Enhancing antitumor response by combining immune checkpoint inhibitors with chemotherapy in solid tumors.

BACKGROUND: Cancer immunotherapy has changed the standard of care for a subgroup of patients with advanced disease. Immune checkpoint blockade (ICB) in particular has shown improved survival compared with previous standards of care for several tumor types. Although proven to be successful in more immunogenic tumors, ICB is still largely ineffective in patients with tumors that are not infiltrated by immune cells, the so-called cold tumors. PATIENTS AND METHODS: This review describes the effects of different chemotherapeutic agents on the immune system and the potential value of these different types of chemotherapy as combination partners with ICB in patients with solid tumors. Both preclinical data and currently ongoing clinical trials were evaluated. In addition, we reviewed findings regarding different dosing schedules, including the effects of an induction phase and applying metronomic doses of chemotherapy. RESULTS: Combining ICB with other treatment modalities may lead to improved immunological conditions in the tumor microenvironment and could thereby enhance the antitumor immune response, even in tumor types that are so far unresponsive to ICB monotherapy. Chemotherapy, that was originally thought to be solely immunosuppressive, can exert immunomodulatory effects which may be beneficial in combination with immunotherapy. Each chemotherapeutic drug impacts the tumor microenvironment differently, and in order to determine the most suitable combination partners for ICB it is crucial to understand these mechanisms. CONCLUSION: Preclinical studies demonstrate that the majority of chemotherapeutic drugs has been shown to exert immunostimulatory effects, either by inhibiting immunosuppressive cells and/or activating effector cells, or by increasing immunogenicity and increasing T-cell infiltration. However, for certain chemotherapeutic agents timing, dose and sequence of administration of chemotherapeutic agents and ICB is important. Further studies should focus on determining the optimal drug combinations, sequence effects and optimal concentration-time profiles in representative preclinical models.

Replicating reoviruses with a transgene replacing the codons for the head domain of the viral spike.

The capacity to modify the reovirus genome facilitates generation of new therapeutic reoviruses. We describe a method for generating replication-competent reoviruses carrying a heterologous transgene. The strategy is based on the expanded-tropism reovirus mutant jin-3, which can infect cells independent of the reovirus receptor junction-adhesion molecule A (JAM-A). Jin-3 harbors a mutation in the S1 segment, resulting in a G196R substitution in the tail of the spike protein σ1. The use of the jin-3 tail-encoding S1 segment allows replacing the codons for the JAM-A-binding head domain by up to 522 nucleotides of foreign sequences, without exceeding the size of the wild-type S1 segment. We inserted the codons for the porcine teschovirus-1 2A element fused with those encoding the fluorescent protein iLOV. Replicating rS1His-2A-iLOV reoviruses were generated by co-transfection of expression plasmids for all reovirus segments. These reoviruses contain the S1His-2A-iLOV segment in the absence of the wild-type S1 segment. Density-gradient centrifugation confirmed the association of the σ1-tail fragment with the capsid. Both JAM-A-positive and -negative cells exposed to the rS1His-2A-iLOV reoviruses exhibited iLOV fluorescence, confirming the jin-3-derived expanded-tropism phenotype. These data demonstrated the feasibility of generating decapitated replication-competent T3D reoviruses carrying a heterologous transgene.

[Towards culturally sensitive care for elderly immigrants! Design and development of a community based intervention programme in the Netherlands]. / Op weg naar cultuursensitieve zorg voor oudere migranten! Opzet en werkwijze van het Stem van de Oudere Migrant project.

