco, San Francisco, San Francisco; Ghent University Hospital, Ghent, Belgium
| | - A van Loevezijn
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; University of California San Francisco, San Francisco, San Francisco; Ghent University Hospital, Ghent, Belgium
| | - E van Werkhoven
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; University of California San Francisco, San Francisco, San Francisco; Ghent University Hospital, Ghent, Belgium
| | - KK van de Vijver
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; University of California San Francisco, San Francisco, San Francisco; Ghent University Hospital, Ghent, Belgium
| | - T Wiersma
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; University of California San Francisco, San Francisco, San Francisco; Ghent University Hospital, Ghent, Belgium
| | - HA Winter-Warnars
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; University of California San Francisco, San Francisco, San Francisco; Ghent University Hospital, Ghent, Belgium
| | - GS Sonke
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; University of California San Francisco, San Francisco, San Francisco; Ghent University Hospital, Ghent, Belgium
| | - M-JT Vrancken Peeters
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; University of California San Francisco, San Francisco, San Francisco; Ghent University Hospital, Ghent, Belgium
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van der Noordaa ME, Vrancken Peeters MJM, Ioan I, Loo CE, van Urk J, van Werkhoven E, Voorthuis R, Wiersma T, Groen E, Rutgers ET, van Duijnhoven FH. Abstract P3-13-02: Breast conserving therapy after neoadjuvant systemic therapy in patients with T3 breast cancer is feasible. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p3-13-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
An important advantage of neoadjuvant systemic therapy (NST) in breast cancer patients is down-sizing of the primary tumor. However, many patients with T3 tumors are treated with mastectomy regardless of response to NST. In this study, we evaluated predictive characteristics for positive margins and local control in T3 breast cancer patients who underwent breast-conserving therapy (BCT) after NST.
Methods
This single institution study included all clinical T3 breast cancer patients (determined by contrast-enhanced magnetic resonance imaging [MRI]) who underwent breast conserving surgery (BCS) after NST between 2000-2015. Clinical T3 was defined as a breast tumor >50mm on MRI pre-NST. Patient, tumor and treatment characteristics were recorded, as well as response on MRI and final pathology. The local recurrence probability was estimated with the Kaplan-Meier method. Predictive characteristics for positive margins in patients undergoing BCS were analyzed using Fishers exact test.
Results
In total, 115 T3 patients were identified. Patient, tumor and MRI findings are presenting in the table. Median tumor size was 60 mm on MRI pre-NST (range 51-120 mm) and 4 mm after NST (range 0-58 mm). Overall pathologic complete response was 19%: 5% in HR+/HER2- patients, 32% in HR-/HER2+ patients and 40% in TN patients. After initial BCS, 73 patients had negative margins (63.5%), 18 focally positive margins (15.7%) and 24 more than focally positive margins (20.9%). Patients with HR+/HER2- tumors (52%) were more likely to have positive margins than patients with HR-/HER2+ and TN tumors (21% and 19%, p=0.002). In addition, positive margins rate was higher in patients with lobular carcinoma compared to patients with ductal carcinoma (57 vs 32%, p=0.031). Presence of non-mass enhancement on pre-NST MRI was predictive for positive margins (52% in patients with and 25% in patients without non-mass enhancement, p=0.003). Of patient with positive margins, 15 underwent radiotherapy with boost, 6 underwent re-excision and 21 underwent mastectomy. Finally, 94/115 patients were treated with BCT (82%). Of these patients, two had a local recurrence after a median follow-up of 6.5 years (6-year local recurrence probability 2.6% (95%-CI 0-7%).
Conclusion
In this series, BCT after NST was successful in 82% of patients with T3 breast cancer and local control in this group was excellent. The positive margin rate after BCS was higher in patients with HR+ tumors, lobular carcinoma and tumors with non-mass enhancement on MRI pre-NST. BCT should always be considered in T3 cancers after NST.
CharacteristicTotal (n=115)Positive margins (focally+ >focally), n=42(%)p-valueHistology 0.031Ductal9229(32) Lobular2313(57) Subtype 0.002HR+/HER2-6132(52) HER2+347(21) TN203(15) MRI morphology of mass pre-NST 0.948Unifocal288(29) Multifocal4012(33) Multicentric134(31) Only non-mass enhancement34 MRI non-mass enhancement before NST 0.003Absent6516(25) Present5026(52) MRI response after NST 0.952rCR5218(35) non-rCR6221(38) Missing1
Citation Format: van der Noordaa ME, Vrancken Peeters M-JM, Ioan I, Loo CE, van Urk J, van Werkhoven E, Voorthuis R, Wiersma T, Groen E, Rutgers ET, van Duijnhoven FH. Breast conserving therapy after neoadjuvant systemic therapy in patients with T3 breast cancer is feasible [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-13-02.
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Affiliation(s)
- ME van der Noordaa
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; Policlinico San Donato, Milano, Italy
| | - M-JM Vrancken Peeters
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; Policlinico San Donato, Milano, Italy
| | - I Ioan
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; Policlinico San Donato, Milano, Italy
| | - CE Loo
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; Policlinico San Donato, Milano, Italy
| | - J van Urk
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; Policlinico San Donato, Milano, Italy
| | - E van Werkhoven
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; Policlinico San Donato, Milano, Italy
| | - R Voorthuis
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; Policlinico San Donato, Milano, Italy
| | - T Wiersma
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; Policlinico San Donato, Milano, Italy
| | - E Groen
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; Policlinico San Donato, Milano, Italy
| | - ET Rutgers
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; Policlinico San Donato, Milano, Italy
| | - FH van Duijnhoven
- Antoni van Leeuwenhoek Hospital / Netherlands Cancer Institute, Amsterdam, Netherlands; Policlinico San Donato, Milano, Italy
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van der Noordaa M, van Duijnhoven F, Loo C, van Werkhoven E, van de Vijver K, Wiersma T, Winter-Warnars H, Sonke G, Vrancken Peeters M. Identifying pathologic complete response of the breast after neoadjuvant systemic therapy with ultrasound guided biopsy to eventually omit surgery: Study design and feasibility of the MICRA trial (Minimally Invasive Complete Response Assessment). Breast 2018; 40:76-81. [DOI: 10.1016/j.breast.2018.04.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/30/2018] [Accepted: 04/18/2018] [Indexed: 12/16/2022] Open
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Kok M, Horlings H, van de Vijver K, Wiersma T, Russell N, Voorwerk L, Sikorska K, van Werkhoven E, Mandjes I, Kemper I, Foekema J, Wilgenhof S, Chalabi M, Stouthard J, Sonke G, Cullen D, Salgado R, Schumacher T, Blank C, Linn S. Adaptive phase II randomized non-comparative trial of nivolumab after induction treatment in triple negative breast cancer: TONIC-trial. Ann Oncol 2017. [DOI: 10.1093/annonc/mdx440.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Wiersma T, Cappers WPRA. [Dutch guideline 'Post-mortem examination for attending doctors' ready at last]. Ned Tijdschr Geneeskd 2016; 160:D344. [PMID: 27334089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
- The central theme of the guideline 'Post-mortem examination for attending doctors' is that the primary aim of the post-mortem examination is not to ascertain death as such, but to investigate whether the person died of natural or unnatural causes.- The guideline gives indications for the content of the post-mortem in order to make this differentiation reliable.- Only in cases of natural death is the attending doctor permitted to fill in a death certificate. - In cases of possible unnatural death where a crime or an imputable act may have been committed, a municipal coroner should be called in. - Post-mortem should be carried out as quickly as possible after notification, with the exception of nocturnal deaths in nursing homes, or comparable care institutions, when this decease is expected.
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Affiliation(s)
- Tj Wiersma
- Nederlands Huisartsen Genootschap, afdeling Richtlijnontwikkeling en Wetenschap, Utrecht
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Damen-van Beek Z, Teunissen D, Dekker JH, Lagro-Janssen ALM, Berghmans LCM, Uijen JHJM, Mientjes GHC, Wiersma T. [Practice guideline 'Urinary incontinence in women' from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2016; 160:D674. [PMID: 27484432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
- The Dutch College of General Practitioners' (NHG) practice guideline 'Urinary incontinence in women' provides guidelines for diagnosis and management of stress, urgency and mixed urinary incontinence in adult women.- General practitioners (GPs) should be alert to signals for urinary incontinence in women and offer active diagnosis and treatment if necessary.- Shared decision making is central in the guideline; the GP and the patient should discuss therapeutic options and decide on treatment policy in mutual consultation.- Women with stress urinary incontinence can choose between pelvic floor exercises or a pessary as initial treatment. Placing a midurethral sling (MUS) will be discussed if initial treatment is insufficiently effective or in the case of serious symptoms.- When bladder training is ineffective in urgency incontinence, the GP will discuss the pros and cons of adding an anticholinergic agent.- Exercise therapy can take place in the GPs practice or under supervision of a pelvic physical therapist.
