The introduction of the practice nurse mental health in general practices in the Netherlands: effects on number of diagnoses of chronic and acute alcohol abuse.

BACKGROUND: Since 2008 mental health practice nurses have been gradually introduced in general practices in the Netherlands as part of health policy aiming to improve early identification and treatment of mental health problems in primary care. This study aims to investigate the effect of the introduction of the practice nurse mental health in general practices in the Netherlands on the number of diagnoses of chronic and acute alcohol abuse. METHODS: The Netherlands Institute for Health Services Research (NIVEL) retrieved data of a representative sample of general practices (n = 155) for this study. Data were aligned at the starting point of the implementation of the PN-MH to compare the practices on our outcome measures after implementation of the PN-MH. Multilevel regression analyses were conducted to investigate differences in average number of chronic and acute alcohol abuse diagnoses between practices with a practice nurse mental health and control practices (without a practice nurse mental health and without a primary care psychologists). RESULTS: A significant decrease over time of chronic alcohol abuse diagnoses was observed (ß = -.52, p < 0.05) as well as a significant decrease over time of acute alcohol abuse diagnoses (ß = -.06, p < 0.05). After adjustment for multiple comparisons, no significant differences were found between practices that implemented a practice nurse mental health or only have a primary care psychologist and control practices. Practices that implemented a practice nurse mental health and have a primary care psychologist, had a higher mean of chronic and acute alcohol abuse diagnoses than control practices during all periods, but the differences between these groups were not statistically significant. CONCLUSIONS: Based on the results of this study it seems that the introduction of practice nurses mental health in general practices is not associated with increased diagnoses of chronic or acute alcohol abuse. Potential explanations are barriers experienced by practice nurses to addressing alcohol use with patients and prioritization of other mental health issues over alcohol abuse. In order to improve the management of alcohol abuse by practice nurses, more research is needed on how practice nurses can be involved in diagnosing and treatment of patients with alcohol abuse.

Daily lives of residents with dementia in nursing homes: development of the Maastricht electronic daily life observation tool.

BACKGROUND: Daily life is a dynamic and multidimensional concept, for which appropriate assessment tools are lacking. This study describes the development of the Maastricht Electronic Daily Life Observation tool (MEDLO-tool), a freely accessible, easy to use, electronic observation tool to assess relevant daily life aspects for nursing home residents with dementia. METHODS: (1) Determining relevant aspects of daily life for nursing home residents with dementia based on a literature search and expert interviews; (2) pilot testing observation procedures and operationalizations of the aspects of daily life; and (3) exploring inter-rater reliability and feasibility of the tool in a nursing home facility with 16 residents (56% female, mean age: 77). RESULTS: The following aspects of daily life are assessed with the MEDLO-tool: (1) activity (activity performed by resident, engagement in this activity, and the degree of physical effort); (2) physical environment (location of the resident and interaction with the physical environment); (3) social interaction (the level and type of social interaction, and with whom this social interaction took place); and (4) emotional well-being (mood and agitation). Each aspect of daily life is observed and scored using standardized scoring options. Agreement on the aspects is high with an average absolute agreement of 86%. Users of the MEDLO-tool indicated that it was feasible in practice and contained clear operationalization of the aspects of daily life. CONCLUSIONS: The MEDLO-tool is a promising tool to gain real time insight into the aspects of the daily lives of nursing home residents with dementia.

Living at the farm, innovative nursing home care for people with dementia - study protocol of an observational longitudinal study.

BACKGROUND: In nursing home care, new care environments directed towards small-scale and homelike environments are developing. The green care farm, which provides 24-h nursing home care for people with dementia, is one such new care environment. Knowledge is needed on the relation between environmental features of green care farms such as nature, domesticity and offering care in small groups and the influence on the daily lives of residents. The aim of this study is to explore (1) the daily lives of residents, (2) the quality of care and (3) the experiences of caregivers on green care farms compared with other nursing home care environments. METHODS/DESIGN: An observational longitudinal study including a baseline and a six-month follow-up measurement is carried out. Four types of nursing home care environments are included: (1) large scale nursing home ward, (2) small scale living facility on the terrain of a larger nursing home (3) stand-alone small scale living facility and (4) green care farm. Quality of care is examined through structure, process and outcome indicators. The primary outcome measure is the daily life of residents, assessed by ecological momentary assessments. Aspects of daily life include (1) activity (activity performed by the resident, the engagement in this activity and the degree of physical effort); (2) physical environment (the location of the resident and the interaction with the physical environment); (3) social environment (the level and type of social interaction, and with whom this social interaction took place) and (4) psychological well-being (mood and agitation). In addition, social engagement, quality of life, behavioral symptoms and agitation are evaluated through questionnaires. Furthermore, demographics, cognitive impairment, functional dependence and the severity of dementia are assessed. Semi-structured interviews are performed with caregivers regarding their experiences with the different nursing home care environments. DISCUSSION: This is the first study investigating green care farms providing 24-h nursing home care for people with dementia. The study provides valuable insight into the daily lives of residents, the quality of care, and the experiences of caregivers at green care farms in comparison with other nursing home care environments including small-scale care environments and large scale nursing home wards.