BACKGROUND: In Western countries, health and social welfare facilities are not easily accessible for elderly immigrants and their needs are sub optimally addressed. A transition is needed towards culturally sensitive services to make cure and care accessible for elderly immigrants. We developed an intervention programme in which ethnic community health workers (CHWs) act as liaisons between immigrant elderly and local health care and social welfare services. METHODS: In a quasi experimental design, the effectiveness of introduction of CHWs, will be evaluated in three (semi) urban residential areas in the Netherlands within three different migrant groups and compared with a control group. The primary outcome is use of health care and social welfare facilities by the elderly. Secondary outcomes are quality of life and functional impairments. Implementation of the intervention programme will be examined with focus groups and data registration of CHW activities. In this paper design and methodological issues are discussed. DISCUSSION: This study can contribute to the improvement of care for elderly immigrants by developing culturally sensitive care whereby the elderly immigrants themselves actively participate. To enable a successful transition, proper identification and recruitment of CHWs is required. Once proven effective, the CHW function can be further integrated into the existing local health care and welfare system.

Long-term effect of a nurse-led psychosocial intervention on health-related quality of life in patients with head and neck cancer: a randomised controlled trial.

BACKGROUND: Head and neck cancer (HNC) patients are prone to have a poor health-related quality of life after cancer treatment. This study investigated the effect of the nurse counselling and after intervention (NUCAI) on the health-related quality of life and depressive symptoms of HNC patients between 12 and 24 months after cancer treatment. METHODS: Two hundred and five HNC patients were randomly allocated to NUCAI (N=103) or usual care (N=102). The 12-month nurse-led NUCAI is problem-focused and patient-driven and aims to help HNC patients manage with the physical, psychological and social consequences of their disease and its treatment. Health-related quality of life was evaluated with the EORTC QLQ-C30 and QLQ H&N35. Depressive symptoms were evaluated with the CES-D. RESULTS: At 12 months the intervention group showed a significant (P<0.05) improvement in emotional and physical functioning, pain, swallowing, social contact, mouth opening and depressive symptoms. At 18 months, global quality of life, role and emotional functioning, pain, swallowing, mouth opening and depressive symptoms were significantly better in the intervention group than in the control group, and at 24 months emotional functioning and fatigue were significantly better in the intervention group. CONCLUSION: The NUCAI effectively improved several domains of health-related quality of life and depressive symptoms in HNC patients and would seem a promising intervention for implementation in daily clinical practice.

Mediators of physical exercise for improvement in cancer survivors' quality of life.

OBJECTIVE: Mediating mechanisms of a 12-week group-based exercise intervention on cancer survivors' quality of life (QoL) were examined to inform future exercise intervention development. METHODS: Two hundred nine cancer survivors ≥ 3 months posttreatment (57% breast cancer) aged 49.5 (± 10.4) years were assigned to physical exercise (n = 147) or wait-list control (n = 62). QoL, fatigue, emotional distress, physical activity, general self-efficacy and mastery were assessed at baseline and post-intervention using questionnaires. Path analysis was conducted using Mplus to explore whether improved physical activity, general self-efficacy and mastery mediated the effects of exercise on fatigue and distress and consequently QoL. RESULTS: The intervention was associated with increased physical activity (ß = 0.46, 95% confidence interval (CI) = 0.14;0.59), general self-efficacy (ß = 2.41, 95%CI = 0.35;4.73), and mastery (ß = 1.75, 95%CI = 0.36;2.78). Further, the intervention had both a direct effect on fatigue (ß = -1.09, 95%CI = -2.12;0.01), and an indirect effect (ß = -0.54, 95%CI = -1.00;-0.21) via physical activity (ß = -0.29, 95%CI = -0.64;-0.07) and general self-efficacy (ß = -0.25, 95%CI = -0.61;-0.05). The intervention had a borderline significant direct effect on reduced distress (ß = -1.32, 95%CI = -2.68;0.11), and a significant indirect effect via increased general self-efficacy and mastery (ß = -1.06, 95%CI = -1.89;-0.38). Reductions in fatigue (ß = -1.33, 95%CI =-1.85;-0.83) and distress (ß = -0.86, 95%CI = -1.25;-0.52) were associated with improved QoL. Further, increased physical activity was directly associated with improved QoL (ß = 3.37, 95%CI = 1.01;5.54). CONCLUSION: The beneficial effect of group-based physical exercise on QoL was mediated by increased physical activity, general self-efficacy and mastery, and subsequent reductions in fatigue and distress. In addition to physical activity, future interventions should target self-efficacy and mastery. This may lead to reduced distress and fatigue, and consequently improved QoL of cancer survivors.

