[Analysis of mental health care utilization data in comparison with medical-specialist and general practitioner health care consumption data]. / Behoefte aan en consumptie van ggz-zorg vergeleken met somatische zorg in Nederland.

BACKGROUND: Quantification of population-level socioeconomic-demographic factors impacting onset and course of health care consumption can help health care commissioning and public health planning.
AIM: To analyse associations between mental health care, medical-specialist care and general practitioner (GP) care with regional socioeconomic-demographic factors. Two cost parameters were examined: (i) absolute costs; and (ii) relative costs, defined as the proportion of PC3-level costs attributable to outliers (defined as costs above the 80th percentile - as a proxy for care intensity).
METHOD: Analysis of Vektis data over the period 2014-2017 in the age range of 18-65 years.
RESULTS: Mental health care cost variation was for 28% reducible to (younger) age, urbanicity, PC3-level ethnic density and PC3-level socioeconomic-demographic factors. Variation in medical-specialist care and GP care costs were reducible principally to (older) age. Costs attributable to outliers ranged from 34% for GP care to 55% for mental health care. Socioeconomic-demographic factors explained a substantial part of the variation in the PC3-level proportion of outlier costs for mental health care (31%), medical-specialist care (43%) and GP-care (33%).
CONCLUSION: Analysis of the degree and pattern of socioeconomic-demographic factors impacting mental health care can inform both public mental health planning and mental health care commissioning. Tijdschrift voor psychiatrie 63(2021)1, 39-47.

Clinical effects and treatment outcomes of long-term compulsory in-patient treatment of treatment-resistant patients with severe mental illness and substance-use disorder.

BACKGROUND: The treatment of homeless dual-diagnosis patients (i.e., those with severe mental illness and substance-use disorder) is difficult and often fails. For patients in the Netherlands who had not responded to earlier voluntary and compulsory treatment, a new treatment facility - Sustainable Residence (SuRe) - was developed to offer long-term compulsory in-patient treatment. AIM OF THE STUDY: To study patterns of changes in clinical and functional outcomes during treatment at SuRe and how these relate to eventual treatment outcome. METHODS: On the basis of the intensity of care needed after four years, three groups of patients were distinguished (total n = 165): those discharged to a less restrictive and less supportive setting (n = 70, 42%), those still hospitalized at SuRe at the end of the four-year study period (n = 69, 42%) and those referred to a more appropriate setting (n = 26, 16%). Random coefficient analysis was used to examine differences between groups regarding changes in clinical and functional outcomes during treatment. During treatment, outcomes were monitored using Routine Outcome Assessment. RESULTS: All three groups made small but significant improvements on global psychosocial functioning, distress and therapeutic alliance (effect sizes (ES) 0.11 to 0.16 per year). Patients who were discharged to a less restrictive setting showed small to moderate improvement in risk to self and others, psychiatric symptoms, and skills for daily living (ES 0.19-0.33 per year and 0.42-0.73 for their mean 2.2-year treatment period). Patients remaining at SuRe showed a small increase in risk to self (ES 0.20 per year; 0.80 for their treatment period of four years or more). Oppositional behaviour was consistently greater in referred patients than in the other groups (ES 0.74-0.75). CONCLUSION: Long-term compulsory treatment appeared to have helped improve clinical and functional outcomes in a substantial proportion (42%) of previously severely dysfunctional, treatment-resistant dual-diagnosis patients, who could then be discharged to a less restrictive and less supportive environment. However, risk-to-self increased in a similar proportion. A smaller number of patients (16%) showed marked oppositional behaviour and needed a higher level of care and protection in another facility.

The use of an electronic clinical rule to discontinue chronically used benzodiazepines and related Z drugs.

