The implementation of integrated emotion-oriented care: did it actually change the attitude, skills and time spent of trained caregivers?

BACKGROUND: Successful implementation is a vital precondition for investigating the outcome of care innovation. This study concerned the evaluation of the implementation of integrated emotion-oriented care (IEOC) in psychogeriatric nursing home wards. The main question was whether the trained caregivers actually applied the knowledge and techniques of IEOC during their daily work. METHODS: The study was conducted within the framework of a randomized clinical trial into the effectiveness of IEOC in 16 wards. Preceding the experimental period, staff from 16 wards were educated and trained to work with a standardized care plan, resulting in a similar level of quality of care at the start of the trial. On the experimental wards IEOC was then implemented by training on the job in addition to training courses for personnel. To examine the implementation effectiveness, a self-report questionnaire, 'Emotion-oriented Skills in the Interaction with Elderly People with Dementia', was administered at baseline and after 7 months to a sample of caregivers from the experimental and the control wards. In addition, participant observation was conducted on four experimental and four control wards, and time spent by care personnel on different type of care tasks was registered. RESULTS: The implementation of IEOC resulted in increased emotion-oriented skills and more knowledge of the residents among the caregivers. Providing IEOC was not more time consuming for the caregivers than providing usual care. CONCLUSION: This study shows that the implementation of IEOC was effective. It is recommended that in intervention studies the correct application of a new intervention or care approach is examined before jumping to conclusions about the effectiveness of the intervention or care approach itself.

[Long-term goals for oral health]. / Lang leve de duurzame mondzorg.

The current, optimistic prognosis is that newborns will reach an average age of 100 years. This increased life-expectancy requires a renewed vision of long-term goals for oral health. The starting-point could be a prospective end-point with minimal oral function which should be reached, for example, in the last years of one's life. The consequence is that adequate oral healthcare for the elderly starts in childhood. Choices such as the extraction of premolars for orthodontic reasons and the dental re-restoration cycle have a great negative impact on reaching this goal. The average sustainability of dental restorations or prosthetic constructions is commonly much shorter than the life-expectancy of a patient. If oral treatment is necessary, it is recommended to give priority to maintaining a minimally functional dentition up to an advanced age, instead offocusing on short- or medium-term goals.

Heterologous expression of mutated eburicol 14alpha-demethylase (CYP51) proteins of Mycosphaerella graminicola to assess effects on azole fungicide sensitivity and intrinsic protein function.

The recent decrease in the sensitivity of the Western European population of the wheat pathogen Mycosphaerella graminicola to azole fungicides has been associated with the emergence and subsequent spread of mutations in the CYP51 gene, encoding the azole target sterol 14alpha-demethylase. In this study, we have expressed wild-type and mutated M. graminicola CYP51 (MgCYP51) variants in a Saccharomyces cerevisiae mutant carrying a doxycycline-regulatable tetO(7)-CYC promoter controlling native CYP51 expression. We have shown that the wild-type MgCYP51 protein complements the function of the orthologous protein in S. cerevisiae. Mutant MgCYP51 proteins containing amino acid alterations L50S, Y459D, and Y461H and the two-amino-acid deletion DeltaY459/G460, commonly identified in modern M. graminicola populations, have no effect on the capacity of the M. graminicola protein to function in S. cerevisiae. We have also shown that the azole fungicide sensitivities of transformants expressing MgCYP51 variants with these alterations are substantially reduced. Furthermore, we have demonstrated that the I381V substitution, correlated with the recent decline in the effectiveness of azoles, destroys the capacity of MgCYP51 to complement the S. cerevisiae mutant when introduced alone. However, when I381V is combined with changes between residues Y459 and Y461, the function of the M. graminicola protein is partially restored. These findings demonstrate, for the first time for a plant pathogenic fungus, the impacts that naturally occurring CYP51 alterations have on both azole sensitivity and intrinsic protein function. In addition, we also provide functional evidence underlying the order in which CYP51 alterations in the Western European M. graminicola population emerged.

