Perceived Criticism in Relation to the Dialectical Behaviour Therapy Network Training in a Residential Program: A Pre-Post Study

Perceived Criticism is a transdiagnostic construct that captures the patients’ perception of criticism. PC seems to be a reliable predictor of negative clinical outcomes concerning recurrence of symptoms or relapse in a broad range of stress-related psychiatric disorders and is thought to be related to underlying stress-related psychobiological vulnerabilities. Dialectical Behavior Therapy (DBT) is a treatment targeting these stress-related psychobiological vulnerabilities. In this pilot study we focus on the possible change in Perceived Criticism due to a (residential) DBT network training. This study follows a pre-post design where PC is recorded in 33 patients (mean age 25 years) and 61 relatives during 8 group sessions of a DBT network training, as part of a residential DBT program. The degree of perceived criticism is systematically assessed using the Perceived Criticism Measure, a two item self-report questionnaire that assesses mutual (perceived) criticism from patients and network members. Overall scores of the perceived criticism measure decrease significantly for both patients and relatives after following the DBT network training. More specific, item scores of both patients and relatives concerning how critical they are towards the other and how critical they thought the other was of them also decreased significantly after following the DBT network training. Findings suggest that a DBT network training as part of a residential DBT program may be instrumental in decreasing levels of perceived criticism. We recommend further exploration of Perceived Criticism as a possible moderator in effect size studies in randomized controlled clinical trials on DBT and in more fundamental research on the putative mechanisms of behavioural change such as improved perspective taking, and the evaluation of social cues (AU)

Influence of Promotion on the Growth of Anchored Colloidal Iron Oxide Nanoparticles during Synthesis Gas Conversion.

Using colloidal iron oxide nanoparticles with organic ligands, anchored in a separate step from the supports, has been shown to be beneficial to obtain homogeneously distributed metal particles with a narrow size distribution. Literature indicates that promoting these particles with sodium and sulfur creates an active Fischer-Tropsch catalyst to produce olefins, while further adding an H-ZSM-5 zeolite is an effective way to obtain aromatics. This research focused on the promotion of iron oxide colloids with sodium and sulfur using an inorganic ligand exchange followed by the attachment to H-ZSM-5 zeolite crystals. The catalyst referred to as FeP/Z, which consists of iron particles with inorganic ligands attached to a H-ZSM-5 catalyst, was compared to an unpromoted Fe/Z catalyst and an Fe/Z-P catalyst, containing the colloidal nanoparticles with organic ligands, promoted after attachment. A low CO conversion was observed on both FeP/Z and Fe/Z-P, originating from an overpromotion effect for both catalysts. However, when both promoted catalysts were washed (FeP/Z-W and Fe/Z-P-W) to remove the excess of promoters, the activity was much higher. Fe/Z-P-W simultaneously achieved low selectivity toward methane as part of the promoters were still present after washing, whereas for FeP/Z-W the majority of promoters was removed upon washing, which increased the methane selectivity. Moreover, due to the addition of Na+S promoters, the iron nanoparticles in the FeP/Z(-W) catalysts had grown considerably during catalysis, while those in Fe/Z-P(-W) and Fe/Z(-W) remained relatively stable. Lastly, as a large broadening of particle sizes for the used FeP/Z-W was found, where particle sizes had both increased and decreased, Ostwald ripening is suggested for particle growth accelerated by the presence of the promoters.

The standardised mortality ratio: the proper quality indicator in acute leukaemia?

BACKGROUND: The standardised mortality ratio (SMR) is a quality indicator used to measure quality of care in the Netherlands. It is subject to much criticism, which was the reason to study the value of the SMR as a quality indicator for the treatment of acute leukaemia. METHODS: A retrospective analysis was performed in patients with acute leukaemia admitted to a Santeon hospital during the period 2005-2009. SMR values were calculated and compared with the overall survival (OS). RESULTS: During the study period, 455 unique patients were admitted with acute leukaemia. SMR calculation was based on 992 admissions. SMR analysis yielded a high mortality ratio in hospital 1, 2, 3 and 4 in comparison with the national average (100), significant for hospital 1 and 4 (180 [CI 95% 126-257] and 187 [CI 95% 134-261], respectively) OS analysis also showed a significantly different outcome between hospitals. However, using OS as outcome parameter, hospital 2 and 6 showed the lowest performance as compared with hospital 1 and 4 using SMR as parameter. After multivariate analysis, age (HR 1.04; CI 95% 1.03-1.05; p < 0.001) and hospital (hospital 5 compared with 6: HR 0.54; CI 95% 0.30- .98; p = 0.043; hospital 2 compared with 1: HR 1.51; CI 95% 1.02-2.23; p = 0.039) were the only significant variables that influenced OS. CONCLUSION: Outcome according to SMR is not equivalent to outcome according to OS. This study shows that the use of the SMR as a quality indicator for the treatment of acute leukaemia does not appear to be justified.

