[Assessment of decision-making competence]. / Wilsbekwaamheid beoordelen.

Care providers are frequently confronted with complicated questions about decision-making competence. This article offers tools to help them to deal with those questions. We also look closely at the underlying legal aspects of competence, how and when competence should be assessed, who is responsible for this assessment and which tools are available for this process.

[The role of patient competence in the new Dutch statute concerning involuntary treatment in psychiatry]. / De rol van wilsbekwaamheid in de Wet verplichte geestelijke gezondheidszorg.

BACKGROUND: In the new Compulsory Mental Health Care Act (Wvggz), patient competence has a more central position. AIM: To describe the new position of patient competence in the Wvggz and to reflect on related moral questions. METHOD: Discussion of relevant legal texts and publications. RESULTS: In case of incompetency of a patient, a surrogate decision-maker has to attempt what decision the patient would make if he or she were competent. A new element in the Wvggz is that grandparents and grandchildren can also act as surrogate decision-makers. A competency judgment is mandatory in every decision on involuntary treatment, with the exception of involuntarily commitment. Competent refusal of care has to be respected, unless the patient is in a life threatening situation or there is a risk of other people getting harmed. CONCLUSION: The question is whether the changed position of patient competence in the new law will contribute to the aim of maintaining and enhancing patients' autonomy. Due care in competency judgments is complex and remains important.

Chronically ill children's participation and health outcomes in shared decision-making: a scoping review.

Based on the United Nations Conventions on the Rights of the Child (CRC), it is a child's right to participate in all matters concerning its wellbeing. Little is known about chronically and/or critically ill children's participation in pediatric shared decision-making (SDM). We explored medical literature to see if and how these children participate in pediatric SDM. We searched relevant medical databases published between January 2008 and January 2020 for studies targeting children aged 4-18 years old, suffering from a chronic and/or critical disease. We found 9 relevant studies. SDM interventions mostly used were decision aids (n=8), questionnaires for caretakers/parents and children (n=4), and a SDM toolkit (n=2). Perceived involvement in SDM and knowledge increased amongst children, adolescents, and caretakers following these interventions. Decisional conflict measured using the 0-100 point DCS scale (higher scores indicate more decisional conflict) was reduced by 15.9 points in one study (p<0.01) and 17.8 points in another (95%CI: 13.3-22.9). Lower scores were associated with higher satisfaction with the decision aid by children, caretakers, and clinicians.Conclusion: Stakeholders should advocate initiatives to facilitate a child's participation preferences regarding pediatric SDM since decision support tools help chronically ill children to be more involved in SDM as they increase the children's knowledge and satisfaction and reduce decisional conflicts. What is Known: • Decision aids can help improve participation, knowledge, satisfaction, and health outcomes. • Quality and consistency of the information exchange impact quality and outcome of SDM. What is New: • Depending on a child's age, evolving capacities, and communication and participation preferences, more evidence is needed on which tools are suitable for chronically ill children to ensure their preferred participation in pediatric SDM. • Pediatricians adopt healthcare SDM tools and techniques that do not always take into account that a child's right to participate in pediatric SDM including the tendency to use interventions that are not specifically designed for pediatrics.

[Problematic attachment]. / Problematische gehechtheid.

Unsafe attachment relationships occur in more than one third of children living at home. In case of severely problematic attachment, it is important that physicians and paramedics recognise this, so that they can refer the child and its caregiver to specialist care. This is because interventions to improve attachment between children and their caregivers are possible. This will make it possible to limit the psychological consequences for the child, even at a later age.

[Decision-making competence in patients with an intellectual disability]. / Wilsbekwaamheid bij mensen met een verstandelijke beperking.