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Affiliation(s)
- Z Damen-van Beek
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschap, Utrecht, The Netherlands
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Rodrigues G, Senan S, Oberije C, Tsujino K, Wiersma T, Moreno-Jimenez M, Kim T, Marks L, Rengan R, De Petris L, Ramella S, DeRuyck K, Rodriguez De Dios N, Warner A, Bradley J, Palma D. Is Intermediate Radiation Dose Escalation With Concurrent Chemotherapy for Stage III Non-Small Cell Lung Cancer Beneficial?: A Multi-institutional Propensity-Score Matched Analysis. Int J Radiat Oncol Biol Phys 2014. [DOI: 10.1016/j.ijrobp.2014.05.1933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Dahele M, Wiersma T, Verbakel W, van de Ven P, de Haan P, Smit E, van Reij E, Slotman B, Senan S. 56O OUTCOMES OF CONCURRENT CHEMO-RADIOTHERAPY FOR LARGE-VOLUME STAGE III NSCLC. Lung Cancer 2013. [DOI: 10.1016/s0169-5002(13)70277-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bouma M, van Geldrop WJ, Numans ME, Wiersma T, Goudswaard AN. [Summary of the practice guideline 'Viral hepatitis and other liver diseases' (second revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2008; 152:2662-2666. [PMID: 19137965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The revised Dutch College of General Practitioners' practice guideline 'Viral hepatitis and other liver diseases' offers advice in the diagnosis and management of viral hepatitis A, B and C and other liver diseases. The guideline is important for general practitioners as well as specialists in internal medicine and gastroenterology. The emphasis is on the management of chronic hepatitis B en C, because the prevalence of these diseases has increased in the Netherlands and, in addition, the treatment options for chronic hepatitis have improved. Consequently, timely recognition and adequate referral of patients with chronic hepatitis B or hepatitis C have become more important. However, many patients with a chronic liver disease have no symptoms. Therefore, the general practitioner should be aware that a patient visiting the practice with fatigue and malaise could have a liver disease if he or she belongs to a high-risk group or has had high-risk contacts. If the general practitioner repeatedly finds increased liver transaminase values during routine examination of asymptomatic patients, additional diagnostic tests should be performed. Further tests should focus on viral hepatitis as well as on non-alcoholic fatty liver disease and non-alcoholic steatohepatitis or, depending on the history-taking, liver damage due to excessive alcohol, medication or drug use.
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MESH Headings
- Antiviral Agents/therapeutic use
- Family Practice/standards
- Hepatitis, Viral, Human/diagnosis
- Hepatitis, Viral, Human/drug therapy
- Hepatitis, Viral, Human/epidemiology
- Hepatitis, Viral, Human/prevention & control
- Humans
- Netherlands
- Practice Patterns, Physicians'
- Risk Factors
- Societies, Medical
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Affiliation(s)
- M Bouma
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschap, Postbus 3231, 3502 GE Utrecht.
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16
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van Pinxteren B, Lagro-Janssen ALM, Wiersma T, Goudswaard AN. [Summary of the practice guideline 'Urinary incontinence' (first revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2008; 152:2559-2563. [PMID: 19174937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Two years after revision of the practice guideline 'Urinary incontinence' from the Dutch College of General Practitioners, it is time for a summary of the most important changes. The use of a bladder diary is recommended. In primary care, a stress test does not provide more information than history taking. Routine urodynamic testing is not indicated for patients presenting to their general practitioner with urinary incontinence. Treatment of stress, urge and mixed incontinence can usually be commenced in primary care; pelvic floor exercises and bladder training are preferred. If bladder training is not effective for urge incontinence, anticholinergic drugs should be considered. The use of oral and vaginal oestrogens and flavoxate is no longer recommended.
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Affiliation(s)
- B van Pinxteren
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschap, Utrecht
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17
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Wind LA, Chavannes NH, Kaper J, Frijling BD, van der Laan JR, Wiersma T, Goudswaard AN. [Summary of the practice guideline 'Smoking cessation' from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2008; 152:1459-1464. [PMID: 18666663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
In general practice important health gain is obtainable by encouraging patients to stop smoking with support from the general practitioner. The practice guideline 'Smoking cessation' differentiates between smokers who are motivated to stop smoking, smokers who are considering smoking cessation, and smokers who are unmotivated to stop smoking. It is important to offer smokers, who are motivated to stop, intensive support at the right moment. Medicinal support in the way of nicotine replacement therapy, nortriptyline or bupropion is, ifpossible, recommended in motivated smokers who smoke at least 10 cigarettes daily.
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Affiliation(s)
- L A Wind
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschap, Postbus 3231, 3502 GE Utrecht.
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Smulders YM, Burgers JS, Scheltens T, van Hout BA, Wiersma T, Simoons ML. Clinical practice guideline for cardiovascular risk management in the Netherlands. Neth J Med 2008; 66:169-174. [PMID: 18424866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Y M Smulders
- Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands.
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20
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Bindels PJE, Grol MH, Ponsioen BP, Salomé PL, Wiersma T, Goudswaard AN. [Summary of the practice guideline 'Asthma in children' (second revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2008; 152:550-555. [PMID: 18402320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
A number of important changes have been made in the second revision of the guideline 'Asthma in children' from the Dutch College of General Practitioners. In children under the age of 6 years, the symptoms stuffiness and recurrent cough are no longer considered part of the symptomatic diagnosis of asthma. Wheezing has become the key symptom of asthma. In children aged 6 years or more, spirometry is the optimal method for both diagnosis and monitoring. This method is preferred over peak flow measurement. Inhalation allergies should be investigated in children under the age of 6 years because the presence of an inhalation allergy may influence the management approach. Starting asthma medication in children under the age of 6 years should always be considered a therapeutic trial, and its effect should always be evaluated. The prescription of allergen-resistant mattresses and bed coverings is only effective when it is one component of a set of allergen reduction measures. At this time, the Dutch Health Council recommends influenza vaccination in children with asthma.
