[Long-term goals for oral health]. / Lang leve de duurzame mondzorg.

The current, optimistic prognosis is that newborns will reach an average age of 100 years. This increased life-expectancy requires a renewed vision of long-term goals for oral health. The starting-point could be a prospective end-point with minimal oral function which should be reached, for example, in the last years of one's life. The consequence is that adequate oral healthcare for the elderly starts in childhood. Choices such as the extraction of premolars for orthodontic reasons and the dental re-restoration cycle have a great negative impact on reaching this goal. The average sustainability of dental restorations or prosthetic constructions is commonly much shorter than the life-expectancy of a patient. If oral treatment is necessary, it is recommended to give priority to maintaining a minimally functional dentition up to an advanced age, instead offocusing on short- or medium-term goals.

Heterologous expression of mutated eburicol 14alpha-demethylase (CYP51) proteins of Mycosphaerella graminicola to assess effects on azole fungicide sensitivity and intrinsic protein function.

The recent decrease in the sensitivity of the Western European population of the wheat pathogen Mycosphaerella graminicola to azole fungicides has been associated with the emergence and subsequent spread of mutations in the CYP51 gene, encoding the azole target sterol 14alpha-demethylase. In this study, we have expressed wild-type and mutated M. graminicola CYP51 (MgCYP51) variants in a Saccharomyces cerevisiae mutant carrying a doxycycline-regulatable tetO(7)-CYC promoter controlling native CYP51 expression. We have shown that the wild-type MgCYP51 protein complements the function of the orthologous protein in S. cerevisiae. Mutant MgCYP51 proteins containing amino acid alterations L50S, Y459D, and Y461H and the two-amino-acid deletion DeltaY459/G460, commonly identified in modern M. graminicola populations, have no effect on the capacity of the M. graminicola protein to function in S. cerevisiae. We have also shown that the azole fungicide sensitivities of transformants expressing MgCYP51 variants with these alterations are substantially reduced. Furthermore, we have demonstrated that the I381V substitution, correlated with the recent decline in the effectiveness of azoles, destroys the capacity of MgCYP51 to complement the S. cerevisiae mutant when introduced alone. However, when I381V is combined with changes between residues Y459 and Y461, the function of the M. graminicola protein is partially restored. These findings demonstrate, for the first time for a plant pathogenic fungus, the impacts that naturally occurring CYP51 alterations have on both azole sensitivity and intrinsic protein function. In addition, we also provide functional evidence underlying the order in which CYP51 alterations in the Western European M. graminicola population emerged.

[Proxy consent and responsibility: professional autonomy and adamant family members]. / Vertegenwoordiging en verantwoordelijkheid. Over medische verantwoordelijkheid en mondige familieleden.

Research into the role of family members in the decision making process concerning medical treatment of incompetent patients in nursing home care, shows that the involvement of a proxy decision maker implies a greater responsibility of the physician. It is the duty of the proxy decision-maker (mostly a family member) to look after the incompetent patient's interests. But it is the physician's duty to decide whether the proxy decision maker indeed fulfills this task. Even so, the physician has the professional responsibility to decide on the medical course of action. Involvement of others (relations and other health care professionals) is of great importance to the answer to the question 'What is good for this patient?' but does not absolve the physician from the obligation to decide professionally what is the right thing to do.

[Death due to or despite the doctor]. / Overlijden dankzij of ondanks de arts.

In the last week of life, the extent and kind of medical practice differ both in intention and in the degree of orientation on the outcome. Patients tend to put long-term prescriptions aside or ask for symptom-relieving medication and sometimes for palliative sedation, euthanasia or physician-assisted suicide. Competent physicians are able to offer or withhold treatment. In case of unconsciousness or severe cognitive impairment, proxies may ask for medical relief of disturbing symptoms. Medical practice is subject to the Dutch Medical Treatment Act (1995). At the start of the specific Dutch law specifying judicial review of euthanasia and physician-assisted suicide (1993, implemented in 2002) 1.8% of deaths concerned euthanasia. In 2005, standard drugs (choice, dose and route of administration) were highly effective in all cases of euthanasia in which they were used (76%): death within a median of 3-4 min, maximum 90 min. In the absence of medical indications for drug overdose, morphine and other choices are now considered obsolete for euthanasia and physician-assisted suicide. The definition of euthanasia must be based exclusively on a standard method and outcome: death on request by a standard medical method with a standard judicial review.

[There is no natural death without suffering, even in a nursing home]. / Geen natuurlijk overlijden zonder lijden, ook in het verpleeghuis.

