Transcutaneous electromyography as a tool to assess recovery of hemidiaphragmatic paresis: A case report.

In this case report, we describe two repeated transcutaneous electromyography of the diaphragm (dEMG) measurements in an infant with suspected paresis of the right hemidiaphragm after cardiac surgery. The first measurement, performed at the time of diagnosis, showed a lower electrical activity of the right side of the diaphragm in comparison with the left side. The second measurement, performed after a period of expectative management, showed that electrical activity of the affected side had increased and was similar to the activity of the left diaphragm. This finding was accompanied by an improvement in the clinical condition. In conclusion, repeated measurement of diaphragmatic activity using transcutaneous dEMG enables the observation and quantification of spontaneous recovery over time. This information may assist the clinician in identifying patients not responding to expectative management and in determining the optimal timing of diaphragmatic surgery.

Clinical use of cold atmospheric pressure argon plasma in chronic leg ulcers: A pilot study.

OBJECTIVE: In the age of multiresistant microbes and the increasing lack of efficient antibiotics, conventional antiseptics play a critical role in the prevention and therapy of wound infections. Recent studies have demonstrated the antiseptic effects of cold atmospheric pressure plasma (APP). In this pilot, study we investigate the overall suitability of one of the first APP sources for wound treatment focusing on its potential antimicrobial effects. METHOD: The wound closure rate and the bacterial colonisation of the wounds were investigated. Patients suffering from chronic leg ulcers were treated in a clinical controlled monocentric trial with either APP or octenidine (OCT). In patients who presented with more than one ulceration in different locations, one was treated with APP and the other one with OCT. Each group was treated three times a week over a period of two weeks. The antimicrobial efficacy was evaluated immediately after and following two weeks of treatment. RESULTS: Wounds treated with OCT showed a significantly higher microbial reduction (64%) compared to wounds treated with APP (47%) immediately after the treatment. Over two weeks of antiseptic treatment the bacterial density was reduced within the OCT group (-35%) compared to a slight increase in bacterial density in the APP-treated group (+12%). Clinically, there were no signs of delayed wound healing observed in either group and both treatments were well tolerated. CONCLUSION: The immediate antimicrobial effects of the APP prototype source were almost comparable to OCT without any signs of cytotoxicity. This pilot study is limited by current configurations of the plasma source, where the narrow plasma beam made it difficult to cover larger wound surface areas and in order to avoid untreated areas of the wound bed, smaller wounds were assigned to the APP-treatment group. This limits the significance of AAP-related effects on the wound healing dynamics, as smaller wounds tend to heal faster than larger wounds. However, clinical wound healing studies on a larger scale now seem justifiable. A more advanced plasma source prototype allowing the treatment of larger wounds will address APP's influence on healing dynamics, synergetic treatment with current antiseptics and effects on multiresistant bacteria.

Rheumatology outpatient nurse clinics: a valuable addition?

OBJECTIVES: "Transmural rheumatology nurse clinics," where nursing care is provided under the joint responsibility of a home care organization and a hospital, were recently introduced into Dutch health care. This article gives insight into outcomes of the transmural rheumatology nurse clinics. METHODS: Patients with rheumatologic conditions who attended a transmural nurse clinic, in addition to receiving regular care, were compared with patients with rheumatologic conditions who received regular care only. The main outcome measures were the need for rheumatology-related information, the use of aids and adaptations, the use of health care services, and daily functioning. RESULTS: Attending a transmural nurse clinic does not influence patients' need for information, the application of practical aids and adaptations, or daily functioning. However, attending a transmural nurse clinic does result in more contacts with rheumatologists and occupational therapists. CONCLUSIONS: Attending transmural nurse clinics does not result in major differences in outcomes compared with regular care. Further studies are needed to appreciate the long-term effects of transmural nurse clinics.

Content and outcomes of Dutch nurse clinics for children with asthma.

Dutch specialist asthma nurses run extramural and transmural nurse clinics for children with asthma. Extramural clinics are run under the responsibility and in the premises of a home care organization. Transmural clinics are run in an outpatient clinic in close collaboration and joint responsibility between home care organizations and hospitals. Effects of and differences between these clinics were determined by using a quasiexperimental design. Visiting a nurse clinic appears to result in a reduced information need and reduced use of health care services. Parents of asthmatic children visiting transmural nurse clinics appeared to have a lower information need than those attending extramural nurse clinics.