A comparison of classroom and online asynchronous problem-based learning for students undertaking statistics training as part of a Public Health Masters degree.

This case-study compared traditional, face-to-face classroom-based teaching with asynchronous online learning and teaching methods in two sets of students undertaking a problem-based learning module in the multilevel and exploratory factor analysis of longitudinal data as part of a Masters degree in Public Health at Maastricht University. Students were allocated to one of the two study variants on the basis of their enrolment status as full-time or part-time students. Full-time students (n = 11) followed the classroom-based variant and part-time students (n = 12) followed the online asynchronous variant which included video recorded lectures and a series of asynchronous online group or individual SPSS activities with synchronous tutor feedback. A validated student motivation questionnaire was administered to both groups of students at the start of the study and a second questionnaire was administered at the end of the module. This elicited data about student satisfaction with the module content, teaching and learning methods, and tutor feedback. The module coordinator and problem-based learning tutor were also interviewed about their experience of delivering the experimental online variant and asked to evaluate its success in relation to student attainment of the module's learning outcomes. Student examination results were also compared between the two groups. Asynchronous online teaching and learning methods proved to be an acceptable alternative to classroom-based teaching for both students and staff. Educational outcomes were similar for both groups, but importantly, there was no evidence that the asynchronous online delivery of module content disadvantaged part-time students in comparison to their full-time counterparts.

Influence of multimorbidity on cognition in a normal aging population: a 12-year follow-up in the Maastricht Aging Study.

OBJECTIVE: The prevalence of multimorbidity has risen considerably because of the increase in longevity and the rapidly growing number of older individuals. Today, only little is known about the influence of multimorbidity on cognition in a normal healthy aging population. The primary aim of the present study was to investigate the effect of multimorbidity on cognition over a 12-year period in an adult population with a large age range. METHODS: Data were collected as part of the Maastricht Aging Study (MAAS), a prospective study into the determinants of cognitive aging. Eligible MAAS participants (N = 1763), 24-81 years older, were recruited from the Registration Network Family Practices (RNH) which enabled the use of medical records. The association between 96 chronic diseases, grouped into 23 disease clusters, and cognition on baseline, at 6 and 12 years of follow-up, were analyzed. Cognitive performance was measured in two main domains: verbal memory and psychomotor speed. A multilevel statistical analysis, a method that respects the hierarchical data structure, was used. RESULTS: Multiple disease clusters were associated with cognition during a 12-year follow-up period in a healthy adult population. The disease combination malignancies and movement disorders multimorbidity also appeared to significantly affect cognition. CONCLUSIONS: The current results indicate that a variety of medical conditions adversely affects cognition. However, these effects appear to be small in a normal healthy aging population.

Quality systems to improve care in older patients with urinary incontinence receiving home care: do they work?

OBJECTIVE: To gain insight into the use of quality systems to improve urinary incontinence (UI) care in older adults receiving home care and to assess the associations between these quality systems and UI-related process and patient outcomes. DESIGN: Cross-sectional survey. SETTING: 19 home care agencies in the Netherlands comprising 155 home care teams. SAMPLE: 3480 adults aged 65 years and older, screened for UI. MAIN OUTCOME MEASURES: Percentage of patients with UI, percentage of patients with a diagnosis regarding type of UI, mean amount of urine loss and mean frequency of urine loss. RESULTS: The quality systems most commonly used included appointing a continence nurse (at the home care agency level) and documenting UI-related actions in the patient's record (home care teams). Mixed model analyses revealed no associations between the quality systems and the UI process or patient outcomes. CONCLUSION: Most home care agencies and home care teams claim that they adopt quality systems to improve UI care for older adults. However, no associations were found between these quality systems and the UI process or patient outcomes. More research with a precise monitoring of implemented systems is therefore needed to gain insight into the effectiveness of quality systems and their applicability in the home care setting.

The effect of dropout on the efficiency of D-optimal designs of linear mixed models.

