Continuity of care for children with anorexia nervosa in the Netherlands: a modular perspective.

Care provision for children with anorexia nervosa is provided by outpatient care teams in hospitals, but the way these teams are organized differs per hospital and hampers the continuity of care. The aim of this study is to explore the organization and continuity of care for children with anorexia nervosa in the Netherlands by using a modular perspective.We conducted a qualitative, exploratory case study and took the healthcare provision for children with anorexia nervosa, provided by outpatient care teams, as our case. We conducted nine interviews with healthcare professionals involved in outpatient care teams from six hospitals. A thematic analysis was used to analyze the data.The modular perspective offered insights into the work practices and working methods of outpatient care teams. We were able to identify modules (i.e. the separate consultations with the various professionals), and components (i.e. elements of these consultations). In addition, communication mechanisms (interfaces) were identified to facilitate information flow and coordination among healthcare professionals. Our modular perspective revealed gaps and overlap in outpatient care provision, consequently providing opportunities to deal with unnecessary duplications and blind spots.   Conclusion: A modular perspective can be applied to explore the organization of outpatient care provision for children with anorexia nervosa. We specifically highlight gaps and overlap in healthcare provision, which in turn leads to recommendations on how to support the three essential parts of continuity of care: informational continuity, relational continuity, and management continuity. What is Known: • Care provision for children with anorexia nervosa requires a network of health care professionals from different organizations, as a result the organization and provision of care faces challenges. What is New: • Modular care provision sheds light on the complexity and organization of outpatient care provision and supports the three dimensions of continuity of care as experienced by children with anorexia nervosa and their parents/caregivers.

1H-MRS measured ectopic fat in liver and muscle is associated with the metabolic syndrome in Danish girls but not in boys with overweight and obesity.

BACKGROUND: The metabolic syndrome (MetS) is a complication to overweight and obesity, which can be observed already in childhood. Ectopic lipid accumulation in muscle and liver has been shown to associate with the development of insulin resistance and dyslipidemia. Thus, the interaction between MetS and ectopic fat may offer clinical relevance. OBJECTIVES: To investigate the prevalence of MetS, or components hereof, and ectopic fat accumulation in liver and skeletal muscle tissue in children, as well as interactions between these. METHODS: Two-hundred-and-sixteen children and adolescents (95 boys) with overweight/obesity were investigated, as well as 47 controls (22 boys) with normal weight. The assessments included anthropometry, fasting blood biochemistry and blood pressure measurements. Liver and muscle lipid contents were assessed by proton magnetic resonance spectroscopy. RESULTS: We observed an odds ratio in girls with overweight/obesity of 12.2 (95% confidence interval: [3.8; 49.0]) for exhibiting MetS when hepatic steatosis was present, whereas no association was observed in boys with overweight/obesity (odds ratio 0.7 [0.2; 2.7]). The odds ratio of exhibiting MetS in the presence of muscular steatosis was 3.5 [1.4; 9.5] in girls with overweight/obesity and 1.0 [0.2; 5.6] in boys with overweight/obesity. Similar results were seen for girls with overweight/obesity exhibiting concurrent hepatic and muscular steatoses. CONCLUSION: Hepatic and muscular steatoses were associated with MetS among girls, but not among boys with overweight/obesity.

Gene expression profiling of malignant mesothelioma cell lines: cDNA array study.

To reveal genes relevant for malignant mesothelioma (MM), we carried out cDNA array experiments on 4 MM cell lines and 2 primary mesothelial cell cultures established from pleural fluid of non-cancer patients. Human cancer gene filters including 588 genes were used for the cDNA array experiments. Our study revealed 26 over-expressed genes that play a role in the regulation of cell fate, cell cycle, cell growth and DNA damage repair and 13 under-expressed genes encoding growth factors, receptors and proteins involved in cell adhesion, motility and invasion to be common to 3 or 4 MM cell lines. We confirmed the cDNA array results using RT-PCR for 5 of the over-expressed genes and for 3 of the under-expressed genes. Our study presents gene expression profiles in MM cell lines and shows the involvement of several genes, such as those encoding JAGGED1, ser/thr protein kinase NIK, Ku80 and cyclin D2, novel in MM.

Rate of persistent perforation after elective tympanostomy tube removal in pediatric patients.

This study was performed to determine the rate of persistent perforations according to age, tube type and duration of intubation in children who underwent elective tympanostomy tube removal. Our retrospective analysis of hospital and clinic charts included all patients who underwent elective tube removal from July 1995 to December 1997 at our institution. Information from the chart review included patient age at time of tube removal, type of tube removed, duration of intubation, presence of granulation tissue/polyps, and concomitant paper patch placement. The outcome of each surