[Progress of Rehabilitation for Cardiac Patients Depending on the Degree of Self-Sufficiency at Admission]. / Verlauf der Rehabilitation bei kardiologischen Patienten in Abhängigkeit vom Selbstversorgungsgrad bei Aufnahme.

INTRODUCTION: There are hardly any publications about the outcome of cardiac rehabilitation considering patients with an increased need for medical, nursing and therapeutic care. The aim of this study, which consecutively included n=387 statutory health insurance inpatients over a period of 2 years, was to find out differences in outcome in self-care patients (Barthel index>70) as compared to patients with a need for complex care (Barthel index≤70). METHODS: Rehabilitation outcomes concerning physical capacity, emotional status and activities of daily living as measured by Barthel index, FIM index, HADS, clinical complications, exercise test, duration of rehabilitation and form of dismission were analyzed and compared between both groups. RESULTS: The inpatients with a Barthel index ≤70 at admission were older, had a longer stay in hospital and in rehabilitation, developed more complications and more often suffered from concomitant diseases. They were readmitted to hospital more often. They showed a comparatively higher increase in indices of self-care and a significant increase in physical performance tests. CONCLUSION: Higher medical care expenses of multimorbid cardiac inpatients are no contraindication against rehabilitation, because even in this group the specific rehabilitation aims of the healthcare payers can be reached.

Imagery and likelihood cognitive bias in pain.

BACKGROUND: Distressing intrusive images are frequently experienced by sufferers from chronic and acute pain. The images (Index images) are correlated with elevations in anxiety, threat, and a cognition that the imaged event might actually happen. The over-estimation that having a negative cognition about an adverse event will increase the probability of the negative event occurring--the likelihood bias--has been observed in a variety of psychological disorders. Preliminary research indicated this cognitive bias might occur in pain sufferers. AIMS: To investigate the occurrence of a cognitive likelihood bias associated with imagery in acute and chronic pain sufferers, and to relate the postulated cognitive bias to psychological characteristics of participants, and four other important cognitive responses to their Index images. METHOD: Fifty-nine pain sufferers completed a newly developed questionnaire (Image-Event-Fusion-pain: IEF-p) to assess cognitive likelihood bias in pain sufferers. The internal consistency, reliability, factor structure and validity of the scale were evaluated. Psychological measures to assess anxiety, depression, PTSD symptoms, and levels of mental defeat were administered. RESULTS: The IEF-p was found to be psychometrically robust with satisfactory test-retest reliability, good internal consistency, single factor structure and criterion validity. The IEF-p was significantly correlated with four key cognitive appraisals of the Index Images (responsibility, likelihood, premonition, and threat). Three of these correlations were independent of depression. High cognitive bias scores were significantly associated with elevated levels of anxiety symptoms, depression, PTSD symptoms, and mental defeat. CONCLUSION: Pain Index images were significantly associated with cognitive bias (IEF-p), increased threat levels, and raised estimate of the likelihood of imaged events actually occurring. The results indicate the prevalence of a cognitive bias associated with pain imagery cognitions, comparable to that established with intrusive cognitions in OCD, notably Thought-Action- Fusion.

Imagery and pain: the prevalence, characteristics, and potency of imagery associated with pain.

BACKGROUND: There is a dearth of information about imagery in pain sufferers. AIM: The aim of this study was to collect data on the characteristics, prevalence, and potency of imagery associated with pain. METHOD: The images of 59 pain sufferers were assessed by means of a semi-structured interview. The emotional, cognitive, behavioural, and pain-inducing properties (potency) of their index images were assessed by an image induction procedure and self-report scales of anxiety, depression and trauma symptoms. RESULTS: The results showed a remarkably high incidence of images in pain sufferers, with 78% of participants reporting one or more repetitive images when in pain. Exposure to their most powerful/distressing image (Index image) resulted in significant increases in negative emotions, negative cognitive appraisals, and in pain levels. In a sub-group of sufferers with significant levels of trauma symptoms, the index images elicited significantly higher levels of emotion and pain increment than did those respondents in a low/no trauma group. CONCLUSION: It was concluded that imagery is a prevalent, often "unobserved" but potent cognition in pain sufferers. The implications for CBT approaches to chronic pain, including image rescripting, are considered.

Localisation of alpha, mu and pi class glutathione S-transferases in kidney: comparison with CuZn superoxide dismutase.