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Affiliation(s)
- P J E Bindels
- Academisch Medisch Centrum/Universiteit van Amsterdam, afd. Huisartsgeneeskunde, Amsterdam
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21
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Starreveld JS, Zwart S, Boukes FS, Wiersma T, Goudswaard AN. [Summary of the practice guideline 'Sore throat' (second revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2008; 152:431-435. [PMID: 18361191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The second version of the practice guideline 'Sore throat' has been updated from the 1999 version. --Infections of the throat generally cure spontaneously within 7 days. In most cases the sore throat is caused by a virus. Group A beta-haemolytic streptococci (GABHS) are the most important bacterial cause ofa sore throat. --In diagnostics, the main focus is placed on evaluating how sick the patient is in general. --In adolescents who have had a sore throat for more than 7 days, the possibility of mononucleosis infectiosa should be borne in mind. This diagnosis can be verified by a test for IgM against Epstein-Barr-virus. --Additional investigations to detect GABHS are not recommended. --Prescribing antibiotics is only recommended for patients who have a severe throat infection or an increased risk of complications. Pheneticillin or phenoxymethylpenicillin remains first choice. --Referral for tonsillectomy should meet the following criteria: 5 or more episodes of sore throat per year or 3 or more episodes per year in the last 2 years.
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Affiliation(s)
- J S Starreveld
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschap, Postbus 323I, 3502 GE Utrecht
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22
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Boukes FS, Wiersma T, Cleveringa JP, Dirven-Meijer PC, Goudswaard AN. [Summary of the practice guideline 'Atopic dermatitis' (first revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2007; 151:1394-8. [PMID: 17668602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The 1996 practice guideline on atopic dermatitis from the Dutch College of General Practitioners has been updated. For diagnosing atopic dermatitis, the use of Williams' criteria is recommended. Testing for food allergy is only useful in case of children under the age of 2 who have other food-related allergic complaints together with dermatitis. In the treatment of atopic dermatitis, keeping the skin in good condition with emollients is essential; furthermore, topical corticosteroids are the therapy of first choice. In case of a severe exacerbation of atopic dermatitis, starting with a class 3 corticosteroid is preferred. In case of frequent recurrences, 'pulse-therapy' is indicated: topical corticosteroids on 2-4 consecutive days per week as maintenance therapy. The role of preparations from tar is marginal. The use of the topical immunomodulators tacrolimus and pimecrolimus in general practice is discouraged.
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Affiliation(s)
- F S Boukes
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschapsbeleid, Postbus 3231, 3502 GE Utrecht.
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23
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Boukes FS, Boeke AJP, Dekker JH, Wiersma T, Goudswaard AN. [Summary of the practice guideline 'Vaginal discharge' (first revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2007; 151:1339-43. [PMID: 17665625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The 1996 practice guideline of the Dutch College of General Practitioners (NHG) on vaginal discharge has been updated. Most women who visit their doctor with complaints about vaginal discharge do not have an increased risk of a sexually-transmitted disease. Investigations into vaginal discharge comprise history taking, physical examination and microscopic analysis in the laboratory of the general practitioner. Additional investigation into Chlamydia, gonorrhoea and Trichomonas infection is only necessary if the patient history reveals an increased risk of a sexually-transmitted disease. A Candida infection or bacterial vaginosis should only be treated if the patient experiences bothersome complaints. Treatment of a Candida infection consists of a vaginally applied imidazole compound. Bacterial vaginosis can be treated with oral administration of metronidazole. Patients with vaginal fluor can be examined and, if necessary, treated by their general practitioner. Referral to a gynaecologist is rarely necessary.
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Affiliation(s)
- F S Boukes
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschapsbeleid, Postbus 3231, 3502 GE Utrecht.
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24
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van Kemenade FJ, Wiersma T, Helmerhorst TJM. [New version of the pathology practice guideline for cervical cytology: sharpened criteria for adequacy; expanded use of new techniques]. Ned Tijdschr Geneeskd 2007; 151:1283-6. [PMID: 17624158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The Dutch Pathology Association (NVVP) has modified the practice guideline for cervical cytology. The changes were made in consultation with the Dutch College ofGeneral Practitioners (NHG) and the Dutch Society for Obstetrics and Gynaecology (NVOG). The four most important changes are: (a) breastfeeding is no longer a contraindication for smear taking; (b) the rejection of smears, under certain conditions, if the cervix has not been visualised; the representativeness of a smear depends in part on the degree to which the requesting physician has verified that the smear was taken from the cervix; if the smear lacks endocervical cells, it must be considered inadequate if the requestor has not seen the cervix or designates the portio as abnormal; (c) the use of thin-layer cytology is accepted; (d) addition of the test for high-risk Human papilloma virus (hrHPV-test) may reduce the number of secondary repeat smears.
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Affiliation(s)
- F J van Kemenade
- VU Medisch Centrum, afd. Pathologie, Postbus 7057, 1007 MB Amsterdam.
