Telephone consultation in palliative care for cancer patients: 5 years of experience in The Netherlands.

GOALS OF WORK: To analyze cancer patient-related consultations of a telephone helpdesk (TH) for palliative care over a period of 5 years in the region of Utrecht, The Netherlands. MATERIALS AND METHODS: A descriptive analysis was performed of consultations over a period of 5 years (2001-2006). The discipline and location of requesting professionals, patient characteristics, reasons for calling, symptoms, palliative care problems and needs for support were registered. MAIN RESULTS: A total of 1,794 consultations were analyzed. There was an increasing number of consultations during the study period. Of the patients, 51% were male and their median age was 65 years (range 0-104). Eighty-four percent were treated at home by their general practitioner. Two thirds of the patients had a life expectancy <4 weeks. Most questions referred to pain (49%), delirium (20%), nausea and vomiting (16%) and dyspnea (12%). The median number of symptoms was 1 (0-6). Of the questions, 54% were related to pharmacological problems, 19% to psychological problems and 21% to the organization of care. Of the requesting professionals, 17% asked for support for themselves. Of the consultations, 14% were related to end-of-life issues: palliative sedation (11%) and euthanasia (3%). CONCLUSION: After more than 5 years, the 24-h telephone consultation service fulfills a need for general practitioners dealing with daily dilemmas in palliative care treatment for cancer patients at home during the last period of their life.

Psychiatric comorbidity among hepatitis C-positive patients.

This study assessed the prevalence of psychiatric disorders among hepatitis C patients at a Veterans Affairs Medical Center. Medical records of 306 randomly selected hepatitis C-positive patients were reviewed for past and present DSM-IV-based psychiatric disorders. Each psychiatric diagnosis was independently confirmed with DSM-IV criteria using symptoms recorded in the chart. Only independently confirmed diagnoses were included for analysis. Mood disorders were present in 38% of patients; personality disorders in 30%; PTSD in 19%; other anxiety disorders in 9%; and psychotic disorders in 17%. Although alcohol use disorders were found in 86% of this patient population, intravenous drug use disorders were present in only 28%. Our data indicate that prevalence rates of a variety of psychiatric disorders are higher in veterans with hepatitis C than in the general population. Mood, anxiety, personality, and psychotic disorders were all relatively common in these patients. Psychiatric disorders may influence the course and treatment of hepatitis C infection, and psychiatrists as well as internists should be aware of the substantial psychiatric comorbidity in patients with this infection.

Integration of care in The Netherlands: the development of transmural care since 1994.

BACKGROUND: integration of primary and hospital services has been the subject of health policy in The Netherlands in the 1990s. A bottom-up facilitating approach was chosen to stimulate development of 'transmural care' between traditionally separate sectors. Transmural care has been defined as, care, attuned to the needs of the patient, provided on the basis of co-operation and co-ordination between general and specialised caregivers with shared overall responsibility and the specification of delegated responsibilities'. We conducted a national survey to determine the success of the bottom-up policy and the extent of the development of transmural care. METHODS: a written questionnaire was distributed among members of two national networks of transmural care executives and project coordinators, which are representative for hospitals and home care organisations in The Netherlands. A total of 271 facilities were included in the study representing 71% of hospitals and 63% of the home care organisations in The Netherlands. The questionnaire covered topics as; type of care provided, participants, population, goals and type of evaluation. RESULTS: all hospitals in The Netherlands provide one or more of the seven types of transmural care, however, there is a great variation in the number of facilities per organisation. Most facilities cater to one or more groups of chronically ill patients. Project coordinators experience difficulties finding adequate financing options for the facilities. Evidence on the effects of transmural care on quality and efficiency is lacking. CONCLUSION: the bottom-up approach towards the development of transmural care has been successful but needs to be followed by top-down measures to insure adequate evaluation and encourage wide-spread implementation.

A Hill type model of rat medial gastrocnemius muscle that accounts for shortening history effects.

The aim of the present study was to develop a Hill type muscle model that accounts for the effects of shortening history. For this purpose, a function was derived that relates force depression to starting length, shortening amplitude and contraction velocity. History parameters were determined from short-range isokinetic experiments on rat medial gastrocnemius muscle (GM). Simulations of isokinetic as well as isotonic experiments were performed with the new model and a standard Hill type model. The simulation results were compared with experimental results of rat GM to evaluate if incorporation of history effects leads to improvements in model predictions. In agreement with the experimental results, the new model qualitatively described force reduction during and after isokinetic shortening as well as the experimental observation that isometric endpoints of isotonic contractions are attained at higher muscle lengths than is expected from the fully isometric length-force curve. Consequently, the new model gave a better quantitative prediction of the experimental results compared to the standard model. It was concluded that incorporation of history effects can improve the predictive power of a Hill type model considerably. The applicability of the model to conditions other than those described in the present paper is discussed.

Modelling functional effects of muscle geometry.