E-health in caring for patients with atopic dermatitis: a randomized controlled cost-effectiveness study of internet-guided monitoring and online self-management training.

BACKGROUND: The Dermatology Department of the University Medical Centre Utrecht, the Netherlands, developed an e-health portal for patients with atopic dermatitis (AD), consisting of e-consultation, a patient-tailored website, monitoring and self-management training. OBJECTIVES: To determine the cost-effectiveness of individualized e-health compared with usual face-to-face care for children and adults with AD. METHODS: A randomized controlled cost-effectiveness study from a societal perspective in adults and parents of children with moderate AD. Outcomes were quality of life, severity of AD, itching and direct and indirect costs. Data were collected at baseline and at 3 and 12 months after randomization. Linear mixed models were used to analyse clinical outcomes. After multiple imputation of missing data, costs and differences in costs were calculated over a period of 1 year. RESULTS: In total, 199 patients were included. There were no significant differences in disease-specific quality of life, severity of AD and intensity of itching between both groups at the three time points. The difference in direct costs between the intervention and control groups was €24 [95% confidence interval (CI) -360 to 383], whereas this difference was -€618 (95% CI -2502 to 1143) for indirect costs. Overall, individual e-health was expected to save €594 (95% CI -2545 to 1227) per patient in the first year of treatment, mainly through a reduction in work absenteeism. Uncertainty analyses revealed that the probability of e-health reducing costs was estimated to be ≥ 73%. CONCLUSIONS: E-health during follow-up of patients with AD is, after initial diagnosis and treatment during face-to-face contact, just as effective as usual face-to-face care with regard to quality of life and severity of disease. However, when costs are considered, e-health is likely to result in substantial cost savings. Therefore, e-health is a valuable service for patients with AD.

Costs and cost-effectiveness of the nursing programme 'Coping with itch' for patients with chronic pruritic skin disease.

BACKGROUND: Itch, a major symptom of many skin diseases, has a great impact on quality of life. The nursing programme 'Coping with itch' aims at reducing itch and at helping patients to cope with itch. OBJECTIVES: To explore costs and cost-effectiveness of the programme. METHODS: A randomized controlled study was carried out with 56 patients. Data were gathered on medical consumption, days off work and the frequency of itching and scratching. Differences between both groups, the cost-effectiveness ratio and the percentage of patients falling into the four quadrants of the cost-effectiveness analysis plane were determined. RESULTS: The intervention group experienced a gain of 6 days with little itching [95% confidence interval (CI) -16-28] at 3 months and a gain of 35 days (95% CI -33-96) at 9 months. They paid more visits to the dermatology nurse than the control group. The point estimate of the incremental cost-effectiveness ratio was euro129.91 and euro16.60 per day with little itching at 3 months and at 9 months, respectively. At 3 months, 70% of the patients experienced favourable results and 14% of them had lower costs. At 9 months, 87% had favourable results and 31% of them had lower costs. CONCLUSIONS: Most of the expenses associated with the 'Coping with itch' programme were incurred during the first 3 months, but the benefits in terms of days with little itch appeared to persist and increase beyond 3 months, thus leading to a more favourable incremental cost-effectiveness ratio.

Effectiveness of the nursing programme 'Coping with itch': a randomized controlled study in adults with chronic pruritic skin disease.