BACKGROUND: Mental competence is a complex concept within the contexts of ethics, law, psychology and medicine. Competency is a prerequisite for giving informed consent for a medical intervention. It has long been wrongly thought that people with intellectual disabilities as a group are incapacitated, but competence is not a categorical trait of a certain group of persons. Capacities can fluctuate over time and can vary per decision or action domain. The more severe the intellectual disability, the less likely that someone is competent in health care decision-making.
AIM: To describe specifically the meaning of the concept of competence in people with intellectual disabilities and the legal frameworks in the Netherlands and Belgium. Furthermore, to provide practices for assessing competence and to focus on supporting competence in this target group.
METHOD: Overview of the most recent theory and practical methods.
RESULTS: The assessment of decision-making competence can be difficult and has far-reaching consequences, and must therefore be applied carefully and well-founded.
CONCLUSION: It is advisable to support people with an intellectual disability in order to be able to make decisions themselves as much as possible.

[Olanzapine in the treatment of adolescents with anorexia nervosa]. / Olanzapine in de behandeling van adolescenten met anorexia nervosa.

This article, which was triggered by a case study of a 15-year-old female patient, gives an overview of the literature on the use of olanzapine as an adjunctive treatment for anorexia nervosa in adolescents. On the basis of studies performed so far (two small double-blind placebo-controlled studies, two open-label trials, one retrospective study, a number of case studies that included adolescents, and four series of case studies on adolescents alone), the short-term results of using olanzapine were promising. However, careful monitoring is needed.

Easy-to-use rapid test for direct detection of Campylobacter spp. in chicken feces.

Human campylobacteriosis is the leading cause of acute bacterial gastroenteritis in developed countries. One important source of infection is poultry. Results from the Dutch Campylobacter Risk Management and Assessment project indicate that meat from broiler flocks shedding >or=7 log CFU Campylobacter per g of feces poses the greatest risk of transmitting campylobacteriosis. The objective of this study was to develop a simple and rapid test that would identify chicken flocks shedding high numbers of Campylobacter. We used lateral flow technology as the alternative test method, and selected the culture method according to International Organization for Standardization guidelines. To evaluate the test under field conditions, we sampled either chicken droppings at farms or cecal contents at the slaughterhouse. PCR was used to confirm presumptive Campylobacter spp. colonies. Under laboratory conditions, chicken feces containing >or=6.7 log CFU/g Campylobacter jejuni or >or=7.1 log CFU/g Campylobacter coli were identified by the lateral flow test. Overall, 3 (33%) of 10, and 29 (85%) of 34 C. jejuni- or C. coli-positive chicken flocks were identified at farms and slaughterhouses, respectively, by using the lateral flow test. Fecal samples containing >or=7.3 log of C. jejuni or C. coli CFU/g as determined by plating were always positive when using the lateral flow test. A single person testing seven flocks at a time could obtain test results within 2 h of sampling. This simple and rapid lateral flow test may contribute significantly to the identification of chicken flocks shedding high numbers of Campylobacter.

Phenotypic and molecular characterization of Staphylococcus aureus strains of veterinary, dairy and human origin.

Austrian veterinary (n=91), dairy (n=86), and human strains (n=48) of Staphylococcus aureus were tested for various phenotypic properties including clumping factor, egg-yolk reaction, production of thermonuclease and susceptibility to 14 antibiotics. In addition the expression of enterotoxins (A-E), and the presence of enterotoxin genes sea to sej and tst was determined. Significant differences in antimicrobial susceptibility were found with 84.6% of veterinary, 57.0% of dairy, and 20.8% of human strains susceptible to all antibiotics tested (P<0.0005). More human strains produced enterotoxins (41.7%) than veterinary (9.9%) and dairy strains (12.6%) while 40.7% and 38.5% of veterinary, 47.7% and 52.3% of dairy, and 77.1% and 87.5% of human strains were se- and tst-positive, respectively. AFLP analysis revealed nine clusters with over- or under-representation of strains with specific characteristics. Strains clustered according to origin (veterinary, dairy, and human) and/or presence of toxin genes and antimicrobial resistance.

Characterization of Staphylococcus aureus strains isolated from bovine milk in Hungary.