PURPOSE: The chronic use of benzodiazepines and benzodiazepine-related drugs (BZ/Z) in older people is common and not without risks. The objective of this study was to evaluate whether the implementation of a clinical rule promotes the discontinuation of chronically used BZ/Z for insomnia. METHODS: A clinical rule, generating an alert in case of chronic BZ/Z use, was created and applied to the nursing home (NH) setting. The clinical rule was a one-off intervention, and alerts did not occur over time. Reports of the generated alerts were digitally sent to NH physicians with the advice to phase out and eventually stop the BZ/Z. In cases where the advice was adopted, a follow-up period of 4 months on the use of BZ/Z was taken into account in order to determine whether the clinical rule alert led to a successful discontinuation of BZ/Z. RESULTS: In all, 808 NH patients were screened. In 161 (19.1%) of the patients, BZ/Z use resulted in a clinical rule alert. From these, the advice to phase out and stop the BZ/Z was adopted for 27 patients (16.8%). Reasons for not following the advice consisted of an unsuccessful attempt in the past (38 patients), patients family and/or patient resistance (37 patients), the non-continuous use of BZ/Z (32 patients) and indication still present (27 patients). Of the 12 NH physicians, seven adopted the advice. CONCLUSIONS: The success rate of a clinical rule for discontinuation of chronically used BZ/Z for insomnia was low, as reported in the present study. Actions should be taken to help caregivers, patients and family members understand the importance of limiting BZ/Z use to achieve higher discontinuation rates.

Energy consumption and water-soluble protein release by cell wall disruption of Nannochloropsis gaditana.

Several cell disruption methods were tested on Nannochloropsis gaditana, to evaluate their efficiency in terms of cell disintegration, energy input and release of soluble proteins. High-pressure homogenization (HPH) and bead milling were the most efficient with >95% cell disintegration, ±50% (w/w) release of total proteins and low energy input (<0.5kWh.kg-1biomass). Enzymatic treatment required low energy input (<0.34kWh.kg-1biomass), but it only released ±35% protein (w/w). Pulsed Electric Field (PEF) was neither energy-efficient (10.44kWh.kg-1biomass) nor successful for protein release (only 10% proteins w/w) and cell disintegration. The release of proteins after applying HPH and bead milling always required less intensive operating conditions for cell disruption. The energy cost per unit of released protein ranged from 0.15-0.25 €.kgProtein-1 in case of HPH, and up to 2-20 €.kgProtein-1 in case of PEF.

Biorefinery of microalgal soluble proteins by sequential processing and membrane filtration.

A mild biorefinery process was investigated on the microalga Nannochloropsis gaditana, to obtain an enriched fraction of water soluble proteins free from chlorophyll. After harvesting, a 100g.L-1 solution of cells was first subjected to cell disruption by either high-pressure homogenization (HPH) or enzymatic treatment (ENZ). HPH resulted in a larger release of proteins (49%) in the aqueous phase compared to the Alcalase incubation (35%). In both cases, an ultrafiltration/diafiltration (UF/DF) was then performed on the supernatant obtained from cell disruption by testing different membrane cut-off (1000kDa, 500kDa and 300kDa). After optimising the process conditions, the combination of ENZ→UF/DF ended in a larger overall yield of water soluble proteins (24.8%) in the permeate compared to the combination of HPH→UF/DF (17.4%). A gel polarization model was implemented to assess the maximum achievable concentration factor during ultrafiltration and the mass transfer coefficient related to the theoretical permeation flux rate.

Usually Available Clinical and Laboratory Data Are Insufficient for a Valid Medication Review: A Crossover Study.

OBJECTIVES: To establish the quality of medication reviews performed by nursing home physicians, general practitioners and pharmacists. DESIGN AND SETTING: 15 Pharmacists, 13 general practitioners and 18 nursing home physicians performed a medication review for three cases (A, B and C), at three evaluation moments. First, they received the medication list. Secondly, they also received laboratory results and reason for admission and finally, we added medical history. Remarks were divided into 6 categories, i.e. indication without medication, medication without indication, contraindications/ interactions, dosage problems, double medication and wrong medication. Remarks were compared to the remarks made by our expert panel and scored according to our grading model as appropriate (0 to +3) or missed or potentially harmful (-1). For each medication error category, the percentage of participants who made this error was computed. RESULTS: After the first evaluation moment, the overall estimated mean percentage score was -1.7% for case A, 3.9% for case B, and 8.7% for case C. After the second review, this score was 15.0% for case A, 19.8% for case B, and 22.2% for case C. This further increased to 30.0% for case A, 36.7% for case B and 44% for case C at the final evaluation. The absence of medication where there was an indication (indication without medication) was frequently missed and did not improve after adding the extra information regarding laboratory results, reason for admission and finally medical history. CONCLUSION: Increasing clinical information helps physicians and pharmacists to improve their medication reviews, however, additional information was still related with a high margin of error. Detection of certain errors becomes easier with additional information, whereas other errors remain undetected. To achieve a high standard of medication review, we have to change the way medication reviews should be performed.