[Proxy consent and responsibility: professional autonomy and adamant family members]. / Vertegenwoordiging en verantwoordelijkheid. Over medische verantwoordelijkheid en mondige familieleden.

Research into the role of family members in the decision making process concerning medical treatment of incompetent patients in nursing home care, shows that the involvement of a proxy decision maker implies a greater responsibility of the physician. It is the duty of the proxy decision-maker (mostly a family member) to look after the incompetent patient's interests. But it is the physician's duty to decide whether the proxy decision maker indeed fulfills this task. Even so, the physician has the professional responsibility to decide on the medical course of action. Involvement of others (relations and other health care professionals) is of great importance to the answer to the question 'What is good for this patient?' but does not absolve the physician from the obligation to decide professionally what is the right thing to do.

A novel substitution I381V in the sterol 14alpha-demethylase (CYP51) of Mycosphaerella graminicola is differentially selected by azole fungicides.

SUMMARY The recent reduction in the efficacy of azole fungicides in controlling Septoria leaf blotch of wheat, caused by Mycosphaerella graminicola, has prompted concerns over possible development of resistance, particularly in light of the recent emergence of widespread resistance to quinone outside inhibitors (QoIs). We have recently implicated alterations in the target-encoding sterol 14alpha-demethylase protein (CYP51), and over-expression of genes encoding efflux pumps, in reducing sensitivity to the azole class of sterol demethylation inhibitors (DMIs) in M. graminicola. Here we report on the prevalence and selection of two CYP51 alterations, substitution I381V and deletion of codons 459 and 460 (DeltaY459/G460), in populations of M. graminicola. Neither alteration has previously been identified in human or plant pathogenic fungi resistant to azoles. The presence of DeltaY459/G460 showed a continuous distribution of EC(50) values across isolates with either I381 or V381, and had no measurable effect on azole sensitivity. Data linking fungicide sensitivity with the presence of I381V in M. graminicola show for the first time that a particular CYP51 alteration is differentially selected by different azoles in field populations of a plant pathogen. Substitution I381V although not an absolute requirement for reduced azole sensitivity, is selected by tebuconazole and difenoconazole treatment, suggesting an adaptive advantage in the presence of these two compounds. Prochloraz treatments appeared to select negatively for I381V, whereas other azole treatments did not or only weakly impacted on the prevalence of this substitution. These findings suggest treatments with different members of the azole class of fungicides could offer a resistance management strategy.

Impact of changes in the target P450 CYP51 enzyme associated with altered triazole-sensitivity in fungal pathogens of cereal crops.

Control of diseases caused by fungi in both medicine and agriculture is heavily dependent on the use of triazoles. As a consequence, resistance to triazoles is a threat to both human health and the sustainability of agricultural production systems. In human pathogens, particularly Candida albicans, mutations encoding alterations in the target cytochrome P450 sterol 14alpha-demethylase (CYP51; where CYP is cytochrome P450) enzyme are the primary determinants of triazole resistance. In fungal pathogens of cereals, CYP51A1 modifications, some at positions known to contribute to a resistant phenotype in human pathogens, have also been identified in isolates with altered triazole-sensitivity. However, unlike medicine where resistance to triazoles is a major clinical problem, failures of triazoles to control crop diseases in the field are rare with mean population sensitivities generally remaining low, perhaps due to differences in the selection pressures imposed on human and cereal pathogen populations. Nonetheless, the biological potential for resistance exists, and the question remains as to whether widespread triazole resistance can develop in an important cereal pathogen.

[Death due to or despite the doctor]. / Overlijden dankzij of ondanks de arts.

