Evaluation of the nation-wide implementation of ALS home monitoring & coaching: an e-health innovation for personalized care for patients with motor neuron disease.

BACKGROUND: To improve the care for patients with motor neuron disease an e-health innovation for continuous monitoring of disease progression and patients' well-being (ALS H&C) was implemented in 10 multidisciplinary rehabilitation settings. The first aim was to evaluate the implementation of ALS H&C by assessing several implementation outcomes, technology acceptance and usability of the innovation according to the end users. The secondary aim was to explore differences in these outcomes between the teams with sustainable and unsustainable implementation. METHODS: The chosen implementation strategy was a combination of the implementation process model by Grol & Wensing and a participatory action research approach. In three meetings with multidisciplinary project groups the innovation was introduced, the expected barriers/facilitators identified, and action plans to resolve each barrier developed. After a 3-month pilot phase, patients and their healthcare providers were asked to complete an online evaluation survey to assess implementation outcomes, based on Proctor's evaluation framework (i.e., acceptability, feasibility, fidelity, sustainability). Telemedicine technology acceptance was assessed according the technology acceptance model of Chau, and user experiences with the System Usability Scale (SUS). Implementation outcomes of teams with sustainable implementation (continuation after completion of the pilot phase) and unsustainable implementation (discontinuation after the pilot phase) were compared. RESULTS: The implementation outcomes from the patients' perspective (N = 71) were positive; they found ALS H&C to be an acceptable and feasible care concept. Patients' technology acceptance was high, with positive attitudes towards ALS H&C, and positive views on perceived technology control, usefulness, and ease of use. Patients rated their satisfaction with the (web) app on a scale from 1 (not satisfied at all) to 10 (very satisfied) with a 7.0 (median; IQR 1.0). Healthcare providers (N = 76) also found ALS H&C acceptable and appropriate as well, but were less positive about the feasibility and usability of ALS H&C (mean SUS 58.8 [SD 11.3]). ALS H&C has largely been implemented as intended and the implementation was sustainable in 7 teams. Teams who discontinued ALS H&C after the pilot phase (N = 2) had more fidelity issues. CONCLUSIONS: A participatory action research approach supported by theoretical approaches used in implementation science led to a sustainable implementation of ALS H&C in 7 of the participating teams. To improve implementation success, additional implementation strategies to increase feasibility, usability and fidelity are necessary. TRIAL REGISTRATION: Trial NL8542 registered at Netherlands Trial Register (trialregister.nl) on 15th April 2020.

[Patients with intellectual disabilities]. / Patiënten met een verstandelijke beperking: 10 tips.

Almost all physicians see patients with intellectual disabilities in their practices. There are still health disparities between people with intellectual disability and the general population. Consultations with this group of patients can be challenging, but there are ways to improve on them. Take your time when it comes to communicating with patients with intellectual disabilities, adapt language use and make use of visual aids. People with intellectual disabilities and complex care needs can be referred to intellectual disability physicians (AVG in Dutch) or syndrome-specific outpatient clinics.

Acceptance of Anxiety through Art Therapy: A Case Report Exploring How Anthroposophic Art Therapy Addresses Emotion Regulation and Executive Functioning.

Anxiety is a major problem for many individuals, causing impairment in daily life. Art therapy is often deployed and although positive results are communicated in clinical practice, its effectiveness and working mechanisms have hardly been studied. Therefore, it is important to systematically describe the intervention process and to detect the working mechanisms to be able to evaluate them. Narrative case studies help to understand the intervention in more depth. A typical case file was selected for case reporting according to scientific (CARE & CARE-AAT) guidelines, with the aim to explore the therapeutic elements that contributed to the reduction of anxiety. The report describes the intervention process of a 54-year-old female, suffering from anxiety since childhood and diagnosed with panic disorder, agoraphobia, claustrophobia and hypochondria. After 14 sessions of anthroposophic art therapy, reduction of anxiety was shown, as well as improvements of emotion regulation and executive functioning. The client indicated that she became more tolerant and accepting towards her anxiety. She noted a softened attitude towards herself and her complaints, even one year after art therapy. The course of treatment suggests that aspects of emotion regulation and executive functioning were addressed through implicit learning processes in different art therapy assignments.

[Distal femur fracture in a woman with a lower limb prosthesis.] / Distale femurfractuur bij vrouw met onderbeenprothese.