Muscle architecture is an important aspect of muscle functioning. Hence, geometry and material properties of muscle have great influence on the force-length characteristics of muscle. We compared experimental results for the gastrocnemius medialis muscle (GM) of the rat to model results of simple geometric models such as a planimetric model and three-dimensional versions of this model. The capabilities of such models to adequately calculate muscle geometry and force-length characteristics were investigated. The planimetric model with elastic aponeurosis predicted GM muscle geometry well: maximal differences are 6, 1, 4 and 6% for fiber length, aponeurosis length, fiber angle and aponeurosis angle respectively. A slanted cylinder model with circular fiber cross-section did not predict muscle geometry as well as the planimetric model, whereas the geometry results of a second slanted cylinder model were identical to the planimetric model. It is concluded that the planimetric model is capable of adequately calculating the muscle geometry over the muscle length range studied. However, for modelling of force-length characteristics more complex models are needed, as none of the models yielded results sufficiently close to experimental data. Modelled force-length characteristics showed an overestimation of muscle optimum length by 2 mm with respect to experimental data, and the force at the ascending limb of the length force curve was underestimated. The models presented neglect important aspects such as non-linear geometry of muscle, certain passive material properties and mechanical interactions of fibers. These aspects may be responsible for short-comings in the modelling. It is argued that, considering the inability to adequately model muscle length-force characteristics for an isolated maximally activated (in situ) muscle, it is to be expected that prediction will fail for muscle properties in conditions of complex movement with many interacting factors. Therefore, modelling goals should be limited to the heuristic domain rather than expect to be able to predict or even approach medical or biological reality. However, the increased understanding about muscular mechanisms obtained from heuristic use of such simple models may very well be used in creating progress in, for example, clinical applications.

Revised planimetric model of unipennate skeletal muscle: a mechanical approach.

OBJECTIVE: Planimetric models which are simple, in the sense that small numerical effort is needed, are used to study functional consequences of skeletal muscle architecture. This paper argues with the approach to derive force of a unipennate muscle based on only equilibrium of the aponeurosis (tendon-sheet). In such an approach intramuscular pressure gradients are neglected and no suitable aponeurosis force can be determined. METHOD: The approach presented in this paper is based on mechanical equilibrium of whole muscle. A volume-related force is introduced to keep muscle volume constant. Mechanical equilibrium of whole muscle yields a different relation between fiber and muscle force as well as length changes as a consequence of pennation, compared with relations derived when only equilibrium of aponeurosis is considered. RESULTS: The newly derived relation improved prediction of the rat gastrocnemius medialis muscle force-length characteristics. CONCLUSION: The prediction of muscle geometry and the prediction of force-length characteristics are very good with a simple model such as a planimetric model. This conclusion suggests that the influence of properties neglected in such a simple model are either small or are internally compensated for in the net effects.

Impact of Helicobacter pylori colonization on immunoreactive epidermal growth factor and transforming growth factor-alpha in gastric juice. Its potential pathogenetic implications.

Epidermal growth factor (EGF), pivotal in mucosal protection, is partly degraded proteolytically at low pH in the gastric milieu; gastric acid secretion, on the other hand, remains influenced by H. pylori colonization. The aim of this study, therefore, was to evaluate the impact of low pH and H. pylori colonization status on immunoreactive EGF and the other member of EGF-family, immunoreactive transforming growth factor-alpha (TGF-alpha). Eighteen patients with nonulcer dyspepsia (NUD) colonized by H. pylori and 55 NUD patients without H. pylori colonization were investigated. Gastric juice samples were aspirated at the beginning of the endoscopy procedure and immediately placed on ice, and their pH was recorded. The measurement of immunoreactive EGF and TGF-alpha was performed using commercially available radioimmunoassays (RIAs) after adjustment of pH to neutral using an assay buffer. Statistical analysis was performed using sigma-Stat for Windows. The concentration of immunoreactive EGF in patients with NUD colonized by H. pylori was 80% lower (P < 0.02) than in those without H. pylori and in both groups immunoreactive EGF was significantly lower when the pH of gastric juice was below 4.0. The concentration of immunoreactive EGF in H. pylori(+) and H. pylori(-) patients was similar when the pH of aspirated gastric juice was above 4.0. However, with gastric juice pH < 4.0, the EGF concentration was 64% lower in H. pylori(+) patients than H. pylori(-) patients (P < 0.05). In general, the concentration of immunoreactive TGF-alpha in gastric juice was unaffected by H. pylori colonization or pH of gastric juice. It is concluded that: (1) significantly lower immunoreactive EGF concentrations in patients with pH below 4.0 indicate that immunoreactive EGF but not immunoreactive TGF-alpha is affected by an acidic gastric milieu; (2) the further reduction of gastric juice immunoreactive EGF at pH below 4.0 in patients colonized by H. pylori suggests that this microorganism may elaborate factors that accelerate its proteolytic degradation or inhibit its rate of synthesis and/or secretion; and (3) this diminished content of immunoreactive EGF at low pH, especially in patients colonized by H. pylori, may facilitate the development and/or progression of mucosal damage.

Quality, costs and cultural beliefs in outpatient treatment with parenteral antibiotics: a comment.

The introduction of outpatient parenteral antibiotic therapy (OPAT) will change the concepts of a hospital and of primary health care. When it is guaranteed by a number of general quality conditions, and short-term transformation costs are left aside, it has a good chance of developing in cities where distances between patient's homes and hospitals are shorter. Cultural beliefs of health care providers in hospitals and in primary health care are an important barrier for the introduction of OPAT. Perhaps countries with hospital-oriented health care systems (Germany, Sweden, USA) will start earlier with OPAT than countries with a strong and independent primary health-care system (the UK, Finland and The Netherlands). On the other hand, the last three countries are better equipped to integrate OPAT into other types of home health service.

[Persistent cystitis in a male cat]. / Persisterende cystitis bij een kater.

The case of a male cat with persistent cystitis is reported. Microscopy of the urine revealed the presence of eggs of Capillaria. The clinical picture and treatment are discussed.