Health and social care of home-dwelling frail older adults in Switzerland: a mixed methods study.

BACKGROUND: Home-dwelling frail older adults are often faced with multimorbidity and complex care needs, requiring health and social care systems that support frail older adults to age in place. The objective of this paper was to investigate the types of formal health and social care as well as informal care and social support used by home-dwelling frail older adults; whether they perceive their support as sufficient; and their experience with and preferences for care and support. METHODS: Using an explanatory sequential mixed methods design, we first conducted a secondary analysis of a subset of cross-sectional data from the ImplemeNtation of a community-baSed care Program for home dwelling senIoR citizEns (INSPIRE) population survey using descriptive analysis. Subsequently, we analyzed existing data from interviews in the parent study to help explain the survey results using applied thematic analysis. Results were organized according to adapted domains and concepts of the SELFIE framework and integrated via a joint display table. RESULTS: Of the parent population survey respondents, 2314 older adults indicating frailty were included in the quantitative arm of this study. Interview data was included from 7 older adults who indicated frailty. Support from health and social, formal and informal caregivers is diverse and anticipated to increase (e.g., for 'care and assistance at home' and 'meal services'). Informal caregivers fulfilled various roles and while some older adults strongly relied on them for support, others feared burdening them. Most participants (93.5%) perceived their overall support to meet their needs; however, findings suggest areas (e.g., assessment of overall needs) which merit attention to optimize future care. CONCLUSIONS: Given the anticipated demand for future care and support, we recommend efforts to prevent fragmentation between health and social as well as formal and informal care.

Changes in content and synthesis of collagen types and proteoglycans in osteoarthritis of the knee joint and comparison of quantitative analysis with Photoshop-based image analysis.

INTRODUCTION: The different cartilage layers vary in synthesis of proteoglycan and of the distinct types of collagen with the predominant collagen Type II with its associated collagens, e.g. types IX and XI, produced by normal chondrocytes. It was demonstrated that proteoglycan decreases in degenerative tissue and a switch from collagen type II to type I occurs. The aim of this study was to evaluate the correlation of real-time (RT)-PCR and Photoshop-based image analysis in detecting such lesions and find new aspects about their distribution. PATIENTS: We performed immunohistochemistry and histology with cartilage tissue samples from 20 patients suffering from osteoarthritis compared with 20 healthy biopsies. Furthermore, we quantified our results on the gene expression of collagen type I and II and aggrecan with the help of real-time (RT)-PCR. Proteoglycan content was measured colorimetrically. Using Adobe Photoshop the digitized images of histology and immunohistochemistry stains of collagen type I and II were stored on an external data storage device. The area occupied by any specific colour range can be specified and compared in a relative manner directly from the histogram using the "magic wand tool" in the select similar menu. In the image grow menu gray levels or luminosity (colour) of all pixels within the selected area, including mean, median and standard deviation, etc. are depicted. Statistical Analysis was performed using the t test. METHOD: With the help of immunohistochemistry, RT-PCR and quantitative RT- PCR we found that not only collagen type II, but also collagen type I is synthesized by the cells of the diseased cartilage tissue, shown by increasing amounts of collagen type I mRNA especially in the later stages of osteoarthritis. RESULTS: A decrease of collagen type II is visible especially in the upper fibrillated area of the advanced osteoarthritic samples, which leads to an overall decrease. Analysis of proteoglycan showed a loss of the overall content and a quite uniform staining in the different zones compared to the healthy cartilage with a classical zonal formation. Correlation analysis of the proteoglycan Photoshop measurements with the RT-PCR using Spearman correlation analysis revealed strong correlation for Safranin O and collagen type I, medium for collagen type II and glycoprotein but weak correlation between PCR aggrecan results. CONCLUSION: Photoshop-based image analysis might become a valuable supplement for well known histopathological grading systems of lesioned articular cartilage.

Surgical treatment of tumours and metastases of the spine by minimally invasive cavity-coblation method.