BACKGROUND: The nursing programme 'Coping with Itch' aims at reducing itch and at helping patients with chronic pruritic skin diseases cope with itch. The programme consists of educational and cognitive behavioural interventions. Dermatology nurses carry out the programme, which supplements standard medical treatment given by a dermatologist, in individual sessions at a nurse clinic organized by the dermatology outpatient department. OBJECTIVES: To evaluate the effectiveness of the nursing programme 'Coping with Itch' in patients with chronic pruritic skin diseases. METHODS: A randomized controlled study was carried out. Patients with chronic pruritic skin diseases were randomly assigned to the intervention group or the control group. The intervention group received standard care from a dermatologist and nursing care according to the programme 'Coping with Itch' for a mean of 2.9 visits. The control group received usual care from a dermatologist. Data collection took place at baseline, at 3 months (t1) and at 9 months (t2) after baseline. Most visits to the nurse clinic took place during the first 3 months of the study. Main outcome measures were the frequency and intensity of itching and scratching, itch-related coping, and skin-related and general psychosocial morbidity. Secondary outcome measures were the number of visits to the dermatologist and the use of medication and ointments. Mann-Whitney tests and analyses of covariance were used to analyse differences between the two groups. RESULTS: Data on 29 patients in the intervention group and 36 patients in the control group were used in the analyses. A trend to significance (P = 0.07) was shown in the difference between the two groups in the frequency of itching and scratching at t1. A significant difference (P = 0.04) was shown between the two groups in catastrophizing and helpless itch-related coping at t1. No significant differences were revealed at t2 between the groups. Patients in the intervention group visited the dermatologist significantly less frequently during the intervention period than did control group patients. CONCLUSIONS: The nursing programme 'Coping with Itch' led to a reduction in the frequency of itching and scratching and to a reduction of catastrophizing and helpless coping in patients with chronic pruritic skin diseases during the period immediately following the intervention. We suggest further follow-up visits to the itch clinic to extend these results over a longer period.

Prevalence and predictors of psychosocial morbidity in patients with chronic pruritic skin diseases.

BACKGROUND: Itch is a major symptom of many skin diseases and causes patients considerable distress, adversely affecting quality of life. Feelings of helplessness and lack of control can influence the perceived itch and psychosocial complaints. OBJECTIVES: To determine the prevalence of psychosocial morbidity among patients with pruritic skin diseases, and the influence of itch-related variables, coping strategies, and demographic variables on psychosocial morbidity. PATIENTS AND METHODS: One hundred and sixty-eight patients with pruritic skin diseases from five hospitals in the Netherlands participated in the study. Skin-related psychosocial morbidity was measured with the Adjustment to Chronic Skin Diseases questionnaire (ACS); general psychosocial morbidity was measured with the Symptom Checklist-90 (SCL-90). The frequency and intensity of itching and scratching was recorded in diaries. Itch-related coping was measured with the Itching Cognitions Questionnaire (ICQ). Multiple regression analyses were used. RESULTS: Patients with pruritic skin diseases had higher SCL-90 scores than a healthy Dutch population. All patients had psychosocial complaints as measured with the ACS. Thirty-nine per cent of the variance in skin-related psychosocial morbidity was explained by 'catastrophizing and helpless coping'; another 11% was explained by itching and scratching. Age and sex together explained another 10%. The frequency of itching and scratching (11%), 'catastrophizing and helpless coping' (19%) and skin-related psychosocial morbidity (10%) explained the variance in general psychosocial morbidity. CONCLUSIONS: Patients with a pruritic skin disease have a high level of psychosocial morbidity. Catastrophizing and helpless coping are the most important predictors of psychosocial morbidity, with itching, scratching and demographic variables having a limited influence.

Fatigue in employees with diabetes: its relation with work characteristics and diabetes related burden.

AIMS: To examine the relations between work characteristics as defined by the Job Demand-Control-Support model (JDCS) (that is, job demands, decision latitude, and social support), diabetes related burden (symptoms, seriousness of disease, self care activities, and disease duration), and fatigue in employees with diabetes mellitus. METHODS: Employees (n = 292) aged 30-60 years, with insulin treated diabetes, filled in self administered questionnaires that assess the above mentioned components of the JDCS model and diabetes related burdens. RESULTS: Both work and diabetes related factors are related to fatigue in employees with diabetes. Regression analyses revealed that work characteristics explain 19.1% of the variance in fatigue; lack of support, and the interaction of job demands and job control contribute significantly. Diabetes related factors explain another 29.0% of the variance, with the focus on diabetes related symptoms and the burden of adjusting insulin dosage to circumstances. Fatigue is more severe in case of lack of social support at work, high job demands in combination with a lack of decision latitude, more burden of adjusting insulin dosage to circumstances, and more diabetic symptoms. Furthermore, regression analysis revealed that diabetic symptoms and the burden of adjusting the insulin dosage to circumstances are especially relevant in combination with high job demands. CONCLUSIONS: Both diabetes and work should be taken into consideration-by (occupational) physicians as well as supervisors-in the communication with people with diabetes.