During the past 30 years, the legal and moral framework for terminal care and hospice provision has changed, both nationally and internationally, but the situation is still not completely clear. The nursing homes in the Netherlands have also developed, described and implemented palliative care. In most regional systems for palliative care, a supportive and sometimes an active therapeutic role is played by medical, nursing, paramedical and pastoral nursing home professionals. In view of the strong relationship between a poor or worsening nutritional state and fluid balance and death, particularly of psychogeriatric nursing-home patients, a multiprofessional guideline has been drawn up for the responsible provision of food and fluids in nursing homes. It is likely, although not certain, that this guideline will contribute to the limitation of the suffering of the dying patient. The guideline will in any case make the compassion of the family and the sympathy of care-givers discussible and almost always manageable. In many nursing homes, meanwhile, it has become accepted practice, soon after admission, to discuss the future suffering of the patient during the process of dying and to record this conversation.

Role of Ascospores in Further Spread of QoI-Resistant Cytochrome b Alleles (G143A) in Field Populations of Mycosphaerella graminicola.

ABSTRACT Strobilurin fungicides or quinone outside inhibitors (QoIs) have been used successfully to control Septoria leaf blotch in the United Kingdom since 1997. However, QoI-resistant isolates of Mycosphaerella graminicola were reported for the first time at Rothamsted during the summer of 2002. Sequence analysis of the cytochrome b gene revealed that all resistant isolates carried a mutation resulting in the replacement of glycine by alanine at codon 143 (G143A). Extensive monitoring using real-time polymerase chain reaction (PCR) testing revealed that fungicide treatments based on QoIs rapidly selected for isolates carrying resistant A143 (R) alleles within field populations. This selection is driven mainly by polycyclic dispersal of abundantly produced asexual conidia over short distances. In order to investigate the role of sexually produced airborne ascospores in the further spread of R alleles, a method integrating spore trapping with real-time PCR assays was developed. This method enabled us to both quantify the number of M. graminicola ascospores in air samples as well as estimate the frequency of R alleles in ascospore populations. As expected, most ascospores were produced at the end of the growing season during senescence of the wheat crop. However, a rapid increase in R-allele frequency, from 35 to 80%, was measured immediately in airborne ascospore populations sampled in a wheat plot after the first QoI application at growth stage 32. After the second QoI application, most R-allele frequencies measured for M. graminicola populations present in leaves and aerosols sampled from the treated plot exceeded 90%. Spatial sampling and testing of M. graminicola flag leaf populations derived from ascospores in the surrounding crop showed that ascospores carrying R alleles can spread readily within the crop at distances of up to 85 m. After harvest, fewer ascospores were detected in air samples and the R-allele frequencies measured were influenced by ascospores originating from nearby wheat fields.

[Stroke services are increasingly effective]. / Stroke-services toenemend effectief.

Since the first Consensus Statement on the treatment of stroke (UK, 1988) and the European Helsingborg Declaration on the treatment of stroke (1995), 69 stroke services have been geographically spread in the Netherlands; these consist of an integrated hospital stroke unit, a nursing home rehabilitation unit, and home care. The Dutch stroke services have improved their outcomes in a cost-effective way in comparison with the usual care. Consensus on patient-oriented outcomes--arranged in order of the International Classification of Functioning, Disability and Health--is recommended.

[Practice guideline 'Influenza prevention in nursing homes and care homes', issued by the Dutch Society of Nursing Home Specialists; division of tasks between nursing home specialist, general practitioner and company doctor]. / De richtlijn 'Influenzapreventie in verpleeghuizen en verzorgingshuizen' van de Nederlandse Vereniging van Verpleeghuisartsen; taakverdeling tussen verpleeghuisarts, huisarts en bedrijfsarts.

The Dutch Society of Nursing Home Specialists has formulated a guideline for the prevention of influenza in nursing homes and care homes in The Netherlands. The guideline recommends the realisation of the highest possible degree of vaccination of both patients and health care workers. At the start of the flu season, the manager of the chronic care institute should organize a scheme for vaccination against influenza and a plan in case of an outbreak of influenza. The division of tasks between the nursing home specialist, the general practitioner and the company doctor should be recorded in both the vaccination scheme and the outbreak plan. In order to decrease the incidence of non-response to the vaccine a double dose of influenza vaccine for nursing home patients should be considered. The outbreak plan should raise the state of alertness for influenza and ensure that virological confirmation of clinical influenza is obtained quickly. Immediately after virological confirmation of clinical influenza, patients with influenza should be treated with oseltamivir and both patients and health care workers in the unit should receive prophylaxis with oseltamivir. Non-vaccinated patients should also be offered vaccination to restrict re-introduction of the virus. During an influenza outbreak, only patients with influenza or those who have had prophylactic treatment may be admitted to the facility. In the case of an influenza pandemic, national guidelines should be followed.

Reduced IFN-gamma production in elderly people following in vitro stimulation with influenza vaccine and endotoxin.