Validity, Reliability and Feasibility of Tools to Identify Frail Older Patients in Inpatient Hospital Care: A Systematic Review.

BACKGROUND: The objective of this study is to identify and review screening tools for frailty in older adults admitted to inpatient hospital care with respect to their validity, reliability and feasibility. METHODS: Studies were identified through systematically searching PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase and PsycINFO and screening reference lists till June 2014. Papers dealing with screening tools aimed at identifying frail older patients in in-hospital care, and including information about validity, reliability or feasibility, were included in the review. The quality of the included studies was critically appraised via the Quality Assessment of Diagnostic Accuracy Studies (QUADAS). RESULTS: From the originally identified 2001 studies 32 studies met the inclusion criteria, in which 16 screening tools were presented. The screening tools showed different characteristics with respect to the number of items, the method of administration and the domains included. The most frequently studied tools with respect to predictive validity were the Identification Seniors At Risk (ISAR) and Triage Risk Stratification Tool (TRST). Studies retrieved poorer information about reliability and feasibility. Overall sensitivity was fairly good. The ISAR, ISAR-HP (Identification Seniors At Risk Hospitalized Patients) and Multidimensional Prognostic Index (MPI) generally had the best sensitivity. CONCLUSIONS: Many screening tools are available for daily practice. These tools to identify frail older patients in inpatient hospital care could be useful. For no tool, however, is clear evidence available yet regarding validity, reliability and feasibility. The overall sensitivity of the included screening tools was fairly good, whereas information on reliability and feasibility was lacking for most tools. In future research more attention should be given to the latter items.

Factors that influence treatment decision-making in elderly DLBCL patients: a case vignette study.

Elderly patients with diffuse large B-cell lymphoma (DLBCL) are frequently not treated with standard immunochemotherapy, and this influences survival negatively. The purpose of this study was to gain more insight into treatment decision-making by hematologists. Case vignettes concerning patients with DLBCL were presented to hematologists in the Netherlands. Patient characteristics (age, comorbidity) differed per case. Respondents were asked in each case if they would treat the patient with curative intent by means of full-dose chemotherapy or chemotherapy with dose reduction or if they would not treat the patient with curative intent. The vast majority of respondents would treat an elderly patient diagnosed with DLBCL without a relevant medical history with full-dose chemotherapy irrespective of age. In the presence of comorbidity, lack of social support, cognitive disorders, and untreated depression dose reductions in advance are frequently applied or patients are not treated with curative intent. This is most pronounced for patients aged older than 80 years. Respondents working in a university hospital more frequently refrain form full-dose chemotherapy with curative intent compared to respondents working in tertiary medical teaching hospitals or general hospitals. Patients without a relevant medical history are generally treated with curative intent irrespective of age. Cognitive disorders, comorbidity, and depression reduce the change of being treated with curative intent. This is most prominent in the eldest patient category.

Comorbidity and treatment decision-making in elderly non-Hodgkin's lymphoma patients: a survey among haematologists.

BACKGROUND: Elderly patients with non-Hodgkin's lymphoma (NHL) are often not treated with standard immunochemotherapy and this might have a negative impact on their survival. Little is known about the determinants that play a role in treatment decision-making of clinicians regarding elderly patients with NHL. The objective of this study was to gain more insight into these determinants. METHODS: A survey was conducted amongst haematologists in the Netherlands. The survey contained questions about comorbidity, polypharmacy, social setting, nutritional status, depression, mild cognitive impairment, dementia, activities of daily living (ADL) and instrumental activities of daily living (IADL) in relation to treatment decisions in elderly NHL patients. RESULTS: Of all comorbidities, respondents designated cognitive disorders and cardiovascular comorbidity as the most important factors when assessing whether an older patient with NHL is eligible for curative treatment. Also in decreasing degree of importance ADL, IADL and depressive disorder are frequently included in treatment decision-making. Almost half of the respondents feel that treatment of the elderly person is complicated as a result of a lack of scientific evidence. CONCLUSION: Haematologists are aware of coexisting problems in elderly patients and they frequently take comorbidities, cognitive disorders and functional status into consideration in treatment decision-making. Future studies are needed to determine the exact role that these factors should play in the treatment of elderly patients. Furthermore, haematologists feel that treatment of the elderly is complicated and there is a lack of scientific evidence, and therefore older adults should be better represented in clinical trials.