We describe studies in whole kidney, cortical and medullary homogenates and, glomerular cells in culture to determine the relative levels of expression of alpha (Ya, Yc, Yk), mu (Yb1/Yb2), pi (Yf) glutathione S-transferases (GST) and CuZn superoxide dismutase (CuZn SOD) in different regions of the nephron. Immunoblotting and immunohistochemistry were used to demonstrate relatively weak expression of alpha, mu GST and, CuZn SOD in the glomerulus compared to that in particularly distal tubules. Whilst expression of Ya was found within glomerular cells, Yc, Yk and Yf were not detected. Immunofluorescence showed that Ya and Yb1/Yb2 but not Yf were expressed in cultured epithelial and mesangial cells studied between passages 1 and 3. While Ya was distributed in cytosol, Yb1/Yb2 was primarily located in nuclei.

Accessibility and use of Primary Health Care: how conclusive is the social-economical situation in Antwerp?

BACKGROUND: The percentage of households that delays medical assistance due to financial reasons is slowly increasing. Moreover, some groups of the population do not ever find their way to primary health care and end up unnecessarily in the emergency department or with specialists. This study wants to examine how primary health care can be made accessible to these groups. AIM: In this study, we aim to discover whether in a city such as Antwerp primary health care is accessible to everyone. METHOD: The statistics were collected from the Health Care Survey done by the Welfare Services Antwerp in cooperation with the City of Antwerp. The questions were asked in three different ways: a postal questionnaire, a telephone questionnaire and a face-to-face interview. RESULTS: We determined that people who live on social welfare delay medical help due to financial reasons more frequently than the global Antwerp population. They often do not have a regular general practitioner (GP). Especially single parents, house-wives and house-husbands, job-seekers, incapacitated people unable to work, unskilled workers and foreigners are among the vulnerable groups where accessibility to primary health care is a concern. CONCLUSION: If we hope to improve the accessibility of primary health care, we must first and foremost inform the above-mentioned groups of the insurability and how this is applied. When this is fulfilled, it will be easier for the GP to receive this vulnerable group within the primary care system, so that the help of specialized care, which is often unnecessary, can be reduced.

Agreement on urgency assessment between secretaries and general practitioners: an observational study in out-of-hours general practice service in Belgium.

BACKGROUND: In some European countries telephone triage (TT) during out-of-hours primary care showed to be safe and effective. Other countries, such as Belgium, may not have trained auxiliary personnel while their national health services want to establish TT. OBJECTIVES: To compare urgency levels assessed by secretaries and general practitioners in one general practice cooperative in Belgium. METHODS: Percentage of correct-, under-, and over-triage were calculated in total and per reason for encounter. Inter-rater agreement was investigated. RESULTS: The secretaries correctly triaged (same urgency level) 77% of the telephone calls, under-triaged 10% and over-triaged 13%.'Shortness of breath', 'skin cuts', 'chest pain', 'feeling unwell' and 'syncope' were often under-triaged. CONCLUSION: Before introducing TT, auxiliary staff should be trained and protocols should be used.

Changing chronic pain experience.

Training in relaxation is a prominent component in multi-disciplinary approaches to the management of chronic pain, although its specific potency in modulating pain has not yet been established. Using a within-session design, the specific effects of relaxation induction were evaluated in a group of benign chronic pain patients (n = 24), and compared to similar patients undergoing a control procedure (n = 22). The results indicated that irrespective of the focus of pain complaint, induction of relaxation over a 20 min period led to significant and sizeable reductions in both sensory and affective pain experience. The overall intensity of pain was significantly reduced. These effects were shown to be reliable and independent of onset level of sensory experience or depression. No significant changes occurred in the control group over a comparable period. The implications of these results were discussed with respect to the process by which relaxation reduces pain.

The effects of persistent pain: the chronic headache sufferer.

A survey of the psychological characteristics of a large sample of chronic headache cases (n = 360), including classical and common migraine and tension headache sufferers, was carried out. Comparing groups defined in terms of the chronicity of their headache problems, it was found that those with a longer history of headache had a higher level of behavioural disruption and a stronger bond between pain experience, and both complaint levels and behavioural avoidance patterns. Despite the common somatic components (sleep disturbance, fatigue, irritability, etc.), depression was not found to be elevated in this chronic pain group. In addition, there was no evidence of depression levels being higher in the populations who had had a longer history of headache problems. Higher levels of complaint were found in those with higher depression and higher extroversion and neuroticism scores. Behavioural avoidance was significantly related to the emotional reaction component of pain. The implications of these findings with respect to the development of chronic headache are discussed.

Recent onset vs. persistent pain: evidence for a distinction.