In the last week of life, the extent and kind of medical practice differ both in intention and in the degree of orientation on the outcome. Patients tend to put long-term prescriptions aside or ask for symptom-relieving medication and sometimes for palliative sedation, euthanasia or physician-assisted suicide. Competent physicians are able to offer or withhold treatment. In case of unconsciousness or severe cognitive impairment, proxies may ask for medical relief of disturbing symptoms. Medical practice is subject to the Dutch Medical Treatment Act (1995). At the start of the specific Dutch law specifying judicial review of euthanasia and physician-assisted suicide (1993, implemented in 2002) 1.8% of deaths concerned euthanasia. In 2005, standard drugs (choice, dose and route of administration) were highly effective in all cases of euthanasia in which they were used (76%): death within a median of 3-4 min, maximum 90 min. In the absence of medical indications for drug overdose, morphine and other choices are now considered obsolete for euthanasia and physician-assisted suicide. The definition of euthanasia must be based exclusively on a standard method and outcome: death on request by a standard medical method with a standard judicial review.

[There is no natural death without suffering, even in a nursing home]. / Geen natuurlijk overlijden zonder lijden, ook in het verpleeghuis.

During the past 30 years, the legal and moral framework for terminal care and hospice provision has changed, both nationally and internationally, but the situation is still not completely clear. The nursing homes in the Netherlands have also developed, described and implemented palliative care. In most regional systems for palliative care, a supportive and sometimes an active therapeutic role is played by medical, nursing, paramedical and pastoral nursing home professionals. In view of the strong relationship between a poor or worsening nutritional state and fluid balance and death, particularly of psychogeriatric nursing-home patients, a multiprofessional guideline has been drawn up for the responsible provision of food and fluids in nursing homes. It is likely, although not certain, that this guideline will contribute to the limitation of the suffering of the dying patient. The guideline will in any case make the compassion of the family and the sympathy of care-givers discussible and almost always manageable. In many nursing homes, meanwhile, it has become accepted practice, soon after admission, to discuss the future suffering of the patient during the process of dying and to record this conversation.

[Stroke services are increasingly effective]. / Stroke-services toenemend effectief.

Since the first Consensus Statement on the treatment of stroke (UK, 1988) and the European Helsingborg Declaration on the treatment of stroke (1995), 69 stroke services have been geographically spread in the Netherlands; these consist of an integrated hospital stroke unit, a nursing home rehabilitation unit, and home care. The Dutch stroke services have improved their outcomes in a cost-effective way in comparison with the usual care. Consensus on patient-oriented outcomes--arranged in order of the International Classification of Functioning, Disability and Health--is recommended.

[Practice guideline 'Influenza prevention in nursing homes and care homes', issued by the Dutch Society of Nursing Home Specialists; division of tasks between nursing home specialist, general practitioner and company doctor]. / De richtlijn 'Influenzapreventie in verpleeghuizen en verzorgingshuizen' van de Nederlandse Vereniging van Verpleeghuisartsen; taakverdeling tussen verpleeghuisarts, huisarts en bedrijfsarts.

The Dutch Society of Nursing Home Specialists has formulated a guideline for the prevention of influenza in nursing homes and care homes in The Netherlands. The guideline recommends the realisation of the highest possible degree of vaccination of both patients and health care workers. At the start of the flu season, the manager of the chronic care institute should organize a scheme for vaccination against influenza and a plan in case of an outbreak of influenza. The division of tasks between the nursing home specialist, the general practitioner and the company doctor should be recorded in both the vaccination scheme and the outbreak plan. In order to decrease the incidence of non-response to the vaccine a double dose of influenza vaccine for nursing home patients should be considered. The outbreak plan should raise the state of alertness for influenza and ensure that virological confirmation of clinical influenza is obtained quickly. Immediately after virological confirmation of clinical influenza, patients with influenza should be treated with oseltamivir and both patients and health care workers in the unit should receive prophylaxis with oseltamivir. Non-vaccinated patients should also be offered vaccination to restrict re-introduction of the virus. During an influenza outbreak, only patients with influenza or those who have had prophylactic treatment may be admitted to the facility. In the case of an influenza pandemic, national guidelines should be followed.

Role of Ascospores in Further Spread of QoI-Resistant Cytochrome b Alleles (G143A) in Field Populations of Mycosphaerella graminicola.