The diagnostic accuracy of the squeeze test to identify arthritis: a cross-sectional cohort study.

OBJECTIVES: In daily practice, the squeeze test is used to screen for arthritis in metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints. This cross-sectional cohort study determined the diagnostic accuracy of this test. METHODS: Patients referred with arthralgia of recent onset that had either a clinical suspicion for progression to arthritis or clinically apparent arthritis were studied. The main outcome was swelling at physical examination of ≥1 MCP or MTP joint. Joint inflammation detected at extremity MRI was the secondary outcome. RESULTS: Both at MCP and MTP joints, a positive squeeze test associated with swollen joints (p<0.005). The sensitivity of the test at the MCP joints was 53%, specificity 82%, positive likelihood ratio (LR+) 3.0, negative likelihood ratio (LR-) 0.6 and area under the receiver operator characteristic curve (AUC) 0.68. At the MTP joints, the sensitivity was 54%, specificity 74%, LR+ 2.1, LR- 0.6 and AUC 0.64. With MRI-detected inflammation as outcome, the sensitivity and specificity were 39% and 86% and 31% and 69% for the test at the MCP and MTP joints, respectively. CONCLUSIONS: A positive squeeze test is associated with local joint inflammation but the sensitivity is low, indicating a high percentage of swollen joints with a negative squeeze test. When the test is used on its own, it is insufficient to detect early arthritis.

Biopsy-proven recurrence of unilateral IgG4-related orbital inflammation after 20 years.

A 38-year-old female patient presented with a painful swelling in the lateral part of the upper eyelid, a diffuse scleritis and slight hypoglobus of the right eye. An orbital biopsy showed a fibrotic idiopathic orbital inflammation (IOI) with, on immunohistochemical staining, an increased number of IgG4-positive plasma cells scored as >200 per high-power field, with IgG4/IgG ratio >0.50, indicating orbital IgG4 related autoimmune disease. On treatment with oral prednisone and azathioprine the symptoms resolved within 6 months. Twenty years prior, the patient had been diagnosed with an IOI of at the same side, for which at that time a biopsy had been taken similarly. Reclassification of the previous biopsy specimen with immunohistological staining also showed evidence of orbital IgG4 related disease. To our knowledge this is the first report of a biopsy-proven unilateral IgG4-related orbitopathy that recurred after 20 years.

PDGF enhances orbital fibroblast responses to TSHR stimulating autoantibodies in Graves' ophthalmopathy patients.

PURPOSE: Thyroid-stimulating hormone receptor (TSHR) stimulating autoantibodies are associated with Graves' ophthalmopathy (GO), the orbital manifestation of Graves' disease (GD). TSHR autoantibody levels and orbital TSHR expression levels correlate positively with GO disease activity. Platelet-derived growth factors (PDGF) are increased in GO and potently activate orbital fibroblast effector functions. We investigated the possible relationship between PDGF and TSHR expression on orbital fibroblasts and how that influences the immunopathological effects of TSHR autoantibodies on orbital fibroblast activity. METHODS: Orbital fibroblasts were stimulated with PDGF-AA, PDGF-AB, and PDGF-BB, and TSHR expression was determined by flow cytometry. Stimulatory effects of bovine TSH and GD immunoglobulins on orbital fibroblasts (with or without PDGF-BB preincubation) were determined by IL-6, IL-8, chemokine (C-C motif) ligand (CCL)-2, CCL5, CCL7, and hyaluronan ELISA. The TSHR blocking antibody K1-70 and the cAMP inhibitor H89 were used to determine involvement of TSHR signaling. RESULTS: PDGF-AB and PDGF-BB stimulation increased TSHR expression on orbital fibroblasts, whereas PDGF-AA did not. Furthermore, stimulation with bovine TSH and immunoglobulins from GD patients induced IL-6, IL-8, CCL2, and hyaluronan production by orbital fibroblasts, and PDGF-BB preincubation enhanced this response of orbital fibroblasts. Blocking studies with a TSHR blocking antibody and a cAMP inhibitor inhibited these effects, indicating the involvement of TSHR signaling and thus of TSHR stimulating autoantibodies herein. CONCLUSIONS: These findings indicate that PDGF-B containing PDGF isoforms amplify the immunopathological effects of TSHR-stimulating autoantibodies in GO patients by stimulating TSHR expression on orbital fibroblasts.