Evidence for a distinction between chronic and recent onset pain on behavioural and subjective indices was reviewed. Pain behaviours and subjective indices of pain were studied in chronic and recent onset low back pain sufferers. No differences were found between chronic and acute sufferers on measures of pain behaviour, nor on subjective indices of pain. However, differences were found in the relationships between the subjective and behavioural indices of pain in these groups. Pain behaviours were found to be independent of the subjective pain experience in recent onset pain. The relationships between subjective pain experience and pain behaviour became stronger with increased pain duration. The relationships between behavioural dimensions of pain weakened with chronicity, as did the relationship between subjective pain dimensions. These findings were discussed in relation to current accounts of chronic and recent onset pain and their implications for both theory and treatment were considered.

Antigenic and morphological differentiation of placental and intestinal isolates of Chlamydia psittaci of ovine origin.

Ewe placental and lamb intestinal isolates of Chlamydia psittaci recovered from flocks affected with ovine enzootic abortion were examined by inclusion morphology, indirect immunofluorescence (IIF) and immunoblot analysis. Chlamydiae recovered from the faeces of sheep from two flocks free of clinical disease were also examined. In cell culture ovine abortion (OA) and intestinal isolates were distinguishable by inclusion development and morphology. Similarly, in two-way IIF tests with one week mouse antisera isolates fell into two distinct groups: abortion or intestinal. Immunoblotting with convalescent sheep abortion antiserum identified 30 out of at least 40 silver staining polypeptides as antigenic both in OA and intestinal isolates. The serum produced a similar reaction pattern to the resolved proteins of each OA isolate, indicating a higher degree of antigenic conservation among these isolates. Considerable cross reactivity between the OA and intestinal isolates was identified, but the serum also showed apparent molecular weight differences between antigens of the two types in the 87-116 kDa, 38-44 kDa and 26-28 kDa regions. Furthermore, the immunoblotting analysis revealed heterogeneity among the intestinal isolates, particularly in antigens between 87-116 kDa and 38-44 kDa.

Thoughts provoked by pain.

Despite the growing interest in the cognitive component of chronic pain, little information has been collected on the variety of thoughts provoked by pain experience. A new assessment instrument (the Cognitive Evaluative Questionnaire--CEQ) has been utilized with 127 chronic pain patients and their cognitions classified into seven discrete clusters. The results confirm the heterogeneity of pain cognitions, the majority of which are likely to play a role in enhancing or perpetuating chronic pain. The relationship of these cognitions to chronic avoidance behavior is discussed.

Acute back pain: a psychological analysis.

A cross-sectional evaluation of 117 people who sustained acute back injuries was undertaken within 15 days of the first report of the pain. The subjects showed no discal or neural signs and had not experienced previous episodes of back or neck pain. All subjects were given a structured interview and filled in a series of psychological evaluation instruments. Results show acute pain reactions to be comparable to those seen in chronic pain groups. The predominant emotion is one of frustration rather than anxiety or depression and considerable behavioural disruption is evident from this early point. The extent to which these data undermine the model of gradual evolution of chronic back pain problems is discussed.

The evolution of chronic back pain problems: a longitudinal study.

A longitudinal evaluation of the recovery from an acute back pain episode was undertaken on 117 sufferers, with assessments at the onset, 3 and 6 months. The number of individuals still reporting pain at 6 months, and therefore qualifying for 'chronic pain', was considerably higher than expected (40%). At 6 months, the persisting pain problems were found to be moderate to severe in intensity in approx. 20% of cases. Despite the pain, the chronic sufferers showed gradual continuing adjustments to it, re-establishing activities despite pain. Most of the change in the pain components (cognitive, subjective, behavioral, depression, anxiety) occur in the first 3 months, after which considerable stability is evident in the residual problem. In contrast, the impact of the pain and the consequent disability decline more markedly and continue to do so right up to the 6 month point. There was no evidence of chronic pain evolving and growing, but rather of a persistence of the acute presentation.

The prevention of chronic pain and disability: a preliminary investigation.

A preliminary investigation was undertaken on 117 acute back pain cases, to assess the utility of counseling at the acute stage upon the course of recovery over the subsequent 6 months. In addition, the extent to which psychological reactions to acute injury would allow the 'tagging' of individuals at risk for chronic pain problems, was studied. The minimal rehabilitation counseling proved inadequate to effect the course of recovery, but remarkably accurate predictions were possible at the sub-chronic point (3 months) as to who would make complete recoveries.

Culture of sheep Chlamydia in a sheep fibroblast cell culture.

Abortion and enteric isolates of Chlamydia psittaci from sheep differed in their growth in a fibroblastic cell culture derived from the small intestine of a lamb. Twenty abortion isolates, each from a different farm, produced large inclusions which could be passaged several times whereas 10 enteric isolates each from different farms (but from some of the farms of origin of the abortion isolates) produced sparse inclusions which could not be passaged. This appears to be a rapid method of distinguishing abortion and enteric isolates and may indicate different nutritional requirements or be related to the invasiveness of the isolates.

Isolation of faecal chlamydia from sheep in Britain and their characterization by cultural properties.

Faeces samples were taken per rectum from sheep on 26 farms in England and Wales and examined for the presence of chlamydia by culture in McCoy cell monolayers. Thirteen of the farms were known to have had abortion outbreaks associated with Chlamydia psittaci (enzootic abortion) and 13 were free of this infection. The chlamydia isolated were characterized by cultural techniques. Chlamydia were isolated from the faeces of lambs on all 26 farms and the prevalence of infection varied form 5-50% on individual farms. There was no significant difference between the proportion of infected lambs on farms where enzootic abortion was present or absent. Lambs first showed infection when they were 3 months old and the prevalence rate of infection increased up to 9 months old. No chlamydia were isolated from the faeces of 316 adult ewes. The chlamydia were identified as enteric rather than abortion type and thus were C. pecorum rather than C. psittaci.

Use of out-of-hours services: the patient's point of view on co-payment a mixed methods approach.

INTRODUCTION: In many countries out of hours (OOH) care is offered by different health care services. General practitioners (GP) tend to offer services in competition with emergency departments (ED). Patients behaviour depends on a number of factors. In this study, we highlight the knowledge and ideas of patients concerning the co-payment system. METHODS: We used a mixed methods design, combining quantitative and qualitative research. During two weekends in January 2005, all patients using the ED or the GP OOH service, were invited for an interview with a structured questionnaire. A stratified random sample of patients participated in a semi-structured interview. Both methods add complementary data to answer the research questions. RESULTS: Most mentioned reasons for seeking help at the ED are: accessibility (15.0%), proximity (6.4%) and competence of the staff (5.6%). Reasons for choosing the GP are: GP is easy to find, minor medical problem or anxiety and confidence in the GP. The odds of not knowing the co-payment system are significantly higher in patients visiting the ED (OR 1.783; 95% CI: 1.493-2.129). Mostly GP users recognize the problem of ED overuse. They suggested especially to provide clear information about the tasks of the different services and about the payment system, to reduce ED overuse. CONCLUSION AND DISCUSSION: When intending to shift from ED to GP services for minor medical problems, aiming at just one measure is no option. Information campaigns aiming to address the entire population, can clarify the role of each player in out-of-hours care.

A low noise preamplifier with optoelectronic overload protection for radioactivity measurement.

Pulses from detectors used for radioactivity measurement can vary in size by several orders of magnitude. Large pulses will lead to saturation at the preamplifier output and extension of the pulse length. As a consequence, the dead time of the system increases and pulses may be lost. Electronic design techniques employed to protect against overloading tend to increase the amplifier noise level. However, an optoelectronic method of overload protection has been devised which has only a negligible effect on noise. An infrared light emitting diode interfaced to the output of the preamplifier is linked by fibre optic cable to an ultra-low leakage photodiode at the input. The conduction of the photodiode increases with the amplitude of the preamplifier output signal. Excess current is thereby prevented from entering the preamplifier and causing saturation. The preamplifier has been tested on 4π beta-gamma and gas counting systems and found to give good protection against overloading.

Experience: the most critical factor in choosing after-hours medical care.

INTRODUCTION: In many countries, a reassessment of after-hours primary care has become necessary. In particular, centralised general practitioner deputizing services (GPDS) have emerged. In this study, consumers' preferences for after-hours medical care were obtained and the use of the new GPDS was predicted. METHOD: On the basis of the Theory of Reasoned Action, a survey was developed that was used at the Free Newborn and Child health care services in Antwerp. Consumers were asked about their knowledge, experience and perceptions concerning the performance of different medical services. RESULTS: 350 questionnaires were used for analysis. 98.6% of the respondents knew about the existence of the emergency department, whereas the GPDS was known by 81.7% of the respondents. The main reasons for preferring emergency department over the other services were an easy access, good explanation by the doctor and a late due time of the payment. Respondents preferred the GPDS mainly because of an expected shorter waiting time. Experience had a strong positive influence on choosing a particular after-hours medical service. CONCLUSION: In our study, the consumers' preferences concerning after-hours medical care were assessed. The following items are crucial for choosing after-hours care: experience with the services, easy access to the service, explanation by the doctor about the illness and the treatment and waiting time.