ABSTRACT Strobilurin fungicides or quinone outside inhibitors (QoIs) have been used successfully to control Septoria leaf blotch in the United Kingdom since 1997. However, QoI-resistant isolates of Mycosphaerella graminicola were reported for the first time at Rothamsted during the summer of 2002. Sequence analysis of the cytochrome b gene revealed that all resistant isolates carried a mutation resulting in the replacement of glycine by alanine at codon 143 (G143A). Extensive monitoring using real-time polymerase chain reaction (PCR) testing revealed that fungicide treatments based on QoIs rapidly selected for isolates carrying resistant A143 (R) alleles within field populations. This selection is driven mainly by polycyclic dispersal of abundantly produced asexual conidia over short distances. In order to investigate the role of sexually produced airborne ascospores in the further spread of R alleles, a method integrating spore trapping with real-time PCR assays was developed. This method enabled us to both quantify the number of M. graminicola ascospores in air samples as well as estimate the frequency of R alleles in ascospore populations. As expected, most ascospores were produced at the end of the growing season during senescence of the wheat crop. However, a rapid increase in R-allele frequency, from 35 to 80%, was measured immediately in airborne ascospore populations sampled in a wheat plot after the first QoI application at growth stage 32. After the second QoI application, most R-allele frequencies measured for M. graminicola populations present in leaves and aerosols sampled from the treated plot exceeded 90%. Spatial sampling and testing of M. graminicola flag leaf populations derived from ascospores in the surrounding crop showed that ascospores carrying R alleles can spread readily within the crop at distances of up to 85 m. After harvest, fewer ascospores were detected in air samples and the R-allele frequencies measured were influenced by ascospores originating from nearby wheat fields.

Classifying the probability of urinary incontinence in psychogeriatric nursing home patients.

Urinary incontinence (UI) frequently occurs in psychogeriatric nursing home patients. In general the personnel involved in the care for these patients act on incontinence noted. Patients are not monitored or classified according to likelihood or severity of incontinence. This study was conducted to develop and validate a model for the classification of the likelihood of UI in demented nursing home patients. A multi-center cross-sectional study was conducted using data on clinical and functional status of 692 subjects. Subjects were subdivided in a Derivation set of 532 patients and a Validation set of 160 patients. The data were ascertained with questionnaires completed by physicians and nursing staff. All psychogeriatric wards (25) of four Dutch nursing homes were included. Using univariate logistic regression analysis on the derivation set we identified correlates of UI among 22 clinical and functional patient characteristics. Subsequently, we developed a classification model for prevalent UI, including independent patient characteristics by means of multivariable logistic regression. Next, we stratified patients into groups with varying likelihood's of UI based on the model developed. Subsequently, we transformed the model to an easy applicable classification rule for the identification of patient subgroups with high or low likelihood on UI. Finally, the rule was validated on the validation set. The independent multivariate factors associated with urinary incontinence were impaired ADL and mobility, diminished alertness and fecal impaction. After transforming the regression model to an easy classification rule, the scores ranged from 0 to 7. The area under the curve was 0.88 (95% Confidence Interval (CI): 0.85-0.91) in the derivation set. In the validation set a similar area under the curve was obtained (0.90 (95% CI: 0.85-0.95)). Among subjects with none of the associated factors the rule classified 0.5% as incontinent patients. In case all associated factors were present the proportion classified as incontinent increased to 91%. In conclusion, the developed classification rule provides means to stratifying nursing home patients according to their likelihood of being incontinent of urine.

Hip fracture in elderly patients: outcomes for function, quality of life, and type of residence.

A prospective study was done to investigate functional outcome, quality of life, and type of residence after hip fracture in patients 65 years of age and older. One hundred two patients admitted consecutively to a university and a general hospital were followed up as long as 4 months after admission. The mean age of the participants was 83 years; 58% of patients came from their own home, and 42 % of patients came from institutions. Nearly 70% of patients had two or more diagnoses other than the hip fracture. Cumulative mortality was 20% at 4 months after fracture. Of surviving patients, 57% were back in their original situation for accommodation, 43% reached the same level of walking ability, and 17% achieved the same level of activities of daily living as before fracture. Patients experienced on average three complications, 26% of which were severe. Quality of life improved in the followup period of 4 months; however, the quality of life at 4 months was worse than the quality of life reported in a reference population. Average costs amounted to euro (Euro) 15.338 (which at the time was nearly equivalent to the US dollar) per patient, with nearly 50% of the costs attributable to hospital costs and 30% attributable to nursing home costs. The results of this study show a poor outcome after hip fracture in elderly patients.