BACKGROUND: People who use a lower limb prosthesis can fracture their distal femur after a trivial fall; however, this kind of fracture is uncommon. CASE DESCRIPTION: A 53-year-old woman with a trans-tibial prosthesis fell in her kitchen. She felt pain just above the socket of the prosthesis, was unable to get up and her knee and leg were swollen. Radiographic imaging showed a distal femur fracture, for which she received a non-operative treatment with a stump cast. In consultation with the rehabilitation physician she received a conventional lower limb prosthesis after consolidation of the fracture. She mobilised adequately and was able to resume her activities at home and at work. CONCLUSION: Distal femur fractures in patients with a lower limb prosthesis can be recognised through pain just above the socket of the prosthesis. Conservative treatment, including the use of a stump cast, followed by mobilisation with an adapted prosthesis under supervision of a rehabilitation physician often results in a good outcome in terms of functionality.

Looking back and moving forward: 50 years of soil and soil fertility management research in sub-Saharan Africa.

Low and declining soil fertility has been recognized for a long time as a major impediment to intensifying agriculture in sub-Saharan Africa (SSA). Consequently, from the inception of international agricultural research, centres operating in SSA have had a research programme focusing on soil and soil fertility management, including the International Institute of Tropical Agriculture (IITA). The scope, content, and approaches of soil and soil fertility management research have changed over the past decades in response to lessons learnt and internal and external drivers and this paper uses IITA as a case study to document and analyse the consequences of strategic decisions taken on technology development, validation, and ultimately uptake by smallholder farmers in SSA. After an initial section describing the external environment within which soil and soil fertility management research is operating, various dimensions of this research area are covered: (i) 'strategic research', 'Research for Development', partnerships, and balancing acts, (ii) changing role of characterization due to the expansion in geographical scope and shift from soils to farms and livelihoods, (iii) technology development: changes in vision, content, and scale of intervention, (iv) technology validation and delivery to farming communities, and (v) impact and feedback to the technology development and validation process. Each of the above sections follows a chronological approach, covering the last five decades (from the late 1960s till today). The paper ends with a number of lessons learnt which could be considered for future initiatives aiming at developing and delivering improved soil and soil fertility management practices to smallholder farming communities in SSA.

Monitoring and statistical modelling of sedimentation in gully pots.

Gully pots are essential assets designed to relief the downstream system by trapping solids and attached pollutants suspended in runoff. This study applied a methodology to develop a quantitative gully pot sedimentation and blockage model. To this end, sediment bed level time series from 300 gully pots, spanning 15 months, were collected. A generalised linear mixed modelling (GLMM) approach was applied to model and quantify the accumulation of solids in gully pots and to identify relevant physical and catchment properties that influence the complex trapping processes. Results show that the retaining efficiency decreases as sediment bed levels increase. Two typical silting evolutions were identified. Approximately 5% of all gully pots experienced progressive silting, eventually resulting in a blockage. The other gully pots show stabilising sediment bed levels. The depth of the sand trap, elapsed time since cleaning and the road type were identified to be the main properties discriminating progressive accumulation from stabilising sediment bed levels. Furthermore, sediment bed levels exhibit no residual spatial correlation, indicating that the vulnerability to a blockage is reduced as adjacent gully pots provide a form of redundancy. The findings may aid to improve maintenance strategies in order to safeguard the performance of gully pots.

Settlement as a driver for sewer rehabilitation.

This paper assesses the influence of (differential) settlement on sewer system functioning. Based on historical data of the vertical position of sewer invert levels, tilt measurements and in-sewer inspection videos, settlement and settlement related influences are analyzed for a case study area in Amsterdam. The average settlement rate of this system was 4 mm/year. Given this settlement rate, it is shown that settlement significantly influences sewer system functioning within the lifetime of a sewer (system).

A comparative in vitro study of the effects of separate and combined products of Citrus e fructibus and Cydonia e fructibus on immunological parameters of seasonal allergic rhinitis.

