Two-year persistence with teriparatide improved significantly after introduction of an educational and motivational support program.

This study evaluated the 2-year persistence with teriparatide in the Netherlands. Analyses showed that the risk of non-persistence was 28% lower in patients who were followed according to an additional educational and motivational support program. INTRODUCTION: Until recently, teriparatide (TPTD) was a third-line treatment option for severe osteoporosis in the Netherlands, which could only be prescribed by medical specialists based on a specific medical statement. We aimed to determine whether an educational and motivational support program (EMSP) increased 2-year treatment persistence with TPTD in patients with severe osteoporosis. METHODS: We evaluated persistence in 1573 Dutch patients treated with TPTD from January 2013 until January 2018. From January 2013 onwards, all patients received a basic support program (BSP) consisting of an educational home visit to initiate TPTD treatment and phone calls (at 1, 2.5 and 8 weeks). Since May 2015, all patients received the EMSP consisting of the BSP extended with evaluation of medication adherence during phone calls, an additional phone call (at 12 months), and motivational letters at 9 and 14 months. RESULTS: The EMSP showed a statistically significantly higher 2-year persistence (78%) with TPTD as compared with the BSP (72%). Reasons for treatment discontinuation were comparable between groups, except for the proportion of patients who had stopped TPTD administration due to side effects, which was significantly lower in the EMSP group (8% vs. 15% in BSP, p < 0.001). Overall, the risk of non-persistence was 28% lower in the EMSP compared with the BSP group (HR: 0.72; 95% CI: 0.55-0.93). CONCLUSION: The introduction of the EMSP has demonstrated to improve the persistence with TPTD, resulting in 78% of the patients being persistent with TPTD during the 2-year treatment period.

Structural transitions of epitaxial ceria films on Si(111).

The structural changes of a (111) oriented CeO2 film grown on a Si(111) substrate covered with a hex-Pr2O3(0001) interface layer due to post deposition annealing are investigated. X-ray photoelectron spectroscopy measurements revealing the near surface stoichiometry show that the film reduces continuously upon extended heat treatment. The film is not homogeneously reduced since several coexisting crystalline ceria phases are stabilized due to subsequent annealing at different temperatures as revealed by high resolution low energy electron diffraction and X-ray diffraction. The electron diffraction measurements show that after annealing at 660 °C the ι-phase (Ce7O12) is formed at the surface which exhibits a (√7 × âˆš7)R19.1° structure. Furthermore, a (√27 × âˆš27)R30° surface structure with a stoichiometry close to Ce2O3 is stabilized after annealing at 860 °C which cannot be attributed to any bulk phase of ceria stable at room temperature. In addition, it is shown that the fully reduced ceria (Ce2O3) film exhibits a bixbyite structure. Polycrystalline silicate (CeSi(x)O(y)) and crystalline silicide (CeSi1.67) are formed at 850 °C and detected at the surface after annealing above 900 °C.

Mapping serotonergic dysfunction in MDMA (ecstasy) users using pharmacological MRI.

3,4-Methylenedioxymethamphetamine (MDMA or ecstasy) is a popular recreational drug that has been shown to induce loss of brain serotonin (5-HT) neurons. The purpose of this study was to determine the usefulness of pharmacological magnetic resonance imaging (phMRI) in assessing 5-HT dysfunction by examining the hemodynamic response evoked by infusion with the selective 5-HT reuptake inhibitor citalopram. We studied the effects of MDMA on brain hemodynamics using arterial spin labeling (ASL) based phMRI following a citalopram challenge (7.5mg/kg, i.v.), combined with [¹²³I]ß-CIT SPECT imaging in ten male MDMA users and seven healthy non-users. Single photon emission computed tomography (SPECT) imaging was used to assess the availability of 5-HT transporters (SERT). Imaging results were compared with the results of behavioral measures and mood changes following drug administration, in both groups (using the Beck Depression Inventory, Barratt Impulsiveness Scale and a visual analog scale). Reductions in SERT binding were observed in the occipital cortex of MDMA users. In line with this, citalopram induced decreases in cerebral blood flow (CBF) in the occipital cortex of MDMA users. ASL based phMRI also detected a CBF decrease in the thalamus of MDMA users. In concordance with imaging findings, behavioral measures differed significantly between MDMA users and controls. MDMA users had higher impulsivity scores and felt more uncomfortable after citalopram infusion, compared with control subjects. Our findings indicate that phMRI is very well suited for in-vivo assessment of 5-HT dysfunction.

Cerebral perfusion long term after therapeutic occlusion of the internal carotid artery in patients who tolerated angiographic balloon test occlusion.