Staphylococcus aureus is a major foodborne pathogen due to its capability to produce a wide range of heat-stable enterotoxins. The primary purpose of this research was to characterize S. aureus isolates recovered from mammary quarter milk of mastitic cows and from bulk tank milk produced on Hungarian dairy farms of different sizes. Macrorestriction analysis of chromosomal DNA from S. aureus isolates was performed using the restriction enzyme SmaI followed by pulsed-field gel electrophoresis (PFGE). The prevalence rates of nine S. aureus enterotoxin genes (sea, seb, sec, sed, see, seg, seh, sei, and sej) and of the toxic shock syndrome toxin 1 gene (tst) were determined by multiplex polymerase chain reaction (PCR). The bulk tank milks of 14 out of 20 farms were contaminated with S. aureus at levels of up to 6.0x10(3 )CFU/ml. Farm size had no significant effect (P>0.05) on the S. aureus counts in bulk milk. The prevalence rates of penicillin resistance were 88.9% and 20.0% among the S. aureus recovered from mastitic quarter milk and bulk tank milk, respectively. After phenotypic characterization, a total of 59 S. aureus isolates were selected for genotyping. PFGE analysis revealed 22 distinct pulsotypes, including 14 main types and 8 subtypes, at a similarity level of 86%. Only one or two main types were observed on each of the farms tested, indicating a lack of genetic diversity among S. aureus isolates within farms, and there were only two pulsotypes which occurred on more than one farm. The PFGE patterns showed genetic relatedness between the S. aureus strains recovered from quarter milk and bulk milk on two large farms, implying that on farms having a high number of mastitic cows, S. aureus from infected udders may contaminate bulk milk and, subsequently, raw milk products. Sixteen (27.1%) of the S. aureus isolates tested by multiplex PCR were found to be positive for enterotoxin genes, with 15 of them carrying just one gene and one strain carrying two genes (seg and sei). The most commonly detected toxin genes were seb, sea, and sec, whereas none of our isolates possessed the see, seh, sej, or tst genes. On 75% of the dairy farms surveyed, no enterotoxigenic staphylococci were recovered from either mastitic quarter milk or bulk tank milk.

Survey on the Listeria contamination of ready-to-eat food products and household environments in Vienna, Austria.

Qualitative and quantitative contamination of ready-to-eat food-stuffs with the pathogen Listeria monocytogenes was studied in 1586 samples collected from 103 supermarkets (n = 946) and 61 households (n = 640) in Vienna, Austria. Seventeen groups of ready-to-eat foods were classified into three risk categories for contamination (CP1-CP3). Three to four samples were randomly collected at the retail level from each CP. Regarding the households, the sampling procedure was started with food items of CP1, and if not available, was continued with sampling of food items of CP2 and finally of CP3. Additionally, 184 environmental samples (swabs from the kitchen area, dust samples from the vacuum cleaner) and faecal samples (household members and pet animals) were included. One-hundred and twenty-four (13.1%) and 45 (4.8%) samples out of 946 food samples collected from food retailers tested positive for Listeria spp. and L. monocytogenes, respectively, with five smoked fish samples exceeding the tolerated limit of 100 CFU/g food. Food-stuffs associated with the highest risk of contamination were twice as frequently contaminated with L. monocytogenes as food-stuffs associated with a medium risk of contamination. Products showing the highest contamination rate were fish and seafood (19.4%), followed by raw meat sausages (6.3%), soft cheese (5.5%) and cooked meat products/patés (4.5%). The overall contamination rate of foods collected at the household level was more than two times lower. Only 5.6% and 1.7% of 640 food-stuffs analysed tested positive for Listeria spp. and L. monocytogenes, respectively. However, CP1 foods were rarely collected. Pulsed-field gel electrophoresis (PFGE) typing of the collected L. monocytogenes isolates revealed a high degree of diversity between the isolates, with some exceptions. PFGE typing of isolates harvested from green-veined cheese revealed a match among strains, although the manufacturer seemed to be distinguishable. Typing of household strains revealed an epidemiological link within one family. In this case, food-stuffs and the kitchen environment were contaminated by an indistinguishable isolate. In addition, the same isolate was collected from a pooled faecal sample of the household members suggesting that consumption of even low contaminated food items (<100 CFU/g) results in Listeria shedding after the passage through the gut.