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25
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van der Weele GM, Rietveld RP, Wiersma T, Goudswaard AN. [Summary of the practice guideline 'The red eye' (first revision) of the Dutch College of General Practitioners (NHG)]. Ned Tijdschr Geneeskd 2007; 151:1232-7. [PMID: 17583091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
The revised NHG-guideline 'The red eye' provides recommendations for the diagnosis and therapy in patients with a red eye. In the presence of pain, decreased visual acuity and photophobia (alarm symptoms) should be considered as sight threatening conditions. In most instances a red eye results from conjunctivitis. The complaint of (an) early morning glued eye(s) makes a bacterial origin of acute infectious conjunctivitis more likely. Itching and a history of infectious conjunctivitis make the probability of bacterial involvement less likely. The type of discharge does not help to adequately distinguish bacterial from viral conjunctivitis. Since an infectious conjunctivitis is a self-limiting condition, no treatment is necessary as a rule. Antibiotic treatment is only rational if conjunctivitis is (most probably) caused by bacteria. It has to be considered only if a patient suffers from much discomfort, if complaints do not begin to decline after 3 days and in patients with preexisting corneal defects. Because of widespread resistance to fusidic acid this should in principle not be prescribed for treatment of conjunctivitis; chloramphenicol is still the drug of choice. During revision of the guideline discussions concentrated on 2 aspects: the position of slit lamp biomicroscopy in general practice and giving a patient with keratoconjunctivitis photoelectrica the remainder of a 'minim' with anaesthetic eye drops. Regarding both topics it was decided not to change the recommendations of the former version of the guideline: the use of slit lamp biomicroscopy remains optional for general practitioners and it remains permitted to give the remainder of a 'minim' with anaesthetic eye drops to a patient with keratoconjunctivitis photoelectrica.
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Affiliation(s)
- G M van der Weele
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschapsbeleid, Postbus 3231, 3502 GE Utrecht
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26
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Boukes FS, Dekker JH, Wiersma T, Goudswaard AN. [The practice guideline 'Pelvic inflammatory disease' (first revision) from the Dutch College of General Practitioners; a response from the perspective of gynaecology]. Ned Tijdschr Geneeskd 2007; 151:837-8. [PMID: 17471616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
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27
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Boomsma LJ, Eekhof JAH, Wiersma T, Goudswaard AN. [Summary of the practice guideline 'Hearing impairment' (first revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2007; 151:466-70. [PMID: 17378302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The Dutch College of General Practitioners recently issued a revised version of the practice guideline 'Hearing impairment'. The modification of the screening for hearing impairment, which now takes place in neonates, has resulted in a much lower number of false-positive diagnoses of perceptive hearing loss than under the previous version of the practice guideline. The expanded diagnostic possibilities for adults, whether or not implemented by the patients themselves, demand an active approach from the general practitioner towards patients with impaired hearing. This guideline helps general practitioners to select patients that will truly benefit from a hearing aid and that will also be more likely to use one. The general practitioner can play an important role by stimulating patients to be referred for a hearing aid.
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Affiliation(s)
- L J Boomsma
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschap, Postbus 3231, 3502 GE Utrecht.
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Boomsma LJ, Rovers MM, van Balen FAM, Wiersma T, Goudswaard AN. [The practice guideline 'Otitis media with effusion' (second revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2007; 151:267-8; author reply 268. [PMID: 17326297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
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29
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Boomsma LJ, Wiersma T, Meerkerk GJ, Goudswaard AN. [Summary of the practice guideline 'Problematic alcohol consumption' (second revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2006; 150:2536-40. [PMID: 17152329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Compared with the former guideline, more attention is paid to the attitude of the general practitioner towards problem drinkers (about 200 problem drinkers in a standard practice of 2350 patients) and the combined use of alcohol and drugs among young people. The five-shot questionnaire has replaced the earlier 'cutdown, annoyed, guilty, eye-opener' (CAGE) test. Laboratory tests are of little value in the diagnosis. The general practitioner is given tools with which to motivate problem drinkers to change their behaviour. Medication is of minor importance.
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Affiliation(s)
- L J Boomsma
- Nederlands Huisartsen Genootschap, Postbus 3231, 3502 GE Utrecht.