BACKGROUND AND PURPOSE: Therapeutic carotid occlusion is an established technique for treatment of large and giant aneurysms of the ICA, in patients with synchronous venous filling on angiography during BTO. Concern remains that hemodynamic alterations after permanent occlusion will predispose the patient to new ischemic injury in the ipsilateral hemisphere. The purpose of this study was to assess whether BTO with synchronous venous filling is associated with normal CBF long term after carotid sacrifice. MATERIALS AND METHODS: Eleven patients were included (all women; mean age, 50.5 years; mean follow-up, 38.5 months). ASL with single and multiple TIs was used to assess CBF and its temporal characteristics. Selective ASL was used to assess actual territorial contribution of the ICA and BA. Collateral flow via the AcomA or PcomA or both was determined by time-resolved 3D PCMR. Paired t tests were used to compare CBF and timing parameters between hemispheres. RESULTS: Absolute CBF values were within the normal range. There was no significant CBF difference between hemispheres ipsilateral and contralateral to carotid sacrifice (49.4 ± 11.2 versus 50.1 ± 10.1 mL/100 g/min). Arterial arrival time and trailing edge time were significantly prolonged on the occlusion side (816 ± 119 ms versus 741 ± 103 ms, P = .001; and 1765 ± 179 ms versus 1646 ± 190 ms, P < .001). Two patients had collateral flow through the AcomA only and were found to have increased timing parameters compared with 9 patients with mixed collateral flow through both the AcomA and PcomA. CONCLUSIONS: In this small study, patients with synchronous venous filling during BTO had normal CBF long term after therapeutic ICA occlusion.

Robustness and reproducibility of flow territories defined by planning-free vessel-encoded pseudocontinuous arterial spin-labeling.

Flow-territory mapping by MR imaging ASL noninvasively provides a unique insight into the distribution of cerebral perfusion. The introduction of planning-free vessel-encoded pCASL made flow-territory mapping feasible for clinical use, though lack of individual planning could impede reproducibility of this technique. We assessed the reproducibility of planning-free vessel-encoded pCASL in patients and controls. Results indicated that planning-free vessel-encoded pCASL is a reproducible method that could assist in clinical decision-making.

Post-deposition annealing of praseodymia films on Si(111) at low temperatures.

Thin heteroepitaxial praseodymia films with fluorite structure on Si(111) were annealed under ultra-high vacuum conditions at temperatures in the region of 100 up to 300 °C. Afterward investigations by x-ray diffraction, grazing incidence x-ray diffraction and x-ray reflectometry were performed to obtain information about structural changes of the film during the annealing process. For this reason, praseodymia Bragg peaks were carefully analyzed within the kinematic diffraction theory. This analysis demonstrates the coexistence of different praseodymia phases depending on the conditions of preparation. Here, annealing of the samples up to 150 °C leads to a homogeneous film with a PrO(1.833) phase and with negligible strain since both the lateral and vertical lattice parameters nearly match the corresponding bulk praseodymia phase. Further annealing leads to oxygen loss accompanied by significantly increased lattice parameters. Since the lateral lattice parameter is pinned at the interface, the vertical lattice constant has to increase considerably due to the tetragonal distortion of the film. This causes the decomposition of the film into two oxide species with significantly different oxygen contents. Annealing at 300 °C reduces the film almost completely to PrO(1.5) which has the minimum content of oxygen.

Photoemission study of praseodymia in its highest oxidation state: the necessity of in situ plasma treatment.

A cold radio frequency oxygen plasma treatment is demonstrated as a successful route to prepare clean, well-ordered, and stoichiometric PrO(2) layers on silicon. High structural quality of these layers is shown by x-ray diffraction. So far unobserved spectral characteristics in Pr 3d x-ray photoelectron (XP) spectra of PrO(2) are presented as a fingerprint for praseodymia in its highest oxidized state. They provide insight in the electronic ground state and the special role of praseodymia among the rare earth oxides. They also reveal that former XP studies suffered from a significant reduction at the surface.

Acquisition time and reproducibility of continuous arterial spin-labeling perfusion imaging at 3T.

Arterial spin-labeling (ASL) is a relatively new and noninvasive MR imaging technique, used to measure cerebral blood flow (CBF). Scanning time and reproducibility remain important issues in the clinical applicability of ASL. We expected both to benefit from higher field strengths. We describe that when performing ASL at 3T, 20 averages suffice to obtain steady and reproducible CBF values. Scanning time can be as short as 3 minutes.

Structural phase transition of ultra thin PrO(2) films on Si(111).

