[Treatment of dementia]. / Behandeling van dementie.

- Treatment options for patients with dementia are limited. This article provides an overview of possible interventions, both pharmaceutical and non-pharmaceutical, for Alzheimer's disease, vascular dementia and mixed dementia.- Pharmaceutical treatment options include cholinesterase inhibitors, memantine and experimental medication. Cholinesterase inhibitors are only recommended for Alzheimer's disease and mixed dementia, not for vascular dementia or mild cognitive impairment. There is no proof of effectiveness for the other pharmaceutical options.- Interventions towards cardiovascular risk factors do not slow down cognitive decline.- Evidence is still lacking for other non-pharmaceutical interventions such as memory training and dietary supplements. Physical exercise may have a positive effect on dementia, but research is still ongoing.- Many patients with dementia exhibit behavioural changes such as agitation and depression. We recommend non-pharmaceutical interventions as a first step to lower the burden of this behaviour for both patients and caregivers.

Caregiver characteristics and economic cost of home-based care: a case study of Maun and Gumare villages in North West District, Botswana.

The home-based care programme in Botswana was initiated partly to augment hospital or clinical care by reducing the healthcare costs associated with chronic illnesses such as HIV/AIDS. A number of studies have pointed to the psyco-social impacts of home based care, however there has been few attempts to quantify the direct and indirect costs associated with home based care. This study was carried out in the North West District of Botswana, which is noted for a relatively larger proportion of households with critically ill persons. The objectives of the study were to identify the characteristics of the caregivers and their patients; to estimate the direct and indirect costs of home-based care; and to estimate caregivers' willingness to pay for care services. Data was collected using a structured questionnaire addressed to 120 primary caregivers and analyzed using SPSS. The economic cost of caregiving was estimated using the replacement cost method. The annual value per caregiver was estimated at P31 320 (US$4818.46). The study also revealed that more often than not, women are involved in caregiving activities.

[Frontal syndrome. A patient with a recognisable clinical picture but without a clear aetiology. A case study]. / Het frontaal syndroom: een patiënt met een herkenbaar klinisch beeld maar zonder duidelijke etiologie.

A 63-year-old man presented with behavioural disturbances but had no problems with memory or orientation. We diagnosed a frontal syndrome and we describe the symptoms and the differential diagnosis. The precise aetiology remains unclear, although an infarction of the nucleus caudatus is suspected.

Improving patient care through implementation of nurse-driven restraint protocols.

Nationally, much attention has been placed on the indiscriminate application and abuse of restraint usage. This was the impetus for health care institutions across the country to relook at the policy, practices, and procedures regarding restraints. Our health care system made changes to our restraint policy, practice guidelines, and procedures in an effort to assure protection of the patients' health and safety while preserving their dignity, rights, and well-being. The mission was to pursue a restraint-appropriate environment by restraining only those patients who were assessed as being at risk of harming self and to protect the patient or others from injury. Our overall goal was to reduce restraint usage. This article describes the current policies, practice guidelines, and procedures for identifying clinically appropriate and adequately justified situations for restraint usage. The focus is on implementation of nurse-driven restraint protocols to improve patient care. All efforts directed at improvements in restraint usage and management of a patient in restraints has reduced our overall numbers of patients in restraints as well as significantly reduced risk of incidence for patients in restraints.

Alpha 4 beta 1 and alpha 5 beta 1 are differentially expressed during myelopoiesis and mediate the adherence of human CD34+ cells to fibronectin in an activation-dependent way.