Orbit-infiltrating mast cells, monocytes, and macrophages produce PDGF isoforms that orchestrate orbital fibroblast activation in Graves' ophthalmopathy.

PURPOSE: Platelet-derived growth factors (PDGF) are regulators of fibroblast activity that may be involved in the pathophysiology of Graves' ophthalmopathy (GO). We unraveled the expression and origin of PDGF family members in GO orbital tissue and investigated the effect of PDGF isoforms on IL-6 and hyaluronan production and proliferation by orbital fibroblasts. METHODS: PDGF-A, PDGF-B, PDGF-C, PDGF-D, PDGF-Rα, and PDGF-Rß expression was determined by real-time quantitative PCR and PDGF-A and PDGF-B protein expression was determined by Western blot in orbital tissues. Orbital tissues were immunohistochemically stained for PDGF-A and PDGF-B expression, together with stainings for T cells, monocytes, B cells, macrophages, and mast cells. Effects of PDGF-AA, PDGF-AB, and PDGF-BB on orbital fibroblast proliferation and IL-6 and hyaluronan production were examined. Finally, effects of PDGF-BB- and PDGF-AA-neutralizing antibodies on IL-6 and hyaluronan production in GO whole orbital tissue cultures were tested. RESULTS: GO orbital tissue showed increased PDGF-A and PDGF-B mRNA and protein levels. Increased numbers of PDGF-A- and PDGF-B-positive monocytes, macrophages, and mast cells were present in GO orbital tissue. PDGF-BB stimulated proliferation and hyaluronan and IL-6 production by orbital fibroblasts the most, followed by PDGF-AB and PDGF-AA. Finally, in particular imatinib mesylate and PDGF-BB-neutralizing antibodies reduced IL-6 and hyaluronan production by whole orbital tissue cultures from GO patients. CONCLUSIONS: In GO, mast cells, monocytes, and macrophages may activate orbital fibroblasts via secretion of especially PDGF-AB and PDGF-BB. Preclinical studies with whole orbital tissue cultures show that blocking PDGF-B chain containing isoforms can be a promising treatment for GO.

[Orbital metastases of breast cancer. Radiologic features]. / Mammakarzinommetastasen der Orbita. Radiologische Eigenschaften.

BACKGROUND: We reviewed the radiologic features of 15 patients with orbital metastases originating from breast cancer. METHODS: This was a retrospective consecutive case series. Fifteen consecutive patients with orbital metastases originating from breast carcinoma were identified between March 1997 and September 2008. A retrospective chart review was carried out, and the radiologic findings were reviewed. RESULTS: The metastases were preseptal in 53%, intraconal in 60%, and both intraconal and extraconal in 33%. Lacrimal gland enlargement was noted in 33%, episcleral space involvement in 33%, bone involvement in 13%, and globe dystopia in 53%. The extraocular muscles were involved in 87%; in 60%, two or more muscles were involved. The medial and lateral rectus muscles were affected in 53% and 47%, respectively, and the inferior and superior rectus muscles in 33%. In 47% one or more radiologic features had not been noted by the radiologist, and in 20% the findings were misinterpreted as an"orbital pseudotumor." CONCLUSION: Orbital metastases originating from breast cancer may present heterogeneously. Orbital imaging most commonly shows unilateral and multifocal involvement of multiple extraocular muscles and intraconal and preseptal areas by an irregular lesion.

Is physician-diagnosed allergic rhinitis a risk factor for the development of asthma?