Tumours and metastases of the spine are extremely stressful for patients, especially for elderly multimorbid patients. The modern cavity/coblation method offers a very good therapeutic alternative for such patients. The goal of this article was to evaluate and present the characteristics, significance, opportunities, issues of the minimum invasive cavity/coblation method as well as the results of the treatment of 302 patients with vertebral tumours and metastases.

Treatment of tumors and metastases of the spine by minimally invasive CAVITY-coblation method (plasma field therapy).

BACKGROUND: A radical surgery of spine metastases is not possible in many cases, especially by elder multi morbid patients. The modern CAVITY/coblation method offers a very good therapeutic alternative for such patients. The goal of this paper was to evaluate and present the method as well as the results of the treatment of 302 patients with vertebral tumors/metastases. METHODS: Patients with vertebral destructions of the spine caused by spinal tumors and metastases were treated. Diagnosis preoperatively: X-ray, MRT, CT, PET, histology. Tumor tissue resection was carried out by plasma field over the percutaneous transpedicular access and was followed by kyphoplasty. Follow-up with clinical and radiological examinations are in 2, 14 days, 3, 6, 12, 24, 36, 48, 60 months postoperatively. RESULTS: Within 6 years (04/2008-05/2014) 302 patients (188 female, 114 male, age range of 31-92, average age of 65.4 years) were treated. It was shown by all patients: less blood loss, no seriously complications, pain reduction, increase in life quality. Postoperatively was possible: rapid mobilization, immediate radiation and chemotherapy for reduction of the local tumor recurrence rate. CONCLUSIONS: CAVITY has shown itself to be a safe, minimal invasive procedure with good short and long term results, a low complication rate, blood loss and short surgery times. The total local recurrence rate was only 13.5%. Important are: comprehensive diagnostic including tumor staging, correct indication, prognostic assessment, precise surgical technique.

Radiolabeled somatostatin analog [177Lu-DOTA0,Tyr3]octreotate in patients with endocrine gastroenteropancreatic tumors.

PURPOSE: There are few treatment options for patients with metastasized or inoperable endocrine gastroenteropancreatic (GEP) tumors. Chemotherapy can be effective, but the response is usually less than 1 year. Here, we present the results of treatment with a radiolabeled somatostatin analog, [177Lu-DOTA0,Tyr3]octreotate (177Lu-octreotate). PATIENTS AND METHODS: One hundred thirty-one patients with somatostatin receptor-positive tumors were treated with up to a cumulative dose of 600 to 800 mCi (22.2 to 29.6 GBq) of 177Lu-octreotate. RESULTS: One patient developed renal insufficiency, and another patient developed hepatorenal syndrome. Creatinine clearance did not change significantly in the other patients. WHO hematologic toxicity grade 3 or 4 occurred after less than 2% of the administrations. We observed complete remission in three patients (2%), partial remission in 32 patients (26%), minor response (tumor diameter decrease of 25% to 50%) in 24 patients (19%), stable disease (SD) in 44 patients (35%), and progressive disease (PD) in 22 patients (18%). Higher remission rates were positively correlated with high uptake on pretherapy somatostatin receptor imaging and a limited number of liver metastases, whereas PD was significantly more frequent in patients with a low performance score and extensive disease. Median time to progression in 103 patients who either had SD or tumor regression was more than 36 months. CONCLUSION: Treatment with 177Lu-octreotate results in tumor remission in a high percentage of patients with GEP tumors. Serious side effects are rare. The median time to progression compares favorably with chemotherapy. Results are better in patients with a limited tumor load. Therefore, early treatment, even in patients who have no PD, may be better.

Endocrine tumours of the gastrointestinal tract. Peptide receptor radionuclide therapy.

