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RATIONALE: To improve the quality of exercise-based cardiac rehabilitation (CR) in patients with chronic heart failure (CHF) a practice guideline from the Dutch Royal Society for Physiotherapy (KNGF) has been developed. GUIDELINE DEVELOPMENT: A systematic literature search was performed to formulate conclusions on the efficacy of exercise-based intervention during all CR phases in patients with CHF. Evidence was graded (1-4) according the Dutch evidence-based guideline development criteria. CLINICAL AND RESEARCH RECOMMENDATIONS: Recommendations for exercise-based CR were formulated covering the following topics: mobilisation and treatment of pulmonary symptoms (if necessary) during the clinical phase, aerobic exercise, strength training (inspiratory muscle training and peripheral muscle training) and relaxation therapy during the outpatient CR phase, and adoption and monitoring training after outpatient CR. APPLICABILITY AND IMPLEMENTATION ISSUES: This guideline provides the physiotherapist with an evidence-based instrument to assist in clinical decision-making regarding patients with CHF. The implementation of the guideline in clinical practice needs further evaluation. CONCLUSION: This guideline outlines best practice standards for physiotherapists concerning exercise-based CR in CHF patients. Research is needed on strategies to improve monitoring and follow-up of the maintenance of a physical active lifestyle after supervised CR.

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BACKGROUND: To improve the quality of exercise-based cardiac rehabilitation (CR) in patients with coronary heart disease (CHD) the CR guideline from the Dutch Royal Society for Physiotherapists (KNGF) has been updated. This guideline can be considered an addition to the 2011 Dutch Multidisciplinary CR guideline, as it includes several novel topics. METHODS: A systematic literature search was performed to formulate conclusions on the efficacy of exercise-based interventions during all CR phases in patients with CHD. Evidence was graded (1-4) according the Dutch evidence-based guideline development (EBRO) criteria. In case of insufficient scientific evidence, recommendations were based on expert opinion. This guideline comprised a structured approach including assessment, treatment and evaluation. RESULTS: Recommendations for exercise-based CR were formulated covering the following topics: preoperative physiotherapy, mobilisation during the clinical phase, aerobic exercise, strength training, and relaxation therapy during the outpatient rehabilitation phase, and adoption and monitoring of a physically active lifestyle after outpatient rehabilitation. CONCLUSIONS: There is strong evidence for the effectiveness of exercise-based CR during all phases of CR. The implementation of this guideline in clinical practice needs further evaluation as well as the maintenance of an active lifestyle after supervised rehabilitation.

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A 63-year-old man with symptoms of depression and sexual disinhibition was admitted to a psychiatric clinic for the elderly. Because the man's symptoms rapidly became more severe he was referred to the emergency room. There, his illness was diagnosed as paraneoplastic limbic encephalitis with positive anti-Hu antibodies; this is a paraneoplastic neurological syndrome presenting with short-term memory loss, epileptic seizures and psychiatric symptoms. For the prognosis of the illness it is essential that the syndrome is diagnosed as early as possible. Since patients sometimes present with mainly psychiatric symptoms it is important that psychiatrists are fully informed about the symptoms and are able to make an accurate diagnosis.

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A man aged 32 with psychotic and depressive symptoms was treated with zuclopentixol and paroxetine, following which priapism developed. After puncture of coagulated blood from the corpora cavernosa urine retention developed and a suprapubic catheter had to be introduced temporarily for urine drainage. Zuclopentixol is an alpha 1-receptor blocker and paroxetine inhibits the hepatic enzyme P450-2D6 required for conversion of the two substances. Separately, and especially in combination, these substances cause a disturbance of the drainage from the corpora cavernosa leading to ischaemia and complications such as dysuria, urine retention, impotence, fibrosis of the corpora cavernosa and gangrene. Consequently, timely treatment is indicated.

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Three women aged 28, 30 and 39 years, attending an emergency room because of attempted suicide by means of an overdose of drugs, refused somatic treatment considered necessary: one refused gastric lavage and two refused to remain in the hospital. After explanation of the procedure, one patient left the clinic without treatment and one agreed to admission--both were subsequently treated in the outpatient department. One patient agreed to giving a blood sample, after which she could leave the hospital without risk of somatic complications--two days later she agreed to admission for further treatment. Obligatory gastric lavage after (auto)intoxication is possible under the Medical Treatment Agreement Act (WGBO) and should follow its rules. However, this may be avoided by using a laboratory test or ECG for the diagnosis and administration of activated charcoal and a laxative for the treatment.

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