BACKGROUND: There is strong evidence that there is a relationship between allergic rhinitis (AR) and asthma, but it is unclear whether there is a causal relation between AR and asthma. The aim of this study was to assess prospectively whether AR is a risk factor for the diagnosis of asthma in a large primary care population. METHODS: We performed a historic cohort study of life-time morbidity that had been recorded prospectively since 1967 in four general practices. Two groups of subjects were selected: (i) patients with diagnosis of AR, (ii) a control group matched using propensity scores. We assessed the risk of physician-diagnosed asthma in patients with physician-diagnosed AR compared to subjects without a diagnosis of AR (controls). RESULTS: The study population consisted of 6491 subjects (n = 2081 patients with AR). Average study follow-up was 8.4 years. In patients with AR, the frequency of newly diagnosed asthma was 7.6% (n = 158) compared to 1.6% (n = 70) in controls (P < 0.001). After adjusting the effect of AR on asthma diagnosis for registration time, age, gender, eczema and socioeconomic status, having AR was a statistically significant risk factor for asthma (hazard ratio: 4.86, P < 0.001, 95% confidence interval: 3.50-6.73, controls as reference). CONCLUSION: A diagnosis of AR was an independent risk factor for asthma in our primary care study population. Having physician-diagnosed AR increased the risk almost fivefold for a future asthma diagnosis.

[Telephone accessibility of Dutch general practices: improvements can be made, but will not fully solve the problem]. / Telefonische bereikbaarheid van huisartsen: verbetering mogelijk, maar probleem niet geheel oplosbaar.

The Dutch Health Inspectorate published a research report on the accessibility by telephone of Dutch general practices. A large proportion of Dutch GPs have not organized their practices according to standard norms as far as accessibility by telephone is concerned. Several developments can explain this substandard accessibility, such as an increasing number of telephone calls and changes in staff practice routine. Technical solutions such as voice response systems or more incoming lines cannot resolve all the problems. More information on the accessibility for patients, smarter systems for repeat prescriptions and the use of email could improve the situation. The development of best practices and research into the efficacy of the proposed solutions is necessary.

[The effect of specialised medical procedures on the hosptial standardised mortality ratio in cardiac centers]. / Hartcentra en het effect van bijzondere medische verrichtingen op het gestandaardiseerde ziekenhuissterftecijfer.

OBJECTIVE: To examine the impact of specialised medical procedures (SMPs) on the hospital standardized mortality ratio (HSMR) in Dutch cardiac centres. DESIGN: Retrospective, calculation of the HSMR. METHOD: Data from 2004 from the National Medical Registration (LMR) were used to calculate the HSMR in 12 cardiac centres and all other hospitals in the Netherlands. The HSMRwas then recalculated for the 12 cardiac centres excluding either percutaneous transluminal coronary angioplasty (PTCA) or open heart surgery or both to determine the impact of these SMPs on the HSMR. RESULTS: Exclusion of SMPs from the HSMR calculation changed the HSMR for individual cardiac centres, ranging from a 4.7% decrease to a 5.3% increase. Change in HSMR was related to the relative frequency of the two procedures at each cardiac centre. Mortality risk was lower than average for PTCA and higher than average for open heart surgery. PTCA accounted for 5.6%-20.2% of total admissions in the 12 cardiac centres. A relatively high proportion of PTCA procedures was associated with a lower HSMR, to a maximum decrease of nearly 7% in one cardiac centre. Open heart surgery accounted for 2.1%-12.6% of total admissions per cardiac centre. A relatively high proportion ofopen heart procedures was associated with an increased HSMR, to a maximum increase of nearly 8% in one cardiac centre. CONCLUSION: Specialised medical procedures for heart conditions influence the HSMR of cardiac centres. The increase or decrease in HSMR is related to the relative frequency of PTCA and open heart surgery. These results can be used to help interpret the differences in HSMR among cardiac centres and other hospitals.

Out-of-hours primary care: development of indicators for prescribing and referring.