Peptide receptor radionuclide therapy is a new treatment modality for patients with inoperable or metastasised neuroendocrine gastroenteropancreatic tumours. After the successful implementation of somatostatin receptor scintigraphy in daily clinical practice, the next logical step was to increase the radiation dose of the administered radiolabelled somatostatin analogue in an attempt to induce tumour shrinkage. Since then, an increasing number of patients has been successfully treated with this approach, resulting in a substantial numbers of patient with objective tumour shrinkage. Serious side-effects have been rare. This article reviews the effectiveness of the different radiolabelled somatostatin analogues used, the currently known side-effects and the survival data available. Furthermore, clinical issues, including indication and timing of therapy, are discussed. Finally, important directions for future research are briefly mentioned to illustrate that, although the currently available results already suggest a favourable outcome compared with other systemic therapies, new strategies are being developed to increase efficacy.

Effects of electroconvulsive therapy on regional cerebral blood flow measured by 99mtechnetium HMPAO SPECT.

Decreased cerebral blood flow is documented in depression. In this study, 15 patients were studied with 99mTc-HMPAO SPECT before and after a course of electroconvulsive therapy (ECT). Improvement in frontal and temporal hypoperfusion was seen only in those patients who responded to ECT. Cerebral hypoperfusion may be a state-dependent marker in depressive illness.

Liver and vertebral uptake of Tc-99m macroaggregated albumin (MAA).

An unusual phenomenon during lung scintigraphy is presented. Besides visualization of the lungs, accumulation of Tc-99m macroaggregated albumin (MAA) was seen in a small part of the liver and in and around several thoracic vertebrae. Contrast-enhanced radiographic computed tomography revealed extensive collateral pathways, which were caused by a partially obstructed superior vena cava. Shunting of systemic venous blood flow through chest wall veins to the portal system was responsible for accumulation of MAA in the liver. Retrograde blood flow through dilated thoracic vertebral veins resulted in visualization of the bone marrow.

Correlation between 3D microstructural and 2D histomorphometric properties of subchondral bone with healthy and degenerative cartilage of the knee joint.

Cartilage degeneration of the knee joint is considered to be a largely mechanically driven process. We conducted a microstructural and histomorphometric analysis of subchondral bone samples of intact cartilage and in samples with early and higher- grade arthritic degeneration to compare the different states and correlate the findings with the condition of hyaline cartilage. These findings will enable us to evaluate changes in biomechanical properties of subchondral bone during the evolution of arthritic degeneration, for which bone density alone is an insufficient parameter. From a continuous series of 80 patients undergoing implantation of total knee endoprosthesis 30 osteochondral samples with lesions macroscopically classified as ICRS grade 1b (group A) and 30 samples with ICRS grade 3a or 3b lesions (group B) were taken. The bone samples were assessed by 2D histomorphometry (semiautomatic image analysis system) and 3D microstructural analysis (high-resolution micro-CT system). The cartilage was examined using the semiquantitative real-time PCR gene expression of collagen type I and II and aggrecan. Both histomorphometry and microstructural and biomechanical analysis of subchondral bone in groups A and B consistently revealed progressive changes of both bone and cartilage compared with healthy controls. The severity of cartilage degeneration as assessed by RT PCR was significantly correlated with BV/TV (Bone Volume Fraction), Tb.Th (Trabecular Thickness) showed a slight increase. Tb.N (Trabecular Number), Tb.Sp (Trabecular separation) SMI (Structure Model Index), Conn.D (Connectivity Density) and DA (Degree of Anisotropy) were inversely correlated. We saw sclerotic transformation and phagocytic reticulum cells. Bone volume fraction decreased with an increasing distance from the cartilage with the differences compared with healthy controls becoming greater in more advanced cartilage damage. The density of subchondral bone alone is considered an unreliable parameter for classifying changes evolving over time. The progressive damage of subchondral bone seen in the present study correlates well with cartilage changes. Trabecular orientation is also impaired, which explains the changes in biomechanical parameters and the inadequate load transfer and excessive loading of cartilage. Besides subchondral bone density, which in turn correlates with cartilage thickness, other parameters such as structure model index and grade of anisotropy best reflect mechanical properties such as Young modulus, compressive strength, tensile stress, and failure energy. However, it remains unclear whether the mechanical interaction of the mineralized subchondral tissues with articular cartilage works vice versa. The possibility of a biochemical signalling from the degenerating cartilage via the synovial fluid and bone- cartilage crosstalks via subchondral pores may indeed explain a certain depth-dependency of subchondral bone changes.