Characterization of Listeria monocytogenes isolates from 50 small-scale Austrian cheese factories.

One hundred eighty-one small-scale cheese factories (annual production < 100,000 kg) were tested for the presence of Listeria monocytogenes in cheese and smear samples from 1997 to 2000. In total, 2615 samples were drawn. Fifty (27.6%) of 181 enterprises yielded L. monocytogenes. From 14 of the cheese-making facilities, we obtained more than four L. monocytogenes isolates. A total of 182 mostly cheese- and smear-borne L. monocytogenes strains were characterized by serotyping and pulsed-field gel electrophoresis. In 12 of 14 cheese factories, over half of the L. monocytogenes isolates were genetically indistinguishable by pulsetype. On average, genetically indistinguishable isolates were recovered for 11.9 months. Regarding serotypes, 27.3% of the isolates were of serovar 4b. Inadequate personal hygiene could explain the high prevalence of serovar 4b isolates in small-scale cheesemaking facilities. Forty-two percent of the serovar 4b isolates recovered from epidemiologically unlinked facilities (in comparison to 40 and 29% of the 1/2a and 1/2b isolates, respectively) were genetically indistinguishable from at least one other isolate. Indistinguishable serovar 1/2a and 1/2b isolates belonged to five and six different pulsetypes, respectively, whereas serovar 4b isolates belonged to only two pulsetypes. This finding suggested a wide distribution of genetically homologous serovar 4b isolates among the facilities tested in our study.

Campylobacter jejuni isolated from poultry and humans in Styria, Austria: epidemiology and ciprofloxacin resistance.

Sixty-six broiler flocks were sampled to determine the presence of Campylobacter spp. at slaughter in 1998. Thirty flocks (45%) tested positive and C. jejuni was identified in all isolates. Combined pulsed-field gel electrophoresis/amplified fragment length polymorphism (PFGE/AFLP) subtyping of 177 isolates from 24 positive flocks revealed 62 subtypes; 16 flocks harboured more than one subtype. When subtyping 101 clinical C. jejuni isolates collected in the same time period and area, 60 PFGE/AFLP types were identified. Comparison of subtypes from poultry and human isolates revealed three shared PFGE/AFLP types, which were present in 11 human isolates. Fifty per cent of all poultry isolates and 39% of all human isolates were resistant to ciprofloxacin. The present study confirms the increase in ciprofloxacin resistance in both human and poultry C. jejuni isolates in Austria, as observed in several countries worldwide. A small number of human isolates shared PFGE/AFLP types with poultry isolates, however, further studies should also focus on the identification of other sources of C. jejuni infection in humans.

Barbecued chicken causing a multi-state outbreak of Campylobacter jejuni enteritis.

BACKGROUND: Although the microbiological safety of food has improved, food-borne disease remains a significant cause of morbidity and mortality in Europe. PATIENTS AND METHODS: We investigated an outbreak of Campylobacter jejuni enteritis attributed to chicken meat, affecting five out of six people attending a private barbecue party in Germany. Patients fell ill in Germany, in Liechtenstein and in Austria. 80% of the cases had been exposed to barbecued chicken; the case that denied having eaten chicken was the party host, who also handled all the food. Three of four patients submitting stool specimens had culture-confirmed C. jejuni infection. RESULTS: The chicken meat was purchased in the Tyrol (Austria) and originated from a flock of 55600 chickens raised in Carinthia (Austria). Caecal swabs were obtained in 7 weeks later from 22 chicken at the incriminated farm: 18 of the 22 samples yielded C. jejuni. The same day, six carcasses out of 22000 slaughtered animals from the incriminated farm were tested and all six food samples yielded C. jejuni. Outbreak-associated human isolates yielded pulsed-field gel electrophoresis patterns indistinguishable from each other and from the meat isolates, but different from four human control strains and from 13 of 16 isolates from caecal swabs. CONCLUSION: Our data show that the outbreak clone had been colonizing the slaughterhouse and was cross-contaminating chickens there. The geographic mobility of people and food necessitates proper epidemiologic investigations to avoid overestimation of the proportion of sporadic occurrence of campylobacteriosis.