Cytokine interferon gamma (IFN-gamma) is pivotal in the defence against viruses and intracellular pathogens and an age-related decreased IFN-gamma production may explain the increased infectious disease morbidity and mortality in the elderly. Therefore, we performed a series of clinical experiments evaluating the influence of age and health status on IFN-gamma production following in vitro stimulation with influenza vaccine or endotoxin. Both healthy and frail elderly people produced significantly lower amounts of IFN-gamma following ex vivo stimulation with influenza vaccine or endotoxin. We conclude that ageing is accompanied by a decreased capacity to produce IFN-gamma. This may explain the increased incidence and case-fatality caused by viruses and intracellular pathogens in the elderly.

Infection control in a skilled nursing facility: a 6-year survey.

In 1981 an infection control programme was started in a 320-bed skilled nursing facility in The Netherlands. The programme consisted of recording the antimicrobial drugs prescribed and the site of infection, culture of urine from patients admitted from hospital and from residents with suspected symptomatic urinary tract infection, restriction of long-term indwelling urethral catheterization and restricted use of antimicrobial drugs. At a weekly staff meeting, these data were reviewed. As a result of the programme, the number of treatments for urinary tract infections decreased by 74% between 1981 and 1986, and the number of courses for recurrent urinary tract infections decreased from 18 to 6% of the total number given. The patients who did not require antimicrobial therapy increased from 51% in 1981 to 70% in 1986.

Measuring disability in nursing home residents: validity and reliability of a newly developed instrument.

A 24-item multidimensional nurse-administered Nursing Home Disabilities Instrument (NHDI) was developed to measure disabilities in nursing home residents. We present the psychometric features and value of this instrument, with the following domains assessed: Mobility, Activities of Daily Living (ADLs), Alertness, Resistance to Nursing Assistance, Incontinence, Cognition, and PERCEPTION: Test-retest and interrater reliability was assessed using the Spearman correlation coefficient. Internal consistency was examined by Cronbach's alpha. Criterion validity tests were performed by comparing the scales with scales of the Elderly Residents Rating Scale (BOP). Test-retest reliability correlation coefficients ranged from 0.63 to 0.94. Interrater reliability was high for the scales Cognition, Mobility, ADL, and Incontinence (0.79 to 0.93), moderate for Resistance (0.51), and low for Perception (0.33). Cronbach's alpha of the scales was high, ranging from 0.78 (Alertness) to 0.93 (Mobility); only Perception showed a low alpha: 0.54. Criterion validity was high for Cognition, ADL, and Mobility (0.75 to 0.78), and moderate for Alertness (0.59). The NHDI appears to be a valid and efficient multidimensional instrument for measuring disabilities in nursing home residents. These findings imply that the NHDI is a useful instrument for nursing homes to achieve a reliable assessment of cognitively impaired elders.

Classifying the probability of urinary incontinence in psychogeriatric nursing home patients.

Urinary incontinence (UI) frequently occurs in psychogeriatric nursing home patients. In general the personnel involved in the care for these patients act on incontinence noted. Patients are not monitored or classified according to likelihood or severity of incontinence. This study was conducted to develop and validate a model for the classification of the likelihood of UI in demented nursing home patients. A multi-center cross-sectional study was conducted using data on clinical and functional status of 692 subjects. Subjects were subdivided in a Derivation set of 532 patients and a Validation set of 160 patients. The data were ascertained with questionnaires completed by physicians and nursing staff. All psychogeriatric wards (25) of four Dutch nursing homes were included. Using univariate logistic regression analysis on the derivation set we identified correlates of UI among 22 clinical and functional patient characteristics. Subsequently, we developed a classification model for prevalent UI, including independent patient characteristics by means of multivariable logistic regression. Next, we stratified patients into groups with varying likelihood's of UI based on the model developed. Subsequently, we transformed the model to an easy applicable classification rule for the identification of patient subgroups with high or low likelihood on UI. Finally, the rule was validated on the validation set. The independent multivariate factors associated with urinary incontinence were impaired ADL and mobility, diminished alertness and fecal impaction. After transforming the regression model to an easy classification rule, the scores ranged from 0 to 7. The area under the curve was 0.88 (95% Confidence Interval (CI): 0.85-0.91) in the derivation set. In the validation set a similar area under the curve was obtained (0.90 (95% CI: 0.85-0.95)). Among subjects with none of the associated factors the rule classified 0.5% as incontinent patients. In case all associated factors were present the proportion classified as incontinent increased to 91%. In conclusion, the developed classification rule provides means to stratifying nursing home patients according to their likelihood of being incontinent of urine.

[Fecal incontinence in the elderly]. / Incontinentie voor ontlasting bij bejaarden.