Liaison nursing for stroke patients: results of a Dutch evaluation study.

Liaison nurses, employed by a home care organization, were introduced into two Dutch hospitals to improve discharge planning for stroke patients. The main aim of the study presented was to gain insight into the effects of liaison nursing on the quality of the discharge process and related outcomes. After the introduction of liaison nursing, hospital nurses completed a questionnaire on satisfaction with the liaison nurse. In addition, both before and after the introduction of liaison nursing, two groups of discharged stroke patients were interviewed by telephone. The records of these patients were also studied with respect to background characteristics and duration of hospital stays. The hospital nurses were, generally, positive about the liaison nurse and the job she did (e.g. they found that home care was better organized). Further, after the introduction of liaison nursing, more patients stated that their post-discharge needs had been discussed not later than 48 hours prior to discharge, and more patients said their aftercare had been discussed with community nurses. However, the number of patients whose medication had arrived at home on time had decreased. The results also indicated that there was no significant difference in the duration of stay between the before and after group. The overall conclusion is that the liaison nurses have been moderately successful in their jobs. However, since the study was conducted in only two Dutch hospitals, findings may not be representative of other settings. Future research on liaison nursing is therefore recommended.

Quality and continuity of care in Dutch nurse clinics for people with rheumatic diseases.

OBJECTIVE: Recently a new form of nurse clinic for people with rheumatic diseases has been introduced into Dutch health care. This study gives insight into: (i) patients' perceptions about the quality and continuity of care given at these (transmural) nurse clinics; and (ii) specialized rheumatology nurses' and rheumatologists' perceptions about the quality and continuity of care in the clinics. DESIGN: Validated measurement tools (QUOTE and QCC) were used, before and after patients visited a clinic, to determine patient perceptions about the quality and continuity of care. Semi-structured interviews with professionals were used to gather information about their perceptions. SETTING: The study was carried out at five locations in The Netherlands where a home care organization and a general hospital collaborated closely and had joint responsibility for a transmural rheumatology nurse clinic. STUDY PARTICIPANTS: A total of 128 patients, six specialist rheumatology nurses and four rheumatologists. INTERVENTION: Transmural nurse clinics for people with rheumatic diseases. RESULTS: In general, patients were positive about the quality and continuity of care given at the clinics. Some continuity aspects, like the presence of a locum nurse and providing the locum with sufficient information could be improved. Professionals were positive about the information given at the clinics, which is additional to the information given by a rheumatologist. Professionals were less positive about some of the clinics' preconditions. CONCLUSION: In this study, a control group (e.g. patients who received standard rheumatologist care) was not available. However, in comparison with patients' experiences of standard medical care in other (comparable) research, patients' experiences in this study were very positive. It was concluded that Dutch transmural nurse clinics, to a large extent, meet patients' and professionals' expectations and were a positive development in the care of rheumatic patients.

Innovations in the nursing care of the chronically ill: a literature review from an international perspective.

This literature review focuses on substitution-related innovations in the nursing care of chronic patients in six western industrialized countries. Differences between primary and secondary care-orientated countries in the kind of innovations implemented are discussed. Health care systems are increasingly being confronted with chronic patients who need complex interventions tailored to their individual needs. However, it seems that today's health care professionals, organizations and budgets are not sufficiently prepared to provide this kind of care. As a result, health care policy in many countries targets innovations which reduce health care costs and, at the same time, improve the quality of care. Frequently, these innovations are related directly to the 'substitution of care' phenomenon, in which care is provided by the most appropriate professional at the lowest cost level, and encompass advanced nursing practice, hospital-at-home care and integrated care. The main conclusion of this paper is that integrated care innovations are implemented in both primary care as well as in secondary care-orientated countries. However, innovations in hospital-at-home care and advanced nursing practice are primarily implemented in primary care-orientated countries. Whether these innovations positively influence the quality of care, costs of care or patients' use of health care facilities remains rather unclear.

Dutch nurse clinics for children with asthma: views of professionals and parents.

In the Netherlands, there are two kinds of nurse clinics for asthmatics. Extramural nurse clinics are run under the sole responsibility of a home care organization while transmural nurse clinics are run under the joint responsibility of a home care organization and a hospital. This article gives insight into the opinions of professionals and parents of asthmatic children about the care given at these clinics. The conclusion is that organizational differences between the clinics do not influence parents' (positive) perceptions about the quality and continuity of care provided at the clinics.

Organization and financing of home nursing in the European Union.