Dropout is often encountered in longitudinal data. Optimal designs will usually not remain optimal in the presence of dropout. In this paper, we study D-optimal designs for linear mixed models where dropout is encountered. Moreover, we estimate the efficiency loss in cases where a D-optimal design for complete data is chosen instead of that for data with dropout. Two types of monotonically decreasing response probability functions are investigated to describe dropout. Our results show that the location of D-optimal design points for the dropout case will shift with respect to that for the complete and uncorrelated data case. Owing to this shift, the information collected at the D-optimal design points for the complete data case does not correspond to the smallest variance. We show that the size of the displacement of the time points depends on the linear mixed model and that the efficiency loss is moderate.

An asymptotically unbiased estimator of exposed versus non-exposed odds ratio from reported dose-response data.

Summary effect measures in meta-analysis of published epidemiological cohort or case control studies are often based on odds ratios reported for several exposure levels with varying arrangements and number of levels across primary studies. Usually only two-way contingency tables together with exposure specific adjusted odds ratios and corresponding standard errors are presented in articles. An asymptotically unbiased estimate of exposed versus non-exposed adjusted odds ratio from reported dose-response data is proposed. This estimate is based on the weighted sum of the exposure specific odds ratios, with the prevalences of the control group as weights. Large sample variance is derived accounting for the dependency between exposure specific adjusted odds ratios. The exposed versus non-exposed adjusted odds ratio could then be used in systematic reviewing.

Are coffee and tea consumption associated with urinary tract cancer risk? A systematic review and meta-analysis.

BACKGROUND: Narrative reviews have concluded that there is a small association between coffee consumption and an increased risk of urinary tract cancer, possibly due to confounding by smoking. No association for tea consumption has been indicated. This systematic review attempts to summarize and quantify these associations both unadjusted and adjusted for age, smoking and sex. METHOD: Thirty-four case-control and three follow-up studies were included in this systematic review. Summary odds ratios (OR) were calculated by meta-regression analyses. RESULTS: The unadjusted summary OR indicated a small increased risk of urinary tract cancer for current coffee consumers versus non-drinkers. The adjusted summary OR were: 1.26 (95% CI : 1.09-1.46) for studies with only men, 1.08 (95% CI : 0.79-1.46) for studies with only women and 1.18 (95% CI : 1.01-1.38) for studies with men and women combined. Neither unadjusted nor adjusted summary OR provided evidence for a positive association between tea consumption and urinary tract cancer. Even though studies differed in methodology, the results were rather consistent. We did not perform dose-response analyses for coffee and tea consumption due to sparse data. CONCLUSIONS: In accordance with earlier reviews, we found that coffee consumption increases the risk of urinary tract cancer by approximately 20%. The consumption of tea seems not to be related to an increased risk of urinary tract cancer.

Local influence to detect influential data structures for generalized linear mixed models.

This article discusses the generalization of the local influence measures for normally distributed responses to local influence measures for generalized linear models with random effects. For these models, it is shown that the subject-oriented influence measure is a special case of the proposed observation-oriented influence measure. A two-step diagnostic procedure is proposed. The first step is to search for influential subjects. A search for influential observations is proposed as the second step. An illustration of a two-treatment, multiple-period crossover trial demonstrates the practical importance of the detection of influential observations in addition to the detection of influential subjects.

The impact of characteristics of cigarette smoking on urinary tract cancer risk: a meta-analysis of epidemiologic studies.

BACKGROUND: Although narrative reviews have concluded that there is strong support for an association between cigarette smoking and urinary tract cancer, the association has never been quantified systematically in reviews. The purpose of this systematic review was to summarize and quantify the impact of different smoking characteristics (status, amount, duration, cessation, and age at first exposure) both unadjusted and adjusted for age and gender. METHODS: The authors included 43 epidemiologic studies (8 cohort and 35 case-control) and calculated summary odds ratios (SORs) by meta-regression analyses for different smoking characteristics. They also evaluated changes in summary estimates according to differences in study methodology. RESULTS: Smoking status and increased amount and duration of smoking were associated with a strong increased risk of urinary tract cancer. Smoking cessation and age at first exposure were negatively associated with the risk of urinary tract cancer. The age- and gender-adjusted SORs for current and former cigarette smokers compared with those for nonsmokers were 3.33 (95% confidence interval [CI], 2.63-4.21) and 1.98 (CI, 1.72-2.29), respectively. Even though the component studies differed in methodology, the results were rather consistent. CONCLUSIONS: The results suggest a substantial increase in risk of cancer of the urinary tract for cigarette smokers. Based on the results of this study and previous literature, the authors conclude that current cigarette smokers have an approximately threefold higher risk of urinary tract cancer than nonsmokers. In Europe, approximately half of urinary tract cancer cases among males and one-third of cases among females might be attributable to cigarette smoking.

