[Supervising quality of care through the patients' eyes; a different approach to inspection is required]. / Toezien op zorgkwaliteit door de ogen van patiënten.

The Netherlands Health and Youth Care Inspectorate (IGJ) wants to take the patient's perspective into account more often in its supervision of quality of care. The inspectorate already has some insight into this perspective via patients' reports; patients report complaints with the aim of preventing recurrence of the problem. However, the inspectorate does not further investigate the vast majority of these complaints and, furthermore, complaints with a clinical aspect are investigated far more often than organisational or communicational problems. Patients reports do not necessarily concern damage caused by deviation from professional guidelines, and if the IGJ really wants to look at quality of care from the patient's perspective then it should take the image presented by the patient more seriously. The patient's perspective suggests that it is important for the IGJ to pay more attention to organisational and communicational factors and other aspects of healthcare, along with medical professional standards.

Inspectors' ethical challenges in health care regulation: a pilot study.

There is an increasing body of research on what kind of ethical challenges health care professionals experience regarding the quality of care. In the Netherlands the Dutch Health Care Inspectorate is responsible for monitoring and regulating the quality of health care. No research exists on what kind of ethical challenges inspectors experience during the regulation process itself. In a pilot study we used moral case deliberation as method in order to reflect upon inspectors' ethical challenges. The objective of this paper is to give an overview of the ethical challenges which health care inspectors encounter in their daily work. A thematic qualitative analysis was performed on cases (n = 69) that were collected from health care inspectors in a moral case deliberation pilot study. Eight themes were identified in health care regulation. These can be divided in two categories: work content and internal collaboration. The work of the health care inspectorate is morally loaded and our recommendation is that some form of ethics support is provided for health care inspectors.

Supervision by the Dutch Healthcare Inspectorate.

The Dutch Healthcare Inspectorate's (Inspectie voor de Gezondheidszorg) supervisory activities are based on proportional use of the instruments. The primary instruments it uses are advice and encouragement. If these do not achieve the desired result, it can implement corrective action by, for example, enhancing its supervision or through agreements limiting the ability to practise a profession. Recourse to disciplinary or administrative measures can be sought, if necessary. There is a tendency to use statutory instruments, which means greater equality before the law and greater legal certainty. It is important in this respect for the Inspectorate to make its considerations more uniform, transparent and predictable.

[The no-suicide contract: a risky ritual]. / Het non-suïcidecontract: een riskant ritueel.

In spite of former research the preventive value of the no-suicide contract is still uncertain. Making up a no-suicide contract should be considered as a risky ritual because there is a chance for underestimation of the actual risk. Less risky alternatives are: systematic risk assessment, the commitment to treatment statement and the delay or reconsideration agreement.

Reaction mechanism for mammalian pyruvate dehydrogenase using natural lipoyl domain substrates.

The pyruvate dehydrogenase (E1) component of the pyruvate dehydrogenase complex (PDC) catalyzes a two-step reaction. Recombinant production of substrate amounts of the lipoyl domains of the dihydrolipoyl transacetylase (E2) component of the mammalian PDC allowed kinetic characterization of the rapid physiological reaction catalyzed by E1. Using either the N-terminal (L1) or the internal (L2) lipoyl domain of E2 as a substrate, analyses of steady state kinetic data support a ping pong mechanism. Using standard E1 preparations, Michaelis constants (Km) were 52 +/- 14 microM for L1 and 24.8 +/- 3.8 microM for pyruvate and k(cat) was 26.3 s(-1). With less common, higher activity preparations of E1, the Km values were > or =160 microM for L1 and > or =35 microM for pyruvate and k(cat) was > or =70 s(-1). Similar results were found with the L2 domain. The best synthetic lipoylated-peptide (L2 residues 163-177) was a much poorer substrate (Km > or =15 mM, k(cat) approximately equals 5 s(-1); k(cat)/Km decreased >1,500-fold) than L1 or L2, but a far better substrate in the E1 reaction than free lipoamide (k(cat)/Km increased >500-fold). Each lipoate source was an effective substrate in the dihydrolipoyl dehydrogenase (E3) reaction, but E3 had a lower Km for the L2 domain than for lipoamide or the lipoylated peptides. In contrast to measurements with slow E1 model reactions that use artificial acceptors, we confirmed that the natural E1 reaction, using lipoyl domain acceptors, was completely inhibited (>99%) by phosphorylation of E1 and the phosphorylation strongly inhibited the reverse of the second step catalyzed by E1. The mechanisms by which phosphorylation interferes with E1 activity is interpreted based on accrued results and the location of phosphorylation sites mapped onto the 3-D structure of related alpha-keto acid dehydrogenases.

[The development of dual specialization: the clinical geriatrician and the nursing home practitioner, 1945-1990]. / Beroepsvorming in tweevoud: de klinisch geriater en de verpleeghuisarts, 1945-1990.

Why are there in the Netherlands two geriatric disciplines and how have the professions of clinical geriatricians and nursing home practitioners been developed? Only written sources have been used for the research: articles, annual reports, archives of scientific associations and umbrella organisations. For the elderly chronic patients increasingly less space was available in hospitals after 1945. These patients obstructed circulation in this institution, which focused more on treatment rather than nursing. Although everyone acknowledged the need for more medical attention for this old age group, there was a lot of opposition against the development of special geriatric units in hospitals. Other specialists agreed that they could effectively treat the elderly patient and felt no need for a geriatrician. Contrary to the geriatric units in hospitals, the development of nursing homes flourished. In these facilities, the nursing home medicine evolved and, as opposed to geriatrics in hospitals, less resistance was encountered. The system of registration of medical specialists made it impossible to recognise only one geriatrician, since they worked in both hospitals as well as in nursing homes. The professional development of nursing home practitioners and clinical geriatricians was delayed partly as a result of the general hesitation of the KNMG in acknowledging new medical disciplines and as a result of internal domain discussions.

[Older chronic patients and their care provisions in the first half of the twentieth century]. / Oudere chronische patiënten en hun voorzieningen in de eerste helft van de twintigste eeuw.

Contrary to popular beliefs the Dutch nursing home came into existence not after, but long before 1945. The special care units for the old chronic patient (developed between 1900 and 1950) were a response to the problematic status of these patients in the workhouses and general hospitals. In both institutions, they occupied 'the wrong bed'. The workhouses were subject to a lot of criticism because the provided housing for the complete range of elderly persons. This criticism triggered a growing need for specialized and separated housing facilities for the able and disabled elderly. In general hospitals the elderly patients occupied beds needed for other patients, while the care was too expensive. This problem increased because of the ageing of the hospital population. The latter was caused by the age-related increase of both the admission ratio and the average length of stay. In reaction to these problems, inside and outside the existing facilities, special care units with emphasis on nursing, were developed for the elderly chronic patient. Thus, during the first half of this century this provided the foundation of the future nursing homes, which developed so successfully after 1950.

[Self-neglect in the elderly--the homeless and the Diogenes syndrome]. / Zelfverwaarlozing bij ouderen--over thuislozen en het Diogenes-syndroom.

In the health service we sometimes have to deal with patients, who have neglected themselves seriously. It is necessary to know the complex psychological and social background of self-neglect in diagnosing and treating these patients. Psychiatric disorders occur frequently. Self-neglect can cause severe bodily damage. Two situations, characterized by self-neglect, are discussed: the homeless and the Diogenes-syndrome or house-filthiness. These patients may deny their bad health and resist treatment.