The aim of this study was to provide an overview of the organization and financing of home nursing in the 15 member states in the European Union. Home nursing was defined as the nursing care provided at the patients' home by professional home nursing organizations. Data were gathered by means of three complementary research methods: desk research, postal questionnaire among identified experts and face-to-face interviews with experts. The results showed that there are large differences between the countries in the way home nursing care is financed. There seems to be a relation between the way of funding and the organizational structure. In member states where the organizations receive a fixed budget, based on the number of inhabitants or the demography of the catchment area, home nursing is mainly provided by one type of organization and is freely accessible for the patients. In this situation there is little competition among the organizations, and the catchment areas of the regional organizations do not tend to overlap. On the other hand, in countries where organizations are reimbursed according to a fee-for-service principle and a referral of a doctor is required, home nursing is provided by different types of organizations and also by independent nurses. It seems that fee-for-service reimbursement stimulates competition between providers and a market-oriented home care. In addition, a fee-for-service method of funding also has the consequence that mainly technical nursing procedures and some basic care are reimbursed; this leaves little room for nurses to perform preventive and psychosocial activities or to provide more integrated care.

Complications and side effects: a problem in general practice?

On basis of secondary analysis of data obtained from the 'Dutch National Survey of Morbidity and Intervention in General Practice', we tried to gain insight into the nature and extent of iatrogenic illnesses in general practice. In this registration project 386,000 contacts of patients with 161 GP's have been recorded, using the International Classification of Primary Care (ICPC). We confined ourselves to 'side effects of medication' and 'complications of medical treatment'. It appears that in two percent of all contacts the GP has made one of these two diagnoses, or has considered these. On average, the patients concerned suffered twice more often serious invalidating or danger of life.Herewith these two groups of iatrogenic harm constitute an important problem in general practice.

The influence of supply-related characteristics on general practitioners' workload.

The workload of general practitioners (GPs) is usually defined in terms of the number of hours worked (divided in time spent on different practice tasks), rates of contact (office consultation and home visit rates) and length of consultations. They are influenced by two groups of factors: demand-related influences and supply-related influences. Demand-related influences refer to the list sizes of GPs and the composition of the practice population. Supply-related influences refer to the way GPs themselves manage their workload. In this article the relative influence of demand- and supply-related variables on the workload of Dutch GPs is assessed. The data for this analysis has been collected as part of the Dutch National Survey of Morbidity and Interventions in General Practice. We draw on four data sources: a three months recording of all contacts between GPs and their patients, a census of the practice population of the GPs, a mailed questionnaire among GPs and a one week diary kept by the GPs. The population consists of 168 GPs. The number of hours spent by GPs on practice activities is mainly determined by demand-related characteristics. List size and the percentage of elderly on the list are positively related to the time spent on direct patient care. Running a free flow consultation hour is the only factor on the supply side with an additional effect. GPs supervising a trainee and those with a larger percentage of elderly and publicly insured patients on their list spent more hours on other activities such as practice administration, deliberation and reading medical literature. List size and the percentage of elderly on the list have a negative influence on the office contact rate, while the percentage of low educated patients on the list and the number of practice secretaries per GP have a positive impact. Furthermore, GPs without a free flow consultation hour and those working in health centres tend to have smaller office contact rate than the others. Home visit rates are smaller when the practice secretaries provide a higher percentage of consultations in the practice, in single handed practices and in the case of female GPs. However, the percentage of elderly on the list is the main determinant of the home visit rate. The average length of consultations is not substantially affected by either supply- or demand-related characteristics.

Cholesterol management in Dutch general practice. A comparison with national guidelines. Dutch College of General Practitioners.

OBJECTIVE: To examine cholesterol diagnosis and treatment by Dutch general practitioners (GPs) in the period before publication of national guidelines, in order to develop implementation strategies based on discrepancies found between daily practice and the guidelines. DESIGN: Data of the 'Dutch National Survey of General Practice', in which GPs were involved in extensive consultation registration, were used. Patients were included for analysis if serum cholesterol, or the ICPC-code lipid metabolism disorder, or cholesterol-lowering treatment was registered. SETTING: General practice. PARTICIPANTS: 161 GPs, 177 practice-nurses. OUTCOME MEASURES: Reasons for consultation, diagnoses, therapy, inter-doctor variation. RESULTS: The main discrepancies between daily practice and the guidelines concerned indications for cholesterol measurement, repeated measurements to diagnose hypercholesterolaemia, and attention for diet advice. A remarkable inter-doctor variation in diagnosis, and less so in treatment, was also found. CONCLUSION: The inter-doctor variation justifies the publication of the standard guidelines. Implementation strategies should aim at indications for cholesterol testing, repeating measurements for diagnosis, and advice on diet.