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Bouma M, Rutten GEHM, Wiersma T. [The practice guideline 'Diabetes mellitus type 2' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. Ned Tijdschr Geneeskd 2006; 150:2339-40. [PMID: 17091545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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31
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Bouma M, Rutten GEHM, Wiersma T. [The practice guideline 'Diabetes mellitus type 2' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. Ned Tijdschr Geneeskd 2006; 150:2339. [PMID: 17089555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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Bouma M, Rutten GEHM, de Grauw WJC, Wiersma T, Goudswaard AN. [Summary of the practice guideline 'Diabetes mellitus type 2' (second revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2006; 150:2251-6. [PMID: 17076359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
The practice guideline 'Diabetes mellitus type 2' (second revision) addresses the diagnosis, treatment and management of adults with diabetes mellitus type 2 in general practice. The aim of management is the prevention and treatment of diabetes-related symptoms and complications such as cardiovascular disease, nephro-, retino- and neuropathy. The general practitioner gives the patient education and lifestyle advice and repeats this regularly. In addition, the general practitioner and the patient strive to achieve good glycaemic control. The agent of first choice in the medicinal treatment of all type 2 diabetic patients is metformin. This is continued even after the addition of a sulphonylurea derivative or insulin. This represents a change compared to the previous version of the practice guideline. The indications for thiazolidinediones are limited. To reduce the cardiovascular risk, it is advised to aim at a systolic blood pressure below 140 mmHg. It is also recommended that each patient be prescribed a statin, unless the patient belongs to a subgroup in which the indication for cholesterol lowering therapy is weak or the patient refuses it. Compared to the former guideline, more emphasis is placed on the prevention of nephropathy. The general practitioner is advised to calculate the creatinine clearance yearly and to test for relevant albuminuria in each patient with a life expectancy of 10 years or more. If microalbuminuria is present, the patient is prescribed an angiotensin converting enzyme (ACE) inhibitor, even if the blood pressure is not elevated. The detection of patients with a high risk of diabetic ulcer is also given more emphasis.
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Affiliation(s)
- M Bouma
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschapsbeleid, Postbus 3231, 3502, GE Utrecht.
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Boomsma LJ, van Balen FAM, Rovers MM, Wiersma T, Goudswaard AN. [Summary of the practice guideline 'Otits media with effusion' (second revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2006; 150:2028-32. [PMID: 17058459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Most children pass through a period of otitis media with effusion, which can be considered as a normal reaction of the body to viral or bacterial infections. The general practitioner provides education and advice regarding the favourable prognosis of the hearing loss and is alert to the detection of high-risk groups and an aberrant course. In most children with otitis media with effusion, the general practitioner can wait for the disease to take its natural course. Children with persistent otitis media with effusion whose development is retarded should be referred to an otorhinolaryngologist. The former screening for perceptive hearing loss in infants resulted in the detection of many children with otitis media with effusion. Children with abnormal results on the new form of neonatal auditory screening should preferably be referred to a centre for audiology.
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Affiliation(s)
- L J Boomsma
- Nederlands Huisartsen Genootschap, afd Richtlijnontwikkeling en Wetenschap, Utrecht.
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Wiersma T, Flikwert S, van Leeuwen JHS, Daemers DOA. [Vitamin-D deficiency]. Ned Tijdschr Geneeskd 2006; 150:1313-4; author reply 1314-5. [PMID: 16821457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
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van Lieshout J, Rutten FH, Walma EP, Wiersma T, Goudswaard AN. [Summary of the practice guideline 'Heart failure' (first revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2005; 149:2668-72. [PMID: 16358616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The guideline entitled 'Heart failure' from the Dutch College of General Practitioners has been revised. The general practitioner makes the diagnosis of heart failure in a patient with the core symptoms (dyspnoea, fatigue, oedema) in combination with paroxysmal nocturnal dyspnoea, orthopnoea, crepitations, elevated central-venous pressure, a third heart sound or ifictus cordis is visible outside the mid-clavicular line. Further investigations include a panel of laboratory investigations, an ECG and possibly echocardiography and radiographic chest investigations. One new recommendation is that on suspicion of heart failure the plasma concentrations of B-type natriuretic peptide (BNP) or N-terminal pro-BNP should be investigated. The step-by-step medication plan has been changed; beta-blockers have been introduced to the plan. In the treatment of acute heart failure, rapidly working sublingual nitrates should be given first and foremost.
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Affiliation(s)
- J van Lieshout
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschap, Postbus 3231, 3502 GE Utrecht
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Wiersma T, Verduijn M, Bouma M, Goudswaard AN. [Atenolol or metoprolol as beta-blocker in the treatment of hypertension]. Ned Tijdschr Geneeskd 2005; 149:2482; author reply 2482-3. [PMID: 16285368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Wiersma T, Flikweert S, Zeeman K, Schagen van Leeuwen JH. [Use of alcohol during conception, pregnancy and lactation]. Ned Tijdschr Geneeskd 2005; 149:1830-2. [PMID: 16128179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Recently, the Dutch Health Council published a report on the risks of the use of alcohol during conception, pregnancy and lactation. Because the medical literature does not prove the safety of the use of small amounts of alcohol, the Health Council recommends using no alcohol whatsoever. One may wonder whether the advice of the Health Council is not too rigid. Since Karl Popper, it is evident that the truth of the hypothesis that the consumption of small amounts of alcohol is safe will never be verified. Because the medical literature also does not prove the harmfulness of the irregular use of small amounts of alcohol, it is not necessary to upset pregnant women who occasionally take an alcoholic beverage. It is preferable to use no alcohol; however, the rare consumption of a single glass does not seem to be harmful.