This paper examined the effects of the combined product, Citrus e fructibus/Cydonia e fructibus (Citrus/Cydonia; Citrus and Cydonia: each 0.01 g/mL), and separate products of Citrus (0.01 g/mL) and Cydonia (0.01 g/mL) on the immunological pathways involved in seasonal allergic rhinitis (SAR). Peripheral blood mononuclear cells (PBMCs) from five healthy and five grass pollen-allergic donors were isolated and analyzed in vitro after polyclonal and allergen-specific stimulation of T cells in the presence of the three extracts. The analyses demonstrated acceptable cell survival with no signs of toxicity. Citrus mainly had a selective effect on reducing allergen-specific chronic inflammatory (TNF-α; Citrus compared to Cydonia and Citrus/Cydonia: -87.4 (P < 0.001) and -68.0 (P < 0.05), resp.) and Th2 pathway activity (IL-5; Citrus compared to Cydonia: -217.8 (P < 0.01); while, both Cydonia and Citrus/Cydonia mainly affected the induction of the allergen-specific Th1 pathway (IFN-γ; Cydonia and Citrus/Cydonia compared to Citrus: 3.8 (P < 0.01) and 3.0 (P < 0.01), resp.). Citrus and Cydonia demonstrated different working mechanisms in the treatment of SAR and the combination product did not demonstrate larger effects than the separate preparations. Further effectiveness and efficacy studies comparing the effects of the products on SAR in vivo are indicated.

Variation in measurements of transtibial stump model volume: a comparison of five methods.

OBJECTIVE: To determine the right moment for fitting the first prosthesis, it is necessary to know when the volume of the stump has stabilized. The aim of this study is to analyze variation in measurements of transtibial stump model volumes using the water immersion method, the Design TT system, the Omega Tracer system, circumferential measurements, and anthropometric measurements. DESIGN: Nine stump models were measured on two occasions, each consisting of two sessions. In each session, two observers measured the model using each of the five methods. The grand mean volume for each method was calculated. Variance components and their two-way interactions were calculated of the measurement conditions. Repeatability coefficients were calculated for each method. RESULTS: The grand means of the five methods show systematic differences in volume measurements. Error variance was small (6.4%) relative to the total variance. Method and interaction between stump model and method contributed 82.6% to the error variance. Repeatability coefficients of the methods ranged from 45 ml for the Omega Tracer system to 155 ml for the anthropometric measurements. CONCLUSIONS: Error variation in measurement results can be attributed for 82.6% to measurement method and interaction between stump model and method. The Omega Tracer system had the smallest repeatability coefficient, indicating that it is the most reliable method.

Citrus/Cydonia comp. can restore the immunological balance in seasonal allergic rhinitis-related immunological parameters in vitro.

In two in vitro studies, we examined the immunological (pathways of the) effects of Citrus/Cydonia comp. from, respectively, a healthy and an allergic donor; peripheral blood mononuclear cells (PBMCs) were isolated out of peripheral blood and analyzed in vitro after polyclonal stimulation of T-cells. The differentiation capacity and the influence with regard to Th1 (IFN-gamma) and Th2 (IL-5) cells were examined. Citrus/Cydonia comp. has a selective effect on the differentiation of T-cells by producing relatively more IL-10 than IL-12. By that, it also seems to have an effect on the induction of regulatory (IL-10 producing) T-cell subsets. It is in vitro capable of neutralizing (to some extent) the changes, characteristic to allergic rhinitis, with regard to the maturation, differentiation, and activity of the immune system. Thus, Citrus/Cydonia comp. can potentially restore the disturbed immune state of rhinitis patients, which essentially could be sufficient to make allergic symptoms disappear permanently.

Skin problems of the stump and hand function in lower limb amputees: A historic cohort study.

The aim of this study was to investigate the relationship between liner-related skin problems of the stump in patients with a lower limb amputation and impaired hand function. Sixty patients who were treated in a rehabilitation hospital from 1998-2006 were included in an historic cohort study. Data were collected concerning the amputation, skin problems of the stump, co-morbidity, hand function, the prosthesis, liner use and mobility score. The study population consisted of 50 trans-tibial and 10 knee disarticulation amputees, 43 male and 17 female, with a mean age of 62.3 years. The majority (63%) had a vascular reason for amputation. Blisters, folliculitis, rash and surface wounds on the stump were operationalized as being liner related. In patients with an impaired hand function, 70% had experienced liner-related skin problems of the stump, whereas 32% of the patients with a normal hand function had experienced skin problems (p = 0.035). This study shows that impaired hand function poses an increased risk for skin problems in the amputation stump in patients with a lower limb amputation and liner use in their prosthesis.

A patient with donning-related stump wounds: a case report.

A patient suffering from diabetes and a trans-tibial amputation presented with stump wounds caused by improper donning of the liner. His diminished hand function resulted in improper donning, with air being trapped between the liner and stump. This caused blisters on the skin after loading the prosthesis.

Use of on-line UV/Vis-spectrometry in the measurement of dissolved ozone and AOC concentrations in drinking water treatment.