To study the receptors involved in the interaction between extracellular matrix proteins and hematopoietic progenitor cells, we analyzed the expression of beta 1 integrins on CD34+ bone marrow cells by means of immunoflowcytometry. Alpha 4 beta 1 and alpha 5 beta 1 were expressed, whereas alpha 1 beta 1, alpha 2 beta 1, alpha 3 beta 1, alpha 6 beta 1, and alpha v beta 1 were virtually absent. Furthermore, we assessed the alpha 4 and alpha 5 expression on committed myeloid progenitor cells. These colony-forming cells were detected in the alpha 4 dull fraction and the alpha 5 dull fraction. During myeloid differentiation, both in vivo and in vitro, a differential expression of alpha 4 beta 1 and alpha 5 beta 1 was observed. alpha 5 beta 1 was found to be lost at the myelocytic-metamyelocytic stage, before the loss of alpha 4 beta 1, at the band stage. Functional studies showed no binding of erythroid progenitor-depleted, CD34+ bone marrow cells to fibronectin. However, protein kinase C activation strongly induced fibronectin binding (68% of the cells). Inhibition experiments with specific antibodies and peptides showed the binding to be mediated by both alpha 4 beta 1 and alpha 5 beta 1. Also, colony-forming cells of granulocytes and macrophages were demonstrated to adhere to fibronectin in an activation-dependent way. During granulocyte colony-stimulating factor-induced in vitro maturation, the activation-dependent fibronectin binding capacity is gradually lost. We conclude that: (1) CD34+ bone marrow cells express alpha 4 beta 1 and alpha 5 beta 1; (2) the expression of alpha 4 beta 1 and alpha 5 beta 1 is differentially expressed during myeloid differentiation; and (3) binding of CD34+ bone marrow cells to fibronectin is activation dependent.

Primary sclerosing cholangitis. An unresolved enigma.

Primary sclerosing cholangitis (PSC) is a disease of the bile ducts which frequently is associated with inflammatory bowel disease. The disease is characterized by stenoses and saccular dilatations of the intra- and/or extra-hepatic bile ducts. Endoscopic retrograde cholangiography is the mainstay of diagnosis of this disease. A liver biopsy gives additional information and is particularly useful to rule out secondary cirrhosis. In a series of 50 patients the 5-year survival was 85%. The etiology is unknown, but in addition to inflammatory bowel disease the disease is associated with the autoimmune haplotype HLA-A1, B8, and DR3. Antibodies to perinuclear antigens in leukocytes are present in 65% of patients with PSC. Ursodeoxycholic acid therapy causes an improvement of symptoms and a decrease of elevated liver enzyme values. There are no drugs as yet with a proven effect on fibrosis or cirrhosis in this disease. Liver transplantation in this disease has a reported 4-year survival of 88%.

An historical view of right to treatment.

The patient's right to treatment is a clear mandate from the Supreme Court that the providers of mental health care must provide treatment. Important Supreme Court decisions have influenced the way in which professional nurses determine what constitutes adequate treatment on an individualized basis. Individualized treatment planning is rooted in meeting legal, regulatory, and funding requirements. The professional nurse is in a unique position to assess the patient's needs and to plan with others how those needs can best be met. Paraprofessional staff may implement those parts of the plan that do not require the direct intervention of the professional nurse. The technicians provide the daily care under the supervision and direction of the professional nurse. However, it is the professional psychiatric nurse who plays a critical role in providing active psychiatric treatment, who determines the nursing component of the treatment plan on an individualized basis, and who monitors the patient's environment, thus safe-guarding the legal rights of the mentally ill.

Adaptive coping mechanisms in adult acute leukemia patients in remission.

The adult leukemia patient in a drug-induced remission possesses a unique set of emotional responses as he adjusts to an altered life-style and a life-threatening disease. Six patients, ranging in age from 24 to 62 years and being treated with monthly maintenance chemotherapy, were interviewed over a six-month period. The adaptive coping mechanisms most frequently identified were denial of being sick, identification with fellow patients to form a "hospital family," and anticipatory grief of one's own losses by participation in grieving another patient's death. The means of adjustment was to adapt to the "hospital family" and benefit from the therapeutic milieu established on the ward. The patient's total response to remission in acute leukemia can be influenced positively by appropriate intervention based on an assessment of his previous and present patterns of coping.