BACKGROUND: Dutch general practitioners have reorganized their out-of-hours primary health care to general practice cooperatives. Good insight into the quality of delivered medical care is important to make the accountability of health practitioners and managers transparent to society and to identify and minimize medical errors. OBJECTIVE: Development of a set of quality indicators for internal quality improvement in out-of-hours primary clinical care. METHOD: A systematic approach combining the opinion of three different general practitioner expert panels, and an empirical test in daily practice. The indicators were based on clinical, evidence-based, national guidelines. We tested the validity, feasibility, reliability and opportunity for quality improvement. RESULTS: Of the 80 available national clinical guidelines, 29 were approved and selected by the first general practitioner expert panel. Out of these 29 guidelines, 73 indicators concerning prescribing and referring were selected by the second panel. In an empirical test on 36 254 patient contacts, 7344 patient contacts (22.7%) were relevant for the assessment of these 73 indicators. Six indicators were excluded because they scored more than 15% missing values. In total, 38 indicators were excluded because the opportunity for quality improvement was limited (performance score > or =90%). In the final meeting, the third general practitioner expert panel excluded five indicators, leading to a final set of 24 indicators. CONCLUSION: This study shows the importance of subjecting indicators to an empirical test in practice. The national clinical guidelines are only partially applicable in the assessment of out-of-hours primary care. They need to be expanded with topics that are related to general practitioner care in an out-of-hours setting and acute medical problems.

Clinical databases in physical therapy.

Clinical databases in physical therapy provide increasing opportunities for research into physical therapy theory and practice. At present, information on the characteristics of existing databases is lacking. The purpose of this study was to identify clinical databases in which physical therapists record data on their patients and treatments and to investigate the basic aspects, data sets, output, management, and data quality of the databases. Identification of the databases was performed by contacting members of the World Confederation for Physical Therapy, searching Pubmed, searching the Internet, and snowball sampling. A structured questionnaire was used to study the characteristics of the databases. The search was restricted to North America, Australia, Israel, and Western Europe. Seven clinical databases on physical therapy were identified. Four databases collected data on specific patient categories, whereas the others collected data on all patients. All databases collected data on patient characteristics, referrals, diagnoses, treatments, and closure, whereas some databases also collected functional status information. The purposes of the databases were diverse, but they can be summarized as quality improvement, research, and performance management. Although clinical databases are new to the field, they offer great potential for physical therapy research. Potential can be increased by further cooperation among databases allowing international comparative studies.

[The practice guideline 'Problematic alcohol consumption' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Problematisch alcoholgebruik' (tweede herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The recently revised version of the practice guideline 'Problematic alcohol consumption' from the Dutch College of General Practitioners offers realistic advice to general practitioners on how to manage problem drinkers. The number of patients with alcohol problems tends to increase among women of middle age. The proportion of patients that report an alcohol problem themselves is larger than is usually assumed. Questionnaires are oflimited value in the detection of an alcohol problem. The general practitioner should look at problem drinking as a chronic disease that demands structured disease management and monitoring. This perspective will lead to less frustration in handling both the problem and the patients.

[Prevalence of urinary and faecal incontinence among community-dwelling elderly patients in Nijmegen, The Netherlands, January 1999-July 2001]. / Prevalentie van incontinentie voor urine en ontlasting bij zelfstandig wonende ouderen in Nijmegen, januari 1999-juli 2001.

OBJECTIVE: To evaluate the prevalence of urinary, faecal and double incontinence in community-dwelling elderly patients. DESIGN: Cross-sectional population-based survey. METHOD: By means of a postal questionnaire, data were collected in the period January 1999-July 2001 from patients aged 60 and over from 9 general practices associated with the academic general practitioner registration network of the St Radboud University Medical Centre (the Nijmegen Monitoring Project). Excluded were patients living in a home for the elderly, as well as patients with dementia, patients who were too ill to participate and patients with a catheter. RESULTS: Of the 5278 patients who received a questionnaire, 4650 (88%) returned it. 885 (19%) respondents had involuntary loss of urine twice a month or more, 299 (6%) had involuntary loss of faeces and 153 (3%) had both. The prevalence of urinary, faecal and double incontinence increased with age in both men and women, in men especially in the age group > 80 years. Urinary incontinence was more prevalent in women (29%) than in men (9%). The prevalence of faecal incontinence showed no sex differences (women: 6%; men: 7%), but the loss of slimy faeces occurred twice as often in men as in women (60% versus 29%). Double incontinence was also more or less equally prevalent in men and women (men: 2%; women: 4%), except in the age group 65-74 years (men: 1%; women: 4%). CONCLUSION: Especially urinary, but also faecal incontinence was common in the community-dwelling elderly. The prevalence increased with age. Because of ageing of the population and the increasing life expectancy in the next decennia, the prevalence of incontinence can be expected to increase considerably.