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Affiliation(s)
- Tj Wiersma
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschapsbeleid, Postbus 3231, 3502 GE Utrecht
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van Balen JAM, Flikweert S, Wieringa-de Waard M, de jonge A, Wiersma T, Goudswaard AN. [Summary of the practice guideline 'Miscarriage' (second revision) from the Dutch College of General Practitioners (NHG)]. Ned Tijdschr Geneeskd 2005; 149:295-8. [PMID: 15730036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
The NHG practice guideline 'Miscarriage' provides guidelines for the diagnosis and management of pregnant women with vaginal bleeding during the period up to and including the 16th week after the first day of the last menstruation. The guideline has been revised on the basis of the developments over the last few years. The most important modifications are: In case of an imminent miscarriage, more consideration than before is given to the patient's preference with regard to ultrasonography, expectant management and curettage. The GP should therefore discuss the advantages and disadvantages of these options with the patient. A midwife was involved in the formulation of the new guideline. Referral from a GP to a midwife for transvaginal ultrasonography is offered as one of the possibilities. The paragraph on 'information' has been expanded on the basis of the results of a patient focus group.
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Affiliation(s)
- J A M van Balen
- Nederland Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschapsbeleid, Postbus 3231, 3502 GE Utrecht
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Bouma M, Rutten FH, Bohnen AM, Wiersma T. [The practice guideline 'Stable angina pectoris' (second revision) from the Dutch College of General Practitioners; a response from the perspective of cardiology]. Ned Tijdschr Geneeskd 2004; 148:2300. [PMID: 15584545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Bouma M, Rutten FH, Bohnen AM, Wiersma T. [Summary of the practice guideline 'Stable angina pectoris' (second revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2004; 148:2221-5. [PMID: 15568627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Typical angina pectoris is characterised by retrosternal complaints that are provoked by exertion, cold, emotional stress or heavy meals and are relieved by rest within 15 minutes or within a few minutes of using sublingual nitroglycerin. If 2 or 3 of these symptoms are present then the term 'atypical angina pectoris' is used. The general practitioner can estimate the risk of significant coronary artery disease on the basis of the anamnesis. Additional diagnostics in the form of an exercise ECG is only worthwhile if the pretest probability of coronary artery disease lies between 30% and 70% (atypical angina pectoris) and not if the diagnosis is extremely likely or extremely unlikely. Patients with angina pectoris should be informed about the alarm symptoms which can be indicative of unstable angina pectoris or acute myocardial infarction. Sublingual nitrate therapy is used for the short-term control of angina. If more than 2 attacks per week occur, a maintenance treatment consisting of beta-blockers, nitrates, or calcium channel blockers should be started in this order of preference. For secondary prevention, acetylsalicylic acid and statins should be prescribed and lifestyle advice should be given, such as smoking cessation, sufficient physical exercise and a healthy diet.
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Affiliation(s)
- M Bouma
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschapsbeleid, Postbus 3231, 3502 GE Utrecht.
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Boomsma LJ, Bartelink ML, Stoffers HEJH, Wiersma T, Assendelft WJJ. [Summary of the practice guideline 'Peripheral vascular disease' (first revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2004; 148:1490-4. [PMID: 15481572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Peripheral vascular disease is a manifestation of atherosclerosis and may occur with or without signs or symptoms. The local prognosis is worse with signs or symptoms. The concomitant atherosclerosis in heart and brain is responsible for long-term morbidity and mortality. Absence of signs and symptoms almost excludes peripheral vascular disease, but for the diagnosis an ankle-brachial index is mandatory. This implies a protocol in general practice. Treatment of peripheral vascular disease consists of advice on cardiovascular risk factors, stopping smoking, walking exercises, and foot care. For peripheral vascular disease, anti-thrombotic medication is advised.
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Affiliation(s)
- L J Boomsma
- Nederlands Huisartsen Genootschap, afd. Richtlijnen, Postbus 3231, 3502 GE Utrecht.
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Wiersma T, Walma EP, Thomas S. [The practice guideline 'Hypertension' (third revision) from the Dutch College of General Practitioners; a response from the perspective of internal medicine]. Ned Tijdschr Geneeskd 2004; 148:1009. [PMID: 15181728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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Wiersma T, Walma EP, Thomas S, Assendelft WJ. [Summary of the practice guideline 'Hypertension' (third division) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2004; 148:923-31. [PMID: 15160558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
The revised practice guideline on hypertension from the Dutch College of General Practitioners has been brought in agreement with the guideline on hypertension from the Dutch Institute for Health Care Improvement. The main changes with regard to the former edition are: The threshold values for the diagnosis 'hypertension' have been lowered to 140 mmHg and 90 mmHg for the systolic and diastolic blood pressures, respectively. Annual screening for hypertension in the elderly is no longer recommended. Henceforth, blood pressure measurement once every five years is considered sufficient, unless the blood pressure is known to be in a borderline area in which treatment is being considered. Often, the decision as to whether a patient should take antihypertensive drugs no longer depends on the presence of hypertension as such: to receive drug treatment, the patient should have at least a 20% risk of developing a cardiovascular disease in the next 10 years. To aid in estimating this risk for individual patients a risk table has been devised. Diuretics and beta-blockers are the drugs of first choice. If the blood pressure remains too high, angiotensin-converting-enzyme (ACE) inhibitors and calcium-channel blockers may be added.