Faecal incontinence in the elderly is not compatible with normal social function and leads to interventions and/or institutionalization. In homes for the elderly about 10% and in nursing homes 42.8% of the patients are faecally incontinent. There are predisposing, precipitating and uncleanliness factors. Four ways of faecal loss are described. The purposes of diagnosis and therapy are: 1. prevent and cure diseases, which cause unintentional faecal loss, 2. maintain lavatory visiting as long as possible and 3. prevent soiling the old patient himself and his surroundings.

[Infections in the elderly, especially in nursing homes]. / Infecties bij bejaarden, met name in het verpleeghuis.

From the viewpoint of defense against micro-organisms it is diagnostically important to differentiate between frontier activity, frontier incident and invasion through the frontier. The barrier of the older body can be characterised by a multiple vulnerability, injury and pathology. Endogenous and exogenous (including therapeutic) causal factors are discussed. A management of vigilance and treatment of functional disturbances of the barrier of the old body is suggested.

[The patient with a long-term indwelling catheter]. / De patiënt met een langudurige verblijfcatheter.

A working-group of the Scientific Council of the CBO has drawn up a report on infection control of patients with longterm indwelling catheterization of the urinary bladder. In the first place, restricted use of catheters and shortening of their indwelling use are intended. Furthermore preventive and diagnostic measures and treatment are recommended in case of urinary tract infection and blocking catheters.

[Measurement or estimation of body length in older nursing home patients]. / Het meten of schatten van de lichaamslengte van oudere verpleeghuispatiënten.

Measurement of body height of elderly persons can be difficult or impossible because of inability to stand or inability to stand in the right position. In seventy-five percent of elderly patients of a nursing home (n = 281) height could not be measured. Measurement of the height in a recumbent position was possible in fifty-five percent of the patients and measurement of arm span, used as a substitute for height, in sixty percent. Knee height could be measured in 95% of the patients; height can however roughly be estimated from knee height. Indices reflecting nutritional status, which require height as a variable (such as Quetelet Index), are of limited use for elderly patients in nursing homes.

[Body weight of elderly patients on admission to a nursing home]. / Het lichaamsgewicht van ouderen bij opname in het verpleeghuis.

Body weight of elderly patients on admission to a 'verpleeghuis' (Nursing-home in the Netherlands) was 5 to 8 kg lower than that of healthy persons of the same age living at home. No difference in body weight was found between 'verpleeghuis' patients on admission and after long stay. Psychogeriatric men weighed more than somatic; the body weight of psychogeriatric and somatic women did not differ. Terminal patients weighed less than chronic patients and patients, who could be discharged from the 'verpleeghuis'. A relationship was found between body weight and age: the older the patient is, the lower he weighs. Body weight of women was also lower in the case of 'unmarried status' and 'admission residential homes'.

[Use of drugs for CNSLD (asthma and COPD) in Dutch residential homes and nursing homes]. / Het gebruik van CARA-geneesmiddelen in verzorgingsen verpleeghuizen.

Of the 1019 residents of eight dutch homes for the elderly and 699 patients of five nursing homes, respectively 6.0 and 8.1% were administered drugs for chronic non-specific lung disease (CNSLD), which is a term covering asthma as well as copd. The treatment consisted of, usually inhaled, beta-agonists and/or anti-cholinergics in 82%, inhaled as well as oral corticosteroids in 60%, and xanthine-derivates and N-acetylcysteïne, both of which were taken orally, in 28 and 21% of the patients respectively. It was found that almost half (47%) of the patients using inhaled drugs, which 90% of them did either with or without help, made at least three mistakes during inhalation. Considering that CSNLD is probably underdiagnosed, especially when it occurs as a cause of co-morbidity and will have an unfavourable influence on the general state of health by reducing lung function, the suboptimal application of inhaled drugs should be a cause of concern for those who treat elderly patients with asthma and or copd.

Long-term ambulatory monitoring of urine leakage in the elderly: an evaluation of the validity and clinical applicability of thermistor signalling.

This study evaluated the validity and applicability of a low-cost Urine Leakage Recording Device (ULRD) in a geriatric setting. The ULRD consisted of a thermistor, connected to a portable, digital datalogger. The thermistor was positioned on a commercially available adult diaper. Five healthy females were instructed to void urine in seven behavioural conditions comprising general motor activity patterns of the average, psychogeriatric elderly in-patient. Voids were verbally indicated by the subjects and concomitantly recorded by the ULRD and the observer. After comparing the ULRD records--scored by three independent assessors--with the subjects' reports, on average (SD) 5.3 (0.6) of a total of 10 voids were classified correctly, whereas 9.3 (1.3) false positive events were indicated. None of the subjects reported any inconvenience as a result of the recording procedure. Although the ULRD is easily applicable, we conclude that it seems to be of little value in its present form as a method for long-term ambulatory monitoring of urine leakage.