Measuring disability in nursing home residents: validity and reliability of a newly developed instrument.

A 24-item multidimensional nurse-administered Nursing Home Disabilities Instrument (NHDI) was developed to measure disabilities in nursing home residents. We present the psychometric features and value of this instrument, with the following domains assessed: Mobility, Activities of Daily Living (ADLs), Alertness, Resistance to Nursing Assistance, Incontinence, Cognition, and PERCEPTION: Test-retest and interrater reliability was assessed using the Spearman correlation coefficient. Internal consistency was examined by Cronbach's alpha. Criterion validity tests were performed by comparing the scales with scales of the Elderly Residents Rating Scale (BOP). Test-retest reliability correlation coefficients ranged from 0.63 to 0.94. Interrater reliability was high for the scales Cognition, Mobility, ADL, and Incontinence (0.79 to 0.93), moderate for Resistance (0.51), and low for Perception (0.33). Cronbach's alpha of the scales was high, ranging from 0.78 (Alertness) to 0.93 (Mobility); only Perception showed a low alpha: 0.54. Criterion validity was high for Cognition, ADL, and Mobility (0.75 to 0.78), and moderate for Alertness (0.59). The NHDI appears to be a valid and efficient multidimensional instrument for measuring disabilities in nursing home residents. These findings imply that the NHDI is a useful instrument for nursing homes to achieve a reliable assessment of cognitively impaired elders.

Randomized controlled trial of seroresponses to double dose and booster influenza vaccination in frail elderly subjects.

Responses to influenza vaccination are poor in frail elderly subjects who suffer the greatest morbidity and mortality due to infection. Therefore, a randomized clinical trial was performed to determine the effect of a double dose and booster vaccination on antibody responses after influenza vaccination. A total of 815 patients (median age 83 years, median disability score 8, median disease categories 2 and median number of medications 4) residing in 14 nursing homes in the Netherlands were vaccinated during the influenza season 1997-98. The first vaccine dose (15 or 30 microg) was given on Day 0 followed by a booster dose (placebo or 15 microg) on Day 84. Blood samples were taken before and 25 days after vaccination. There were four treatment groups: (i) 15 microg and placebo, (ii) 15 microg and 15 microg booster, (iii) 30 microg and placebo and (iv) 30 microg and 15 microg booster. Geometric mean antibody titers of those receiving the double vaccine dose was 15% (95% CI, 6% to 24%, P = 0.001) higher as compared to the standard 15 microg dose. A booster dose, given 84 days after the first vaccination, yielded postvaccination titters that were 14% (95% CI, 9% to 19%, P = 0.001) higher as compared to placebo. Subgroup analysis did not reveal patient groups that had a proportionally greater benefit from adapted vaccination strategies. It is concluded that higher antibody responses can be achieved in frail elderly people by a double vaccine dose or a booster vaccination.

Reduced IFN-gamma production in elderly people following in vitro stimulation with influenza vaccine and endotoxin.

Cytokine interferon gamma (IFN-gamma) is pivotal in the defence against viruses and intracellular pathogens and an age-related decreased IFN-gamma production may explain the increased infectious disease morbidity and mortality in the elderly. Therefore, we performed a series of clinical experiments evaluating the influence of age and health status on IFN-gamma production following in vitro stimulation with influenza vaccine or endotoxin. Both healthy and frail elderly people produced significantly lower amounts of IFN-gamma following ex vivo stimulation with influenza vaccine or endotoxin. We conclude that ageing is accompanied by a decreased capacity to produce IFN-gamma. This may explain the increased incidence and case-fatality caused by viruses and intracellular pathogens in the elderly.