Prediction of depression 6 months to 3 years after treatment of head and neck cancer.

BACKGROUND: Head and neck cancer and its treatment can have important psychosocial implications. Many patients become depressed. The aim of this prospective study is to examine whether pretreatment variables can be used to predict depression up to 3 years after treatment. METHODS: Head and neck cancer patients (n = 197) treated with surgery and/or radiotherapy completed both before and after treatment a questionnaire including items on social support, coping, depressive symptoms, physical functioning, and physical symptoms. RESULTS: Eight pretreatment variables (tumor stage, sex, depressive symptoms, openness to discuss cancer in the family, available appraisal support, received emotional support, tumor-related symptoms, and size of the informal social network) were used to calculate a risk score to determine which patients were depressed at 6 months to 3 years after treatment (positive predicted value, 58%; negative predicted value, 83%). CONCLUSIONS: Eight pretreatment variables can be used to predict accurately those head and neck cancer patients who are likely to become depressed up to 3 years after treatment.

Sociodemographic factors and quality of life as prognostic indicators in head and neck cancer.

Pre-treatment quality of life (QOL) has been found to be an independent prognostic factor for survival in cancer patients, in particular in patients with advanced cancer. Sociodemographic factors such as marital and socioeconomic status have also been recognised as prognostic factors. We studied the influence of QOL and mood (measured with the European Organization for Research and Treatment of Cancer Core Questionnaire (EORTC QLQ-C30) and the Head and Neck Cancer Questionnaire (EORTC QLQ-H&N35), and with the Center for Epidemiologic Studies-Depression Scale (CES-D)) as measured before treatment, the use of cigarettes and alcohol and sociodemographic factors (age, gender, marital status, income and occupation) on recurrence and survival in 208 patients with head and neck cancer prior to treatment with surgery and/or radiotherapy, using Kaplan-Meier and Cox regression analyses. Cognitive functioning and, to a lesser degree, marital status were independent predictors of recurrence and survival, along with medical factors (stage and radicality). Patients with less than optimal cognitive functioning and unmarried patients had a relative risk (RR) of recurrence of 1.72 (95% confidence interval (95% CI) 1.01-2.93) and 1.85 (95% CI 1.06-3.33), respectively, and a RR of dying of 1.90 (95% CI 1.10-3.26) and 1.82 (95% CI 1.03-3.23), respectively. Performance status, physical functioning, mood and global QOL and smoking and drinking did not predict for recurrence and survival. The influence of cognitive functioning might be related to the use of alcohol. Marital status may influence prognosis through mechanisms of health behaviour and/or social support mechanisms.

Prediction of depressive symptomatology after treatment of head and neck cancer: the influence of pre-treatment physical and depressive symptoms, coping, and social support.

BACKGROUND: Head and neck cancer and its treatment can have important psychosocial implications, and many patients become depressed. The aim of this prospective study is to examine whether pretreatment variables can be used to predict depression 6 and 12 months later. METHODS: Head and neck cancer patients (155) treated with surgery and/or radiotherapy completed a questionnaire including items on social support, coping, depressive symptoms, physical functioning, and physical symptoms before and after treatment. RESULTS: By using 5 variables (physical symptoms, depressive symptoms, emotional support, extent of the social network, and avoidance coping), it was possible to predict those patients who would have symptoms at 6 (81%) and 12 months (67%) after treatment. Inclusion of actual physical symptoms reported at follow-up increased these percentages to 89% and 82%. CONCLUSIONS: It is concluded that screening for psychosocial variables and physical symptoms before treatment can be used to determine which patients are at risk of developing depressive symptoms after treatment.