Ultra thin heteroepitaxial PrO(2) films on Si(111) were annealed under UHV conditions and investigated by x-ray diffraction (XRD), x-ray reflectometry (XRR) and spot profile analysis low energy electron diffraction (SPALEED) with regard to structural stability and phase transitions due to the high oxygen mobility of the oxide. This gives information about the manageability of the material and its application as a model catalyst system in surface science. While the samples are stable in UHV at room temperature, annealing at 300 °C exhibits a terminated phase transition from PrO(2) and PrO(2-Δ) to cub-Pr(2)O(3) with an increase in the silicate at the interface and a decrease in the crystalline praseodymia layer mainly due to atomic diffusion of silicon into the oxide film. Strain effects during the phase transition also cause mosaic formation at the surface. Further annealing up to 600 °C shows only little change in the film structure. This will finally lead to a model of the film structure during the annealing process.

Legal issues in the development and use of clinical practice guidelines.

Over the last ten years, the development and dissemination of practice guidelines has increased at a rapid pace. From a legal point of view, it should always be made clear whether a guideline has been developed to improve the quality of care and is based on medical evidence and professional experience, or whether other concerns and considerations (organisational, financial) did prevail. Guidelines should not simply be imposed on health professionals; that would result in a standardisation of care that does no justice to individual patient needs and preferences. Patients have the right to be informed about reasonable and realistic treatment alternatives, even if they are not included in the guideline. Using cost effectiveness analysis in guideline development can help to reduce care of dubious effectiveness. But if cost considerations are used as a reason to limit effective medical care, the guidelines in question need political legitimation.

Late termination of pregnancy in cases of severe abnormalities in the fetus.

Developments in medical technology have increased the possibility of diagnosing severe structural abnormalities in the fetus. In such circumstances, the woman may request termination of her pregnancy. This raises serious ethical and legal questions, in particular if the abnormalities are discovered after 24 weeks of gestation, when the fetus is considered viable. This article discusses the legal aspects of this problem, with particular reference to the Netherlands. If one accepts that, in exceptional circumstances, third trimester abortion may be justified on medical grounds, the law should make provision for it. However, the general protection provided by the law to fetal life-especially in the third trimester--should remain firmly in place.

PIP: This article considers the legal issues surrounding induced abortion in cases when severe fetal abnormality has been diagnosed in the third trimester of pregnancy. After an introduction, the article examines how European law treats such cases and concludes that the 1950 European Convention for the Protection of Human Rights would allow state discretion in late termination of pregnancy in hopeless cases. However, only France, Belgium, and the UK have provisions for abortion in such cases. In the UK, the Royal College of Obstetricians and Gynaecologists also offers criteria for assessing the seriousness of the disability. Next, the article reviews abortion law and practice in the Netherlands where abortion becomes a criminal act in cases of fetal viability (after 24 weeks except in special circumstances). Recognizing the need for third trimester abortion in cases of fetal abnormality, the Netherlands Association for Obstetrics and Gynaecology issued criteria and practice guidelines in 1994. Two of these three criteria, however, would expose the physician to criminal prosecution. A 1990-94 study by the Health Inspectorate for North Holland revealed that an estimated 150 late abortions occur each year in the Netherlands in cases when continuing the pregnancy would be pointless or extremely stressful for the mother. This report led to creation of a commission to set up guidelines for reconciling medical justification for late abortion with existing law. It is concluded that existing law should not be changed but that clear rules should be devised and a board created to review late term abortions.

Euthanasia: law and practice in The Netherlands.

In The Netherlands, euthanasia is defined as the deliberate termination of the life of a person on his request by another person. Although, in this limited sense, euthanasia is only one of the issues raised by medical decision-making at the end of life, it is, in particular, the acceptance of euthanasia in this country that has attracted attention from abroad. Also, in The Netherlands itself, the toleration of the courts of euthanasia (if carried out by a physician under strict conditions) has given rise to much debate. This contribution surveys the developments in the law (including recent legislation), and in medical practice, and explores the relation between the two, with particular attention to the position of the physician.

Clinical practice guidelines; legal aspects.

In many countries, practice guidelines are considered an important means to make medical decisions more effective and rational. The growing use of such standards raises a number of legal questions: What is the legal status of practice guidelines? What are the responsibilities of the makers? To what extent do guidelines allow for clinical discretion or for patient preferences? How are they applied by the courts? This paper briefly discusses these questions in the context of Dutch law and medicine. It also addresses the issue, to what extent cost-benefit considerations may be taken into account in developing clinical guidelines.

Clinical practice guidelines; legal aspects.

The number of clinical guidelines is rapidly increasing. The proliferation of guidelines and their growing use in medical practice make them also more conspicuous from a legal point of view. Legal questions relate first of all to guideline development: what are the responsibilities of the makers? when are they liable for 'defects' in their 'products'? Other questions concern the position of doctor and patient: to what extent do guidelines allow for clinical discretion or for patient preferences? How are they to be applied by the courts? The paper briefly discusses these issues, in particular the question to what extent cost-benefit considerations may be taken into account in developing clinical guidelines.