Utility of desensitisation for allergy to antibiotics.

Immediate-type allergic reactions to medication are potentially life threatening and can hamper the drug therapy of several medical conditions. If no alternative drug treatment is available, a desensitisation procedure may secure the continuation of necessary therapy by inducing a temporal state of tolerance. Desensitisation is only appropriate in case of a strong suspicion of an IgE-mediated allergic reaction. It should be performed by trained clinicians (allergy specialists) in a hospital setting where treatment of a potential anaphylactic reaction can be done without any delay. In this article, literature describing desensitisation procedures for several antibiotics is reviewed.

Influence of cell-internalization on relaxometric, optical and compositional properties of targeted paramagnetic quantum dot micelles.

Quantum dot micelles (pQDs) with a paramagnetic coating are promising nanoparticles for bimodal molecular imaging. Their bright fluorescence allows for optical detection, while their Gd payload enables visualization with contrast-enhanced MRI. A popular approach in molecular MRI is the targeting of abundantly expressed cell surface receptors. Ligand-receptor binding often results in cell internalization of the targeted contrast agent. The interpretation of molecular imaging with pQDs therefore requires knowledge about the consequences of cellular internalization for their relaxometric, optical and compositional properties. To study these, Cd-containing core-shell-shell QDs coated with a monolayer of lipids, of which 50 mol% was a Gd-containing lipid, were incubated with human umbilical vein-derived endothelial cells (HUVECs) for up to 24 h. α(ν) ß(3)-integrin targeted (RGD) and non-targeted (NT) pQDs were compared. pQDs uptake was monitored by fluorescence microscopy, FACS, ICP-MS, relaxometry and MRI. Cell-associated pQDs displayed longitudinal relaxation rates and fluorescent intensities which were linear with the cell-associated Gd and Cd concentrations, implying that the Gd and Cd uptake by HUVECs can be quantified using relaxometric and optical measurements, respectively. However, the Gd-to-Cd molar ratio in pellets of pQD-incubated cells was consistently higher than the Gd-to-Cd molar ratio of the pQDs as prepared. It is proposed that this increase in Gd-to-Cd molar ratio was due to non-specific lipid-transfer between the pQDs and the cellular membranes. These findings show that, in the case of contrast agents that are formed by non-covalent interactions, experimental procedures are needed with which representative components of the probes can be monitored.

Clinical practice: drug desensitization in children.

Immediate type allergic reactions to medication are potentially life threatening and can hamper drug therapy of several medical conditions. Exact incidence and prevalence data for these reactions in children are lacking. If no alternative drug treatment is available, a desensitization procedure may secure the continuation of necessary therapy. Desensitization is only appropriate in case of a strong suspicion of an IgE-mediated allergic reaction. It should be performed by trained clinicians (allergy specialists) in a hospital setting where treatment of a potential anaphylactic reaction can be done without any delay. In this article, literature describing desensitization procedures for several antibiotics, antineoplastic agents, and vaccines in children is reviewed. In general, desensitization schemes for children differ only in final dose from schemes for adults. Contradictory data were found regarding the protective effects of premedication with antihistamines and glucocorticoids.

Crisis intervention and acute psychiatry in Amsterdam, 20 years of change: a historical comparison of consultations in 1983 and 2004-2005.

