Development of the ProPal-COPD tool to identify patients with COPD for proactive palliative care.

BACKGROUND: Our objective was to develop a tool to identify patients with COPD for proactive palliative care. Since palliative care needs increase during the disease course of COPD, the prediction of mortality within 1 year, measured during hospitalizations for acute exacerbation COPD (AECOPD), was used as a proxy for the need of proactive palliative care. PATIENTS AND METHODS: Patients were recruited from three general hospitals in the Netherlands in 2014. Data of 11 potential predictors, a priori selected based on literature, were collected during hospitalization for AECOPD. After 1 year, the medical files were explored for the date of death. An optimal prediction model was assessed by Lasso logistic regression, with 20-fold cross-validation for optimal shrinkage. Missing data were handled using complete case analysis. RESULTS: Of 174 patients, 155 patients were included; of those 30 (19.4%) died within 1 year. The optimal prediction model was internally validated and had good discriminating power (AUC =0.82, 95% CI 0.81-0.82). This model relied on the following seven predictors: the surprise question, Medical Research Council dyspnea questionnaire (MRC dyspnea), Clinical COPD Questionnaire (CCQ), FEV1% of predicted value, body mass index, previous hospitalizations for AECOPD and specific comorbidities. To ensure minimal miss out of patients in need of proactive palliative care, we proposed a cutoff in the model that prioritized sensitivity over specificity (0.90 over 0.73, respectively). Our model (ProPal-COPD tool) was a stronger predictor of mortality within 1 year than the CODEX (comorbidity, age, obstruction, dyspnea, and previous severe exacerbations) index. CONCLUSION: The ProPal-COPD tool is a promising multivariable prediction tool to identify patients with COPD for proactive palliative care.

Acute medical units: The way to go? A literature review.

BACKGROUND: Acute healthcare chains in the Netherlands are increasingly under pressure because of rising emergency department (ED) admissions, relative bed shortages and government policy changes. In order to improve acute patient flow and quality of care through hospitals, an acute medical unit (AMU) might be a solution, as demonstrated in the UK. However, limited information is available concerning AMUs in the Netherlands. Therefore, the aims of this study were to METHODS: A systematic literature search was performed searching 3 electronic databases: PubMed, Cochrane and EMBASE. All 106 hospitals in the Netherlands were contacted, inquiring about the status of an ED, the AMU or future plans to start one. RESULTS: The literature search resulted in 31 studies that met inclusion criteria. In general, these studies reported significant benefits on number of admissions, hospital length of stay (LOS), mortality, other wards and readmissions. Among the Dutch hospitals with an ED, 33 out of 93 implemented an AMU or similar ward, these are however organized heterogeneously. Following current trends, more AMUs are expected to be realized in the future. CONCLUSION: In order to improve the current strain on the Dutch acute healthcare system, an AMU could potentially provide benefits. However, uniform guideline is warranted to optimize and compare quality of care throughout the Netherlands.

Progressive hereditary hearing impairment caused by a MYO6 mutation resembles presbyacusis.

Since deafness is the most common sensorineural disorder in humans, better understanding of the underlying causes is necessary to improve counseling and rehabilitation. A Dutch family with autosomal dominantly inherited sensorineural hearing loss was clinically and genetically assessed. The MYO6 gene was selected to be sequenced because of similarities with other, previously described DFNA22 phenotypes and a pathogenic c.3610C > T (p.R1204W) mutation was found to co-segregate with the disease. This missense mutation results in a flat configured audiogram with a mild hearing loss, which becomes severe to profound and gently to steeply downsloping later in life. The age-related typical audiograms (ARTA) constructed for this family resemble presbyacusis. Speech audiometry and results of loudness scaling support the hypothesis that the phenotype of this specific MYO6 mutation mimics presbyacusis.

Primary care spirometry.

Primary care spirometry is a uniquely valuable tool in the evaluation of patients with respiratory symptoms, allowing the general practitioner to diagnose or exclude chronic obstructive pulmonary disease (COPD), sometimes to confirm asthma, to determine the efficacy of asthma treatment and to correctly stage patients with COPD. The use of spirometry for case finding in asymptomatic COPD patients might become an option, once early intervention studies have shown it to be beneficial in these patients. The diagnosis of airway obstruction requires accurate and reproducible spirometric measurements, which should comply with the American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines. Low acceptability of spirometric manoeuvres has been reported in primary care practices. This may hamper the validity of the results and affect clinical decision making. Training and refresher courses may produce and maintain good-quality testing, promote the use of spirometric results in clinical practice and enhance the quality of interpretation. Softening the stringent ATS/ERS criteria could enhance the acceptability rates of spirometry when used in a general practice. However, the implications of potential simplifications on the quality of the data and clinical decision making remain to be investigated. Hand-held office spirometers have been developed in recent years, with a global quality and user-friendliness that makes them acceptable for use in general practices. The precision of the forced vital capacity measurements could be improved in some of the available models.

Comparison of a new automatically controlled electrocoagulator (Valleylab NS 2000-INSTANT RESPONSE technology) with a high-frequency coagulator.

Bipolar electrocoagulation is one of the most important procedures in modern neurosurgery. However, there are still many practical problems, especially tissue adherence to the tips of the coagulating forceps and the difficulty removing carbonized clots from the tips. Both make the process less accurate and more time-consuming. To prevent formation of coagulum, recently, irrigation with a saline solution and coating of the forceps tips with a special metal have been tried. In this work, we compare a new bipolar electrocoagulator with automatic output control in relation to tissue impedance (Auto Suture - Valleylab NS 2000 with INSTANT RESPONSE technology) with a high-frequency coagulator (Erbotom ICC 350, Erbe). The femoral arteries and nerves of Wistar rats, weighing on average 360 g, were prepared and coagulation was carried out with variable power settings during a constant time (3 seconds). Sections were stained with haematoxylin-eosin, van Gieson and Luxol-Fast-Blue for histological examination. Coagulation with Erbotom ICC 350 resulted in tissue sticking to the tips of the forceps in all cases, regardless of the power chosen. With the new electrocoagulator, tissue adherence to the forceps tips was not seen. With the new system, effective coagulation was also achieved at comparably lower power settings.

Influence of insulin and glucose on pyruvate catabolism in perfused rat hindlimbs.

The effects of insulin and glucose on the oxidative decarboxylation of pyruvate in isolated rat hindlimbs was studied in non-recirculating perfusion with [1-14C]pyruvate. Insulin increased the calculated pyruvate decarboxylation rate in a concentration-dependent manner. At supramaximal insulin concentrations, the calculated pyruvate decarboxylation rate was increased by about 40% in perfusions with 0.15-1.5 mM-pyruvate. Glucose up to 20 mM had no effect. In the presence of insulin and low physiological pyruvate concentrations (0.15 mM), glucose increased the calculated pyruvate oxidation. This effect was abolished by high concentrations of pyruvate (1 mM). The data provide evidence that in resting perfused rat skeletal muscle insulin primarily increased the activity of the pyruvate dehydrogenase complex. The effect of glucose was due to increased intracellular pyruvate supply.