Semiquantitative analysis of ECM molecules in the different cartilage layers in early and advanced osteoarthritis of the knee joint.

The study was conducted to examine the expression of collagen type I and II in the different cartilage layers in relation to other ECM molecules during the progression of early osteoarthritic degeneration in human articular cartilage (AC). Quantitative real-time (RT)-PCR and colorimetrical techniques were used for calibration of Photoshop-based image analysis in detecting such lesions. Immunohistochemistry and histology were performed with 40 cartilage tissue samples showing mild (ICRS grade 1b) respectively moderate/advanced (ICRS grade 3a or 3b) (20 each) osteoarthritis compared with 15 healthy biopsies. Furthermore, we quantified our results on the gene expression of collagen type I and II and aggrecan with the help of real-time (RT)-PCR. Proteoglycan content was measured colorimetrically. The digitized images of histology and immunohistochemistry stains were analyzed with Photoshop software. T-test and Spearman correlation analysis were used for statistical analysis. In the earliest stages of AC deterioration the loss of collagen type II was associated with the appearance of collagen type I, shown by increasing amounts of collagen type I mRNA. During subsequent stages, a progressive loss of structural integrity was associated with increasing deposition of collagen type I as part of a natural healing response. A decrease of collagen type II is visible especially in the upper fibrillated area of the advanced osteoarthritic samples, which then leads to an overall decrease. Analysis of proteoglycan showed losses of the overall content and a loss of the classical zonal formation. Correlation analysis of the proteoglycan Photoshop measurements with the RT-PCR revealed strong correlation for Safranin O and collagen type I, medium for collagen type II, alcian blue and glycoprotein but weak correlation with PCR aggrecan results. Photoshop based image analysis might become a valuable supplement for well known histopathological grading systems of lesioned articular cartilage. The evidence of collagen type I production early in the OA disease process coupled with the ability of chondrocytes to up-regulate collagen type II production suggests that therapeutic agents that suppress collagen type I production and increase collagen type II production may enable chondrocytes to generate a more effective repair response.

[Langerhans cell histiocytosis of the dens axis]. / Langerhanscelhistiocytose van de dens axis.

BACKGROUND: Langerhans cell histiocytosis, formerly known as histiocytosis X, is characterised by clonal proliferation of pathologic cells resembling Langerhans cells. Langerhans cell histiocytosis is commonly localised in the bones of the skull or in the skin; however, a great variety of foci has been described. CASE: A general practitioner referred a 25-year-old man to the neurologist because of progressive pain in the neck that had arisen spontaneously. The pain had become so severe over a period of 3 weeks that he had had to support his head with both hands to ease it. Chiropractic treatment had resulted in a worsening of the symptoms. On physical examination, two pathologically enlarged lymph nodes were palpable on the left side of the neck. CT, MRI and PET scans revealed an osteolytic lesion at the site of the dens axis (C2). Immunohistochemistry of the lymph node demonstrated positive staining for CD1a and S100, characteristic of Langerhans cell histiocytosis. The patient was treated with chemotherapy and osteosynthesis of the C1-C2-C3 vertebrae; he was able to return to work after 9 months. CONCLUSION: Langerhans cell histiocytosis is an extremely rare condition; its diagnosis is often missed or made at a later time. The golden diagnostic standard is histopathological analysis of the abnormality. The condition's prognosis is related to its extent. Its localisation in the dens axis has not been previously described.