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Affiliation(s)
- Tj Wiersma
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschapsbeleid, Postbus 3231, 3502 GE Utrecht
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Wiersma T, Flikweert S, van den Bosch WJ. [Summary of the practice guideline 'Rheumatoid arthritis' (first revision) from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2004; 148:559-64. [PMID: 15074177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
The guideline covers the evaluation of patients with one or more painful joints without previous injury and focuses on the distinction between rheumatoid arthritis and other joint complaints. In the case of rheumatoid arthritis, the arthritis is based on aseptic synovitis and is nearly always associated with tenderness, warmth, swelling, and impaired function. Redness is not present in most cases. The diagnosis is primarily made on the basis of the case history and physical examination. Laboratory tests and X-ray are only of secondary importance. NSAIDs are recommended as the initial treatment for patients with rheumatoid arthritis or serious indications for this. If the arthritis does not settle within a period of 6 to 12 weeks after the onset of the complaints, the patient should be referred to a rheumatologist to start treatment with one or more disease-modifying antirheumatic drugs (DMARDs). DMARDs suppress the activity of the disease and can prevent joint damage. However, which combination of DMARDs gives the best results is still unclear.
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Affiliation(s)
- Tj Wiersma
- Nederlands Huisartsen Genootschap, Domus Medica, Postbus 3231, 3502 GE Utrecht
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Wiersma T, Daemers DO, Oldenziel JH, Flikweert S, Assendelft WJ. [The practice guideline'Pregnancy and puerperium' (first revision) from the Dutch College of General Practitioners; a response from the perspective of gynaecology]. Ned Tijdschr Geneeskd 2004; 148:155-6; author reply 156. [PMID: 14964032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
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Wiersma T, de Bock GH, Assendelft WJJ. [Summary of the Dutch College of General Practitioners' practice guideline 'Diagnosis of breast cancer']. Ned Tijdschr Geneeskd 2003; 147:547-50. [PMID: 12693083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
The general practitioner should encourage women aged 50-75 who are eligible for the national screening program for the early detection of breast cancer to participate. When any abnormalities are seen on the mammogram, the general practitioner should refer the woman for further investigations and inform her about the procedure to be followed. In the case of a lump, a mammogram or ultrasound examination of the breasts is indicated, unless the abnormality disappears during a different phase of the woman's menstrual cycle. Local pain and brown or bloody discharge from the nipples also necessitate further investigation. Women with a greater than 20% risk of ever developing breast cancer during their life based on a positive family history for breast cancer have an indication for periodic examination of the breasts and a mammogram before they are 50. If the risk is greater than 30%, consultation with a clinical geneticist can be suggested.
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Affiliation(s)
- Tj Wiersma
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschapsbeleid, Postbus 3231, 3502 GE Utrecht
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Wiersma T, Cleveringa JP, Oltheten JMT, Blom GH, Baggen MEJM, Assendelft WJJ. [Summary of the practice guideline 'Refraction errors' from the Dutch College of General Practitioners]. Ned Tijdschr Geneeskd 2002; 146:1781-4. [PMID: 12369439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
The practice guideline 'Refraction errors' from the Dutch College of General Practitioners describes the examinations that need to be carried out in patients complaining about a gradual loss of vision. A measurement of vision by means of a Snellen chart is insufficient to determine if the condition is caused by a refraction error or if other pathology of the eye such as cataract, glaucoma or retinopathy is involved. It is therefore recommended that the vision should also be measured with a simple device containing spherical lenses of +0.5 and -0.5 dioptre, so-called diagnostic refraction. Improvement of vision with the negative lens indicates myopia. Improvement or at least a stable vision with the positive lens makes hyperopia very likely. Diagnostic refraction, which can be used in patients of six years and older, enables the general practitioner to distinguish between patients needing glasses or contact lenses, and patients requiring referral to an ophthalmologist.
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Affiliation(s)
- Tj Wiersma
- Nederlands Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschapsbeleid, Postbus 3231, 3502 GE Utrecht
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Wiersma T, Flikweert S. [Pilot study of hypovitaminosis D in apparently healthy veiled Turkish women: severe vitamin D deficiency in 82%]. Ned Tijdschr Geneeskd 2002; 146:1517; author reply 1518. [PMID: 12198836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
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Wiersma T. [Less chance of a stroke due to hypotensive medication, regardless of blood pressure]. Ned Tijdschr Geneeskd 2002; 146:874; author reply 874. [PMID: 12038229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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Wiersma T, Cappers WP. [Dutch Burial Act]. Ned Tijdschr Geneeskd 2001; 145:2400-2. [PMID: 11770270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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