Multigenerational caregiving and well-being: distress of middle-aged daughters providing assistance to elderly parents.

This article investigates whether being a caregiver of an elderly parent and the caregiver's involvement in multiple roles increases distress in middle-aged women. Previous studies assumed that providing care to frail parents causes distress in women, in particular when they have other social roles as well. Longitudinal data were collected within a cohort of middle-aged women (n = 934; n = 743). The acquisition or loss of the caregiver role did not appear to affect levels of distress of middle-aged women, nor did additional roles of caregivers increase distress levels or caregiver role strain. Most distressed were women not performing any major social role, suggesting that the lack of social roles rather than the multiplicity of roles is associated with distress. The caregiver role might even reduce distress when women have very few other roles. Findings are explained in terms of the role scarcity, the role expansion and role accumulation hypotheses of role theory.

Elevated risk of cancer of the urinary tract for alcohol drinkers: a meta-analysis.

OBJECTIVES: Recent narrative reviews have concluded that there is no support for an association between alcohol consumption and urinary tract cancer. Many individual studies, however, have reported positive associations, although rarely statistically significant. The purpose of this meta-analysis is to summarize and quantify this relationship with more statistical power and to perform a sensitivity analysis on the study characteristics. METHODS: We included 16 epidemiological studies published up to April 1999 and calculated summary odds ratios (SORs), both upgraded and adjusted for age, sex and smoking by meta-regression analyses. The age- and smoking-adjusted SORs (current alcohol drinking vs. non-drinking) were 1.3 (95% CI 0.9-2.0) for six studies with men and 1.0 (95% CI 0.4-2.6) for four studies with women. RESULTS: The age-, sex- and smoking-adjusted SOR was 1.2 (95% CI 0.9-1.7) for seven studies with men and women combined. CONCLUSION: Even though studies differed in methodology, the results were rather consistent. Subgroup analyses by type or amount of alcohol were not possible due to sparse data. We conclude that the available data suggest a slightly increased risk of urinary tract cancer from alcohol consumption for men. The risk related to alcohol consumption for women and the influence of the amount and type of alcohol remain unclear.

The endoscope and the radiofrequency unit in DCR surgery.

Endoscopic laser-assisted dacryocystorhinostomy (DCR) offers several advantages over standard external (SE) DCR. The technique eliminates the cutaneous scar and cosmetic blemish of an external dissection and causes less surgical trauma and bleeding than SE-DCR, with shortened postoperative recovery time and lessened postoperative pain. However, the equipment is expensive. We modified this technique using simple instruments such as the curette, Kerrison punch, Freer elevator, Storz endoscope, Ellman Surgitron unit, and the Javate DCR electrodes instead of the laser. Fifty patients with epiphora and nasolacrimal obstruction underwent surgery with our new technique. Fifty age-matched, paired external DCR were performed, and comparisons were made with the endoscopic procedure described. If preoperative epiphora was resolved and nasolacrimal patency was confirmed by lacrimal irrigation 3 months after tube removal, the operation was considered a success. The study attained a 90% success rate for endoscopic radiofrequency-assisted DCR, as compared to a 94% success rate (p > 0.05, not statistically significant) for the SE-DCR.

The reliability of ovulation prediction by a single ultrasonographic follicle measurement.

Since ultrasonographic ovulation detection has been introduced many authors have speculated about the ovulation predictive value of this new technique. Reliable studies in this respect, however, are lacking. The present study describes ultrasonographic data of 158 spontaneously ovulating, infertile patients. Each patient contributed only one cycle to the study. To construct individual follicle growth curves serial follicular measurements were performed. A wide range existed in mean maximum diameters of the preovulatory follicles. Furthermore, the slopes of the follicle growth curves, as well as the durations of the follicle growth phases showed considerable variations. The intrinsic variability in the various characteristics of follicle growth makes a single measurement as accurate as serial measurements in predicting ovulation. A formula has been devised by means of the data of the first 100 women, which correlates follicular diameter with the time interval to ovulation. The formula was developed based on one randomly selected measurement per patient. The validity of the formula has been tested in 58 additional women, also contributing one measurement each. According to this validation the adequacy of the prediction rule was demonstrated. Ultrasound appeared to be a less sensitive method for prediction of ovulation than has been speculated by some investigators. It is, however, an improvement, compared to the prediction of ovulation based upon the length of the previous menstrual cycles. A single follicle measurement may therefore be helpful in timing post-coital tests or artificial inseminations, in addition to being an adjuvant to more reliable methods.