The concentrations of dissolved ozone and assimilable organic carbon (AOC) are important performance parameters in drinking water production. For the measurement of ozone, a spectral algorithm was developed that allows quantification in situ using a UV/Vis spectrometer probe. Furthermore, a strong correlation between the change in the absorption spectrum after individual treatment steps and the formation or removal of AOC in that treatment step was observed. This allowed the development of a spectral algorithm that predicts AOC formation during ozonation and subsequent removal in further treatment steps. This method has been verified at one pilot plant of the Amsterdam drinking water supply.

[Deep venous thrombosis in an amputation stump]. / Diepveneuze trombose in een amputatiestomp.

A 34-year-old patient underwent a knee exarticulation amputation and developed symptoms of pain, redness and swelling of the stump in combination with a feeling of tightness in the chest. These symptoms were first attributed to muscle pain and exertion but further examination revealed deep venous thrombosis (DVT) of the stump and a pulmonary embolism for which he was treated with nadroparine and acenocoumarol. Shortly after treatment he could resume the use of the prosthesis. A DVT in the amputation stump is not frequently encountered, but is a serious complication that can, together with a pulmonary embolism, be life threatening. The literature mentions an incidence ranging from 0-12%. Physical examination is often not conclusive and further examination of the patient with duplex scanning is necessary, with a ventilation-perfusion scan if a pulmonary embolism is suspected. Patients with a lower extremity amputation have a higher risk of developing a DVT because of immobility and increased venous pooling in the residual limb. Symptoms of a red, swollen, warm and painful stump should trigger the physician to suspect a DVT.

Optimal flow distribution over multiple parallel pellet reactors: a model-based approach.

A drinking water treatment plant has a typical configuration of parallel lanes to provide safe drinking water 24 h a day. A new approach for optimising the production of drinking water treatment plants is proposed. This approach is applied to the softening process step and shows promising results in terms of cost reduction by optimising the water distribution over several parallel reactors. The proposed scheme relies on optimal model-based control of a single softening reactor and the use of a bypass.

Literature review of the possible advantages of silicon liner socket use in trans-tibial prostheses.

The silicon liner socket has been used in the trans-tibial prosthesis since the 1980s. Silicon liner sockets are sleeves of silicon material that are rolled onto the stump and fix the prosthesis to it. The producers of the liners propagate many advantages in their use i.e. better suspension of the prosthesis, protection of the stump skin and improved cosmetic appearance. This review was performed to find objective documentation in the literature in support of the advantages in prosthetic fitting and use of silicon liners. A medline search was performed with the key words: "silicon liner socket, Icelandic Roll On Silicon Socket (ICEROSS), trans-tibial prosthesis, lower leg prosthesis and stump sockets". Six articles remained after application of the selection criteria. In two studies clinical examination was done while in the rest questionnaires were used to collect data. The indication for amputation varied from vascular insufficiency, diabetes mellitus and infection to trauma. Most studies mentioned improved prosthetic suspension compared to the conventional supracondylar fitting. Also the walking performance improved with less use of walking aids. There were reports of positive but also negative effects on the skin such as excessive perspiration and itching. Patients had a general preference in prosthetic appearance in favour of the prosthesis with a silicon liner. Further research is needed with the use of objective clinical parameters and a homogenous study group objectively to find advantages in the use of the silicon liner socket in the trans-tibial prosthesis.

BIOMED-I concerted action report: flow cytometric immunophenotyping of precursor B-ALL with standardized triple-stainings. BIOMED-1 Concerted Action Investigation of Minimal Residual Disease in Acute Leukemia: International Standardization and Clinical Evaluation.