Prevalence and characterization of Listeria monocytogenes in the feces of healthy Austrians.

The aims of the study were to determine the prevalence of Listeria monocytogenes in the feces of healthy Austrians and to characterize the isolates by various typing methods. Stool specimens from 505 healthy volunteers from the Tyrol were tested for the presence of L. monocytogenes using cold enrichment for 6 months and five different detection methods: conventional plating onto Palcam and Rapid'L.MONO agar, immunomagnetic separation (IMS) followed by conventional plating, enzyme-linked fluorescent immunoassay (ELFA), ELISA, and PCR. L. monocytogenes was isolated by conventional plating from one specimen (0.2%), and a further three were positive on immunomagnetic separation (0.8%). Only one specimen tested positive with ELFA and EIA, although it tested negative by conventional culture, IMS, and PCR. Eighteen of 505 samples were positive by PCR (3.6%), and this included three of the four culture-confirmed specimens. Serotyping, phage-typing, arsenic cadmium, antimicrobial-resistance typing and pulsed-field gel electrophoresis showed that multiple L. monocytogenes isolates from three of the four carriers were indistinguishable. Our data indicate that the Austrian fecal carriage rate is at least 0.8%. In view of a listeriosis incidence of 0.16/100,000 per year, the chances of fecal carriage developing into listeriosis appear to be very low.

Comparison of different approaches to quantify Staphylococcus aureus cells by real-time quantitative PCR and application of this technique for examination of cheese.

Two different real-time quantitative PCR (RTQ-PCR) approaches were applied for PCR-based quantification of Staphylococcus aureus cells by targeting the thermonuclease (nuc) gene. Purified DNA extracts from pure cultures of S. aureus were quantified in a LightCycler system using SYBR Green I. Quantification proved to be less sensitive (60 nuc gene copies/microl) than using a fluorigenic TaqMan probe (6 nuc gene copies/microl). Comparison of the LightCycler system and the well-established ABI Prism 7700 SDS with TaqMan probes revealed no statistically significant differences with respect to sensitivity and reproducibility. Application of the RTQ-PCR assay to quantify S. aureus cells in artificially contaminated cheeses of different types achieved sensitivities from 1.5 x 10(2) to 6.4 x 10(2) copies of the nuc gene/2 g, depending on the cheese matrix. The coefficients of correlation between log CFU and nuc gene copy numbers ranged from 0.979 to 0.998, thus enabling calculation of the number of CFU of S. aureus in cheese by performing RTQ-PCR.

Detection and quantification of the iap gene of Listeria monocytogenes and Listeria innocua by a new real-time quantitative PCR assay.

A real-time quantitative polymerase chain reaction (PCR) assay for direct detection and enumeration of Listeria monocytogenes and Listeria innocua was developed and applied to artificially contaminated milk samples. The iap gene present in both species was used as a target for amplification of a 175-bp (L. monocytogenes) and a 309-bp (L. innocua) fragment. To ensure that L. monocytogenes and L. innocua are specifically detectable, tests were carried out using 42 L. monocytogenes strains and 33 L. innocua strains belonging to different serovars. Specificity was also confirmed using 22 bacterial strains not belonging to the genus Listeria, including closely related bacteria. In addition to specificity, the reported assay is characterized by a wide dynamic range of quantification and a high sensitivity, as we could detect as few as six copies of the iap gene per PCR using purified DNA as template. When applied to direct detection and quantification of L. monocytogenes in milk, the more rapid real-time quantitative PCR assay was as sensitive as the traditional plate count method, but real-time quantitative PCR-derived iap gene copy numbers were one to two logs higher than colony-forming units obtained by the plate count method.