Pretreatment factors predicting quality of life after treatment for head and neck cancer.

BACKGROUND: Quality of life (QOL) has become an important issue in head and neck cancer. Explanation of factors predicting QOL after treatment has important implications for patient management. METHODS: In this prospective study we analyzed which pretreatment factors predicted QOL after surgery and/or radiotherapy with curative intent in a cohort of 153 patients with cancer of the oral cavity, oropharynx, hypopharynx, or larynx. The patients completed the EORTC Core Questionnaire, the EORTC Head and Neck Cancer module, and the Center for Epidemiologic Studies Depression scale before treatment and 6 and 12 months later. The influence of gender, age, performance status, and depressive symptoms at baseline, site, stage, and treatment on QOL (and its dimensions) and depressive symptoms after 6 and 12 months was studied, using linear regression analysis. RESULTS: A high level of depressive symptoms and a low performance status at baseline and combination treatment were significant predictors of increased severity of symptoms and poor functioning after treatment. Treatment was a predictor of head and neck symptoms, whereas performance status and depressive symptoms were predictors of general symptoms and functioning. Gender and age had little predictive value. CONCLUSIONS: Patients with depressive symptoms or a low performance status who receive combination treatment for cancer of the head and neck are at risk for physical and psychologic morbidity after treatment. Special attention should be given to these patients in rehabilitation programs.

Negative and positive influences of social support on depression in patients with head and neck cancer: a prospective study.

Patients with head and neck cancer have to cope not only with a life threatening diagnosis, but also with an altered facial appearance and the loss or impairment of important functions as a result of treatment. As a consequence they are prone to psychosocial problems. Social support might influence their ability to adapt to the illness and its treatment. The aim of this prospective study is to examine the influence of different aspects of social support on the depressive symptomatology in head and neck cancer patients treated with surgery and/or radiotherapy. Patients completed a questionnaire relating to available and received support, the extent of the social network, depressive symptoms, and general health complaints before and 6 months after treatment. Received support was found to be associated with more depressive symptomatology at baseline and available support led to less depressive symptomatology. The relationship between social support and depressive symptoms was especially apparent in patients with few general health complaints. Whereas the availability of support seemed to be beneficial regardless of the situation, the effect of received support was equivocal. The provision of support should be tailored to the needs of the individual patient.

Long-term quality of life of patients with head and neck cancer.

OBJECTIVES: To describe prospectively the long-term changes of quality of life and mood in patients with squamous cell carcinoma of the head and neck treated with surgery and/or radiotherapy. PATIENTS AND METHODS: One hundred seven patients completed the European Organization for Research and Treatment of Cancer (EORTC) Core Questionnaire, the EORTC Head and Neck Cancer Module, and the Center for Epidemiological Studies Depression Scale before treatment, and 6, 12, 24, and 36 months later. RESULTS: There was limited deterioration of physical and role functioning and of many head and neck symptoms at 6 months, with improvement thereafter. After 36 months only physical functioning, taste/ smell, dry mouth, and sticky saliva were significantly worse, compared with baseline. Female sex, higher cancer stage, and combination treatment were associated with more symptoms and worse functioning. Despite physical deterioration, there was a gradual improvement of depressive symptomatology and global quality of life. CONCLUSION: Treatment for head and neck cancer results in short-term morbidity, most of which resolves within 1 year. Despite an initially high level of depressive symptomatology, there is gradual improvement of psychological functioning and global quality of life over the course of 3 years. In this prospective study, the impact of the disease and its treatment in long-term survivors seems to be less severe than it is often assumed to be.

Predictive validity of the BRASS index in screening patients with post-discharge problems. Blaylock Risk Assessment Screening Score.