Professional reimbursement and management of time in general practice. An international comparison.

A hypothetical model was proposed for explaining the relationship between general practitioners' system of payment and the amount of time spent in patient and non-patient work. It was hypothesized that GPs reactions to higher workload vary according to the payment system. In this paper we compare two health care systems which have both mixed systems of payment of GPs. In England and Wales up until April 1990 GPs are partly paid by capitation (approx 45% of their income), partly by allowance (38% of their income) and for a much smaller part fee for service (18% of their income). In the Netherlands GPs are paid by capitation for the publicly insured patients (63% of the average practice list) and fee for service for the privately insured patients. We expect (among other things) a stronger, positive relationship between list size and hours worked in the Netherlands and a comparably strong, negative relationship between list size and booking intervals in the Netherlands and in England and Wales. Drawing on data collected from national surveys of GP workload in the Netherlands and England and Wales these propositions were examined. The results of this comparative analysis showed some support for the propositions in that the relation between list size and number of hours worked in patient related activities is stronger in the Dutch setting than in England and Wales, and about the same strength for the relationship between list size and booking intervals.

List size, composition of practice and general practitioners' workload in The Netherlands.

Workload of general practitioners plays an important role in discussions about list size and remuneration in health care systems with fixed patient lists and capitation payments, such as in the Netherlands and in the United Kingdom. Against the background of the fairness of differences in income level between GPs the question is posed to what extent differences in list size reflect differences in workload and to what extent differences in patient characteristics influence workload. Both list size and practice composition relate to the demand led character of general practice. Data collected in the National Study of Morbidity and Interventions in General Practice are used. Central to this study is a three month recording of all contacts of 161 general practitioners (and their locums, assistant GPs and trainees) in the Netherlands. For each practice a patient register has been made to relate contacts to the practice population. The participating GPs kept a detailed diary covering 24 hr a day during one week. As indicators of workload several contact rates, hours worked in practice per week (in direct patient care and in other activities) and average length of office consultations are used. Demand related characteristics have the strongest relation to the number of hours worked by GPs, particularly the number of hours spent in patient-related activities. Rates of contacts, with the exception of the office contact rate, are not related to list size, but mainly to practice composition. The average length of consultations is negatively related to list size and some characteristics of the practice population.

Workload and job satisfaction among general practitioners: a review of the literature.

The workload of general practitioners (GPs) is an important issue in health care systems with capitation payment for GPs services. This article reviews the literature on determinants and consequences of workload and job satisfaction of GPs. Determinants of workload are located on the demand side (list size and composition of the patient population) and the supply side (organization of the practice and personal characteristics of the GP). The effects of workload and job satisfaction on workstyle and quality of work have been reviewed. The length of consultations or booking intervals seems to be an important restriction for workstyle and quality of work.

Severe thrombocytopenia in a pregnant patient with platelet-associated IgM, and known von Willebrand's disease; a case report.

In this report, a patient with known von Willebrand's disease is presented with severe thrombocytopenia developing during pregnancy, which at first was believed to be caused by immune thrombocytopenic purpura. For several reasons this first diagnosis had to be rejected, but subtyping of von Willebrand's disease pointed out that the patient suffered from type IIB, which, according to recent literature, can lead to platelet destruction in pregnancy. Early subtyping of von Willebrand's disease can have a major influence on the management of pregnancy.

Improving primary health care through technological innovation.

As a result of policy changes and developments on the demand side, the importance of technology in primary health care will grow fast. An approach to the implementation of new technologies in primary health care is presented in this article. First we describe the main problems in Dutch primary health care. The second step is to identify new technologies which are becoming available. Subsequently, the interface between these problems and their possible technological resolution has to be found. The fact that a technological innovation appears to be a solution is not sufficient reason for introducing it. There are all kinds of reasons why an innovation that has proved useful in the hospital situation, for example, might be of doubtful use in primary health care. Accordingly, the next step is to assess whether a technological solution to a problem in primary health care is indeed an improvement. To acknowledge the particular situation of primary health care, a scheme has been developed that may be used to determine criteria of evaluation.