Patients either contacting a general practice cooperative or accident and emergency department out of hours: a comparison.

INTRODUCTION: Lack of collaboration between general practice (GP) cooperatives and accident and emergency (A&E) departments and many self referrals may lead to inefficient out-of-hours care. METHODS: We retrospectively analysed the records of all patients contacting the GP cooperative and all patients self referring to the A&E department out of hours in a region in the Netherlands. RESULTS: 258 patients contacted the GP cooperative and 43 self referred to the A&E department per 1000 patients per year. A wide range of problems were seen in the GP cooperative, mainly related to infections (26.2%). The A&E department had a smaller range of problems, mainly related to trauma (66.1%). Relatively few urgent problems were seen in the GP cooperative (4.6%) or for self referrals in the A&E department (6.1%). Women, children, the elderly, and rural patients chose the GP cooperative significantly more often, as did men and patients with less urgent complaints, infections, and heart and airway problems. DISCUSSION: The contact frequency of self referrals to the A&E department is much lower than that at the GP cooperative. Care is complementary: the A&E department focuses on trauma while the GP cooperative deals with a wide range of problems. The self referrals concern mostly minor, non-urgent problems and can generally be treated by the general practitioner, by a nurse, or by advice over the telephone, particularly in the case of optimal collaboration in an integrated care facility of GP cooperatives and A&E departments with one access point to medical care for all patients.

[Giant mucocele of all paranasal sinuses with massive bilateral globe displacement]. / Riesen-Mukozele der Nasennebenhöhlen mit bilateraler Bulbusverlagerung.

Although of benign nature and slowly progressive, paranasal sinus mucoceles may, depending on their localization, cause a multitude of ophthalmological symptoms due to compression and displacement of adjacent tissue. Here we report the unusual case of a patient suffering from a progressively growing giant mucocele that developed years after ENT surgery and that was neglected for almost 2 decades despite massive symptoms. This case report demonstrates the importance of including mucoceles of the paranasal sinuses into the differential diagnosis of unilateral or bilateral proptosis.

Efficacy and side effects of 'swinging eyelid' orbital decompression in Graves' orbitopathy: a proposal for standardized evaluation of diplopia.

OBJECTIVES: To evaluate the efficacy and side effects of 'swinging eyelid' orbital decompression in patients with Graves' orbitopathy (GO). To calculate the incidence of postoperative new-onset diplopia (NOD) using a newly proposed scoring system for diplopia. METHODS: We reviewed the clinical data on proptosis, visual acuity, and diplopia in 104 consecutive patients (198 orbits) with GO, who underwent orbital decompression. A combined lateral canthal and inferior fornix incision ('swinging eyelid' approach) was used for removal of the medial wall, the orbital floor and, if indicated, the lateral wall. Indications for surgery were disfiguring/congestive GO (DGO) in 79 patients (149 orbits) and compressive optic neuropathy (CON) in 25 patients (49 orbits). Diplopia was scored according to four grades. In both groups, the incidence of new-onset (continuous) diplopia (NOD), deterioration of diplopia (DOD), and improvement of diplopia (IOD) were calculated, using strictly defined criteria. Our data on NOD were compared to those from other series, after recalculation according to our criteria. RESULTS: The mean proptosis reduction was 4.6 mm (range 0-9.5 mm) after three-wall decompression (95 patients, 180 orbits) vs 3.1 mm (range 0-7 mm) after two-wall decompression (nine patients, 18 orbits). The visual acuity improved in 98% of the patients with CON. In patients with DGO, NOD occurred in 14%. In patients with CON, NOD was not observed, but DOD occurred in 41%. Our data compare favourably to the reported incidence of NOD after either transantral or transnasal decompression. CONCLUSIONS: "Swinging eyelid' orbital decompression is efficacious for proptosis reduction as well as for optic nerve decompression. A scoring system for standardized evaluation of diplopia is proposed.