AIM: There has been a striking increase in the number of compulsory admission proceedings in the Netherlands since 1992, to such an extent that treatment in Amsterdam's psychiatric clinics is in danger of being dominated by coercive treatment. Our aim was to establish a picture of the changes in emergency psychiatry that have contributed to the increase in the number of acute compulsory admissions. METHODS: A cohort (N = 460) of psychiatric emergency consultations with the city crisis service in 1983 was compared with a similar cohort (N = 436) in 2004-2005. The study focused on the following variables: patient characteristics, crisis-service procedures and consultation outcomes. RESULTS: Compared with 1983, there are now more services involved in crisis support in the public domain for psychiatric patients. The number of patients referred by the police has risen from 29% to 63%. In 1983, all consultations took place where the patients were located; at present, 60% take place at the crisis service premises. The number of psychotic patients in the cohort has increased from 52.0% and 63.3 %. There has been an increase in the proportion of compulsory admissions and a sharp decrease in the proportion of voluntary admissions from 61% to 28% of all admissions. Overall, the percentage of consultations leading to a psychiatric admission has fallen from 42% to 27%. CONCLUSION: The front-line outreach service of 1983 has changed into a specialist psychiatric emergency department with a less pronounced outreach component. Voluntary admissions to psychiatric hospitals have almost disappeared as a feature of the crisis service.

Aquatic worms grown on biosolids: biomass composition and potential applications.

The increasing production of biological waste sludge from wastewater treatment plants is a problem, because stricter legislation inhibits the use of traditional disposal methods. The use of the aquatic worm Lumbriculus variegatus can minimise sludge production. Because the worms can feed and grow on this waste sludge, valuable compounds that are present in the sludge can be recovered by the worms. This paper describes a systematic approach for finding possible applications of the produced biomass. The worm biomass mainly consists of protein and smaller fractions of fat, sugar and ash. It also contains low concentrations of heavy metals. The potential produced amount is relatively small, compared to other waste streams, and is produced decentrally. Therefore, the most promising applications are specific components of the biomass, for example specific amino acids or fatty acids. However, until the process is optimized and there is a stable supply of worms, the focus should be on simple applications, later on followed by specific applications, depending on the market demand. Worm biomass grown on clean sludges has a broader application potential, for example as consumption fish feed.

Risk modelling of outcome after general and trauma surgery (the IRIS score).

BACKGROUND: A practical, easy to use model was developed to stratify risk groups in surgical patients: the Identification of Risk In Surgical patients (IRIS) score. METHODS: Over 15 years an extensive database was constructed in a general surgery unit, containing all patients who underwent general or trauma surgery. A logistic regression model was developed to predict mortality. This model was simplified to the IRIS score to enhance practicality. Receiver operating characteristic (ROC) curve analysis was performed. RESULTS: The database contained a consecutive series of 33 224 patients undergoing surgery. Logistic regression analysis gave the following formula for the probability of mortality: P (mortality) = A/(1 + A), where A = exp (-4.58 + (0.26 x acute admission) + (0.63 x acute operation) + (0.044 x age) + (0.34 x severity of surgery)). The area under the ROC curve (AUC) was 0.92. The IRIS score also included age (divided into quartiles, 0-3 points), acute admission, acute operation and grade of surgery. The AUC predicting postoperative mortality was 0.90. CONCLUSION: The IRIS score accurately predicted mortality after general or trauma surgery.

[Changes in crisis intervention and emergency psychiatry, Amsterdam emergency consultations in 1983 and 2005]. / Veranderingen in crisisinterventie en acute psychiatrie; Amsterdamse consulten in 1983 en 2005.

BACKGROUND: Since 1992 The Netherlands has seen a striking increase in the number of compulsory admissions. There is a danger that coercion will become the dominant form of treatment in the Amsterdam clinics. AIM: To build up a picture of the changes in emergency psychiatry which have contributed to the increase in the number of acute compulsory admissions. METHOD: A cohort (n = 460) of consultations conducted by the city crisis service in 1983 was compared with a similar cohort (n = 436) of consultations conducted in 2004-2005 based on the following variables: crisis-service procedures, patient characteristics, diagnosis and consultation outcomes. RESULTS: In 2003-2004 more services were involved with psychiatric patients in acute situations in the public domain than were involved in 1983. The number of patients referred by the police almost doubled, rising from 29.3 to 62.7%. In 1983 all consultations took place where the patients were located; in 2004-2005 60% took place at the premises of the crisis service. The number of psychotic patients in the cohort rose from 52 to 63.3%. There was a rise in the number of compulsory admissions (from 16.7 to 20%) and a sharp decline in voluntary admissions (from 25.7 to 7.6%). The total number of admissions following a consultation decreased from 42 to 28%. CONCLUSIONS: The front-line outreach service of 1983 has been transformed into a specialist psychiatric emergency department with only a modest outreach component. Voluntary admissions via the consultation service have almost ceased. Further research is needed into the characteristics of the consultations and into the variables that play a role in the use of compulsion in emergency psychiatry.

Patients' representations of their end-stage renal disease: relation with mortality.

BACKGROUND: Self-regulation theory explains how patients' illness perceptions influence self-management behaviour (e.g. via adherence to treatment). Following these assumptions, we explored whether illness perceptions of ESRD-patients are related to mortality rates. METHODS: Illness perceptions of 182 patients participating in the NECOSAD-2 study in the period between December 2004 and June 2005 were assessed. Cox proportional hazard models were used to estimate whether subsequent all-cause mortality could be attributed to illness perception dimensions. RESULTS: One-third of the participants had died at the end of the follow-up. Mortality rates were higher among patients who believed that their treatment was less effective in controlling their disease (perceived treatment control; RR = 0.71, P = 0.028). This effect remained stable after adjusting for sociodemographic and clinical variables (RR = 0.65, P = 0.015). CONCLUSIONS: If we consider risk factors for mortality, we tend to rely on clinical parameters rather than on patients' representations of their illness. Nevertheless, results from the current exploration may suggest that addressing patients' personal beliefs regarding the effectiveness of treatment can provide a powerful tool for predicting and perhaps even enhancing survival.

Morphology, binding behavior and MR-properties of paramagnetic collagen-binding liposomes.

Collagen is an important component of the extracellular matrix (ECM) and plays an important role in normal tissue maturation and in pathological processes such as atherosclerosis and myocardial infarction. The diagnostics of the latter diseases using MRI could strongly benefit from the use of collagen-specific contrast agents. The current study aimed to develop a bimodal liposomal MR contrast agent that was functionalized with CNA35, a collagen adhesion protein of the Staphylococcus aureus bacterium. The liposomes were characterized in terms of CNA35 protein conjugation and loading. The overall morphology was assessed with DLS and cryo-TEM, while cryo-TEM tomography was used to visualize the protein coverage of the liposomes. The binding properties of the contrast agent were investigated using a fluorescence assay based on the rhodamine content of the liposomes. The bulk relaxivity was determined using regular relaxometry while the MR-properties of liposomes in their bound state were studied using NMR depth profiling. This CNA35 functionalized contrast agent and the set of in vitro experiments we performed indicate the potential of this technology for in vivo molecular imaging of collagen.

Secondary intention healing after excision of nonmelanoma skin cancer of the head and neck: statistical evaluation of prognostic values of wound characteristics and final cosmetic results.

BACKGROUND: Most data on secondary intention healing of skin cancer defects in the head and neck are empirical and descriptive. This study statistically evaluates the prognostic value of several wound characteristics and location on the final cosmetic result of skin defects left to heal by secondary intention after tumor removal. METHODS: A chart review of all facial reconstructions using secondary intention healing performed in one center between 1992 and 2001 was undertaken. Patient and wound characteristics were analyzed. For analysis of cosmetic outcome, the most recent photographs of the scars were assessed by three independent raters using a categorical judgment scale. RESULTS: There were a total of 89 patients with 95 wounds. Forty-three percent of the wounds (41 of 95) healed with an "excellent" outcome. In the univariate analysis, the rating excellent was given more often to scars derived from wounds that were small and superficial and that were located in concave areas of the face, in particular, near the medial canthus and medial cheek. Multivariable logistic regression revealed independent associations of an excellent cosmetic outcome with wound size and contour of wound surface only. CONCLUSION: This is the first study presenting statistical evidence of what has been known empirically for a long time: wounds in concave areas of the face that are left to heal by secondary intention have a high chance of healing with an excellent cosmetic outcome, especially if these wounds are small, superficial, and located near the medial canthus and medial cheek.