Characterization of a novel class of plant homeodomain proteins that bind to the C4 phosphoenolpyruvate carboxylase gene of Flaveria trinervia.

We are interested in the regulatory mechanisms responsible for the mesophyll-specific expression of C4 phosphoenolpyruvate carboxylase (PEPCase). A one-hybrid screen resulted in the cloning of four different members of a novel class of plant homeodomain proteins, which are most likely involved in the mesophyll-specific expression of the C4 PEPCase gene in C4 species of the genus Flaveria. Inspection of the homeodomains of the four proteins reveals that they share many common features with homeodomains described so far, but there are also significant differences. Interestingly, this class of homeodomain proteins occurs also in Arabidopsis thaliana and other C3 plants. One-hybrid experiments as well as in vitro DNA binding studies confirmed that these novel homeodomain proteins specifically interact with the proximal region of the C4 PEPCase gene. The N-terminal domains of the homeodomain proteins contain highly conserved sequence motifs. Two-hybrid experiments show that these motifs are sufficient to confer homo- or heterodimer formation between the proteins. Mutagenesis of conserved cysteine residues within the dimerization domain indicates that these residues are essential for dimer formation. Therefore, we designate this novel class of homeobox proteins ZF-HD, for zinc finger homeodomain protein. Our data suggest that the ZF-HD class of homeodomain proteins may be involved in the establishment of the characteristic expression pattern of the C4 PEPCase gene.

Detection and differentiation of Listeria spp. by a single reaction based on multiplex PCR.

The iap gene encodes the protein p60, which is common to all Listeria species. A previous comparison of the DNA sequences indicated conserved and species-specific gene portions. Based on these comparisons, a combination consisting of only five different primers that allows the specific detection and differentiation of Listeria species with a single multiplex PCR and subsequent gel analysis was selected. One primer was derived from the conserved 3' end and is specific for all Listeria species; the other four primers are specific for Listeria monocytogenes, L. innocua, L. grayi, or the three grouped species L. ivanovii, L. seeligeri, and L. welshimeri, respectively. The PCR method, which also enables the simultaneous detection of L. monocytogenes and L. innocua, was evaluated against conventional biotyping with 200 food hygiene-relevant Listeria strains. The results indicated the superiority of this technique. Thus, this novel type of multiplex PCR may be useful for rapid Listeria species confirmation and for identification of Listeria species for strains isolated from different sources.

3-D flow velocity vector estimation with a triple-beam lens transducer-experimental results.

Current commercial ultrasound blood flow measurement systems only measure the axial component of the true blood flow velocity vector. In order to overcome this limitation, a technique which tracks blood cell scatterers as they move between three ultrasound beams has been developed. With this technique, the entire 3-D blood flow velocity vector can be estimated. Previous work has presented the theory behind the technique, lens transducer design and construction, as well as results of computer simulations and preliminary experimental results. This work presents the first experimental results obtained with a prototype system for continuous, fully developed flow in a flow phantom under a wide range of flow rates and flow directions. The results indicate that the accurate measurement of the 3-D flow velocity vector using this technique is possible.

Current time-domain methods for assessing tissue motion by analysis from reflected ultrasound echoes-a review.

The Doppler technique has traditionally been the method used to extract motion information from ultrasonic echoes reflected by moving tissues. The Doppler technique has been around for a long time, and has been extensively reviewed and analyzed in the literature. Recently, time-domain methodologies for estimating tissue motion have gained in popularity. Time-domain methods have advantages over Doppler methods in many applications, and as of yet have not been comprehensively reviewed. An overview of time-domain techniques that have appeared in the literature over the past few years is presented. Their potential advantages over Doppler are examined, and the individual techniques are compared.