The flow cytometric detection of minimal residual disease (MRD) in precursor-B-acute lymphoblastic leukemias (precursor-B-ALL) mainly relies on the identification of minor leukemic cell populations that can be discriminated from their normal counterparts on the basis of phenotypic aberrancies observed at diagnosis. This technique is not very complex, but discordancies are frequently observed between laboratories, due to the lack of standardized methodological procedures and technical conditions. To develop standardized flow cytometric techniques for MRD detection, a European BIOMED-1 Concerted Action was initiated with the participation of laboratories from six different countries. The goal of this concerted action was to define aberrant phenotypic profiles in a series of 264 consecutive de novo precursor-B-ALL cases, systematically studied with one to five triple-labelings (TdT/CD10/CD19, CD10/CD20/CD19, CD34/CD38/CD19, CD34/CD22/CD19 and CD19/CD34/CD45) using common flow cytometric protocols in all participating laboratories. The use of four or five triple-stainings allowed the identification of aberrant phenotypes in virtually all cases tested (127 out of 130, 98%). These phenotypic aberrancies could be identified in at least two and often three triple-labelings per case. When the analysis was based on two or three triple-stainings, lower incidences of aberrancies were identified (75% and 81% of cases, respectively) that could be detected in one and sometimes two triple-stainings per case. The most informative triple staining was the TdT/CD10/CD19 combination, which enabled the identification of aberrancies in 78% of cases. The frequencies of phenotypic aberrations detected with the other four triple-stainings were 64% for CD10/CD20/CD19, 56% for CD34/CD38/CD19, 46% for CD34/CD22/CD19, and 22% for CD19/CD34/CD45. In addition, cross-lineage antigen expression was detected in 45% of cases, mainly coexpression of the myeloid antigens CD13 and/or CD33 (40%). Parallel flow cytometric studies in different laboratories finally resulted in highly concordant results (>90%) for all five antibody combinations, indicating the high reproducibility of our approach. In conclusion, the technique presented here with triple-labelings forms an excellent basis for standardized flow cytometric MRD studies in multicenter international treatment protocols for precursor-B-ALL patients.

Regenerating normal B-cell precursors during and after treatment of acute lymphoblastic leukaemia: implications for monitoring of minimal residual disease.

We studied 57 childhood acute lymphoblastic leukaemia (ALL) patients who remained in continuous complete remission after treatment according to the Dutch Childhood Leukaemia Study Group ALL-8 protocols. The patients were monitored at 18 time points during and after treatment [640 bone marrow (BM) and 600 blood samples] by use of cytomorphology and immunophenotyping for the expression of TdT, CD34, CD10 and CD19. Additionally, 60 BM follow-up samples from six patients were subjected to clonality assessment via heteroduplex polymerase chain reaction (PCR) analysis of immunoglobulin VH-JH gene rearrangements. We observed substantial expansions of normal precursor B cells in regenerating BM not only after maintenance therapy but also during treatment. At the end of the 2-week intervals after consolidation and reinduction treatment, B-cell-lineage regeneration was observed in BM with a large fraction of immature CD34+/TdT+ B cells. In contrast, in regenerating BM after cessation of maintenance treatment, the more mature CD19+/CD10+ B cells were significantly increased, but the fraction of immature CD34+/TdT+ B cells was essentially smaller. Blood samples showed a profound B-cell lymphopenia during treatment followed by a rapid normalization of blood B cells after treatment, with a substantial CD10+ fraction (10-30%). Heteroduplex PCR analysis confirmed the polyclonal origin of the expanded precursor B cells in regenerating BM. This information regarding the regeneration of BM is essential for the correct interpretation of minimal residual disease studies.

BIOMED-1 concerted action report: flow cytometric characterization of CD7+ cell subsets in normal bone marrow as a basis for the diagnosis and follow-up of T cell acute lymphoblastic leukemia (T-ALL).

The European BIOMED-1 Concerted Action was initiated in 1994 to improve and standardize the flow cytometric detection of minimal residual disease (MRD) in acute leukemia (AL). Three different protocols were defined to identify the normal subsets of B, T and myeloid cells in bone marrow (BM), and were applied to the different types of AL in order to study aberrant immunophenotypes. Using sensitive acquisition methods ('live gate') T cell subsets in normal BM could be identified with five triple-stains: CD7/CD5/CD3, CD7/CD4/CD8, CD7/CD2/CD3, CD7/CD38/CD34 and TdT/CD7/surface or cytoplasmic (cy)CD3 (antibodies conjugated with FITC/PE/PECy5 or PerCP, respectively). The identification of T cell subsets in BM allowed definition of 'empty spaces' (ie areas of flow cytometric plots where normally no cells are found). All studied T-ALL cases (n = 65) were located in 'empty spaces' and could be discriminated from normal T cells. The most informative triple staining was TdT/CD7/cyCD3, which was aberrant in 91% of T-ALL cases. In most cases, two or more aberrant patterns were found. Apparently the immunophenotypes of T-ALL differ significantly from normal BM T cells. This is mostly caused by their thymocytic origin, but also the neoplastic transformation might have affected antigen expression patterns. Application of the five proposed marker combinations in T-ALL contributes to standardized detection of MRD, since cells persistent or reappearing in the 'empty spaces' can be easily identified in follow-up BM samples during and after treatment.