RATIONALE: Discharge planning is a nursing intervention that aims to ensure continuity of care; it consists of several steps of which selecting patients in need of it is the first one. The Blaylock Risk Assessment Screening Score (BRASS) index is a risk screening instrument which can be used early after admission to identify those patients in need of discharge planning. AIM: To test the predictive validity of the BRASS index in screening patients with post-discharge problems. DESIGN: Prospective longitudinal design with prediction instrument measured at admission, and outcomes measured at discharge and 7 and 30 days after discharge. OUTCOME MEASURES: length of stay, discharge destination, status after discharge. INSTRUMENTS: BRASS index, Problems after discharge Questionnaire, Nottingham Health Profile, COOP/WONCA charts. RESEARCH METHOD: 503 elderly patients were screened at admission with the BRASS index. Length of stay and discharge destination were measured at discharge in these same patients. Outcomes after discharge were gathered only in patients who were discharged home and with length of stay of more than 3 days (n=226); outcomes were measured by postal questionnaires at day 7 and day 30 after discharge. RESULTS: patients identified by the BRASS index as high risk are frequently not discharged home and have a longer length of stay. The BRASS scores correlate significantly with the outcome scores after discharge: the higher the BRASS score, the higher the difficulty score after discharge on all domains. However, the sensitivity of the BRASS index is rather low. CONCLUSION: This study demonstrates that the BRASS index is a good predictor instrument for indicating patients who are not discharged home, that the BRASS scores correlate significantly with problems experienced after discharge and that it has high specificity to predict patients with problems after discharge. Clinical use, however, is limited due to the low sensitivity. The BRASS index is a promising case-finding instrument for discharge planning, but needs further development.

Transition of care: an evaluation of the role of the discharge liaison nurse in The Netherlands.

Problems in the transition of care from hospital to the home situation have led to the introduction of the discharge liaison nurse role in the Netherlands. A nation-wide hospital survey was carried out to gain insight into the role and function of discharge professionals. It was found that 56 of the 117 hospitals in the Netherlands (48%) have a special discharge professional. The discharge professional is a relatively new concept. On average it covers a full-time position. The function differs greatly between hospitals. Three working profiles can be distinguished: the organizational type, the advisory type and the policy-making type. In most cases the discharge professional is a nurse from a community agency based in the hospital and therefore best fits the description of a discharge liaison nurse. Of the 56 hospital-based initiatives involving discharge professionals, 11 (20%) have been systematically evaluated. A critical review of these evaluation studies showed a positive outcome on some aspects of quality of care, but no results were given on efficiency aspects. There was general appreciation of the discharge liaison nurse and continuation of the function was widely recommended. The quality of the evaluation studies was rather poor, and it is suggested that more substantial research should be carried out on this relatively new function.

Teaching clinically experienced physicians communication skills. A review of evaluation studies.

CONTEXT: Interest in the teaching of communication skills in medical schools has increased since the early seventies but, despite this growing interest, relatively limited curricular time is spent on the teaching of communication skills. The limited attention to the teaching of these skills applies even more to the physicians' clinical years, when attention becomes highly focused on biomedical and technical competence. Continuing training after medical school is necessary to refresh knowledge and skills, to prohibit decline of performance and to establish further improvements. OBJECTIVE: This review provides an overview of evaluation studies of communication skills training programmes for clinically experienced physicians who have finished their undergraduate medical education. The review focuses on the training objectives, the applied educational methods, the evaluation methodology and instruments, and training results. METHODS: CD-ROM searches were performed on MedLine and Psychlit, with a focus on effect-studies dating from 1985. RESULTS: Fifteen papers on 14 evaluation studies were located. There appears to be some consistency in the aims and methods of the training programmes. Course effect measurements include physician self-ratings, independent behavioural observations and patient outcomes. Most of the studies used inadequate research designs. Overall, positive training effects on the physicians' communication behaviour are found on half or less of the observed behaviours. Studies with the most adequate designs report the fewest positive training effects. CONCLUSION: Several reasons are discussed to explain the limited findings. Future research may benefit from research methods which focus on factors that inhibit and facilitate the physicians' implementation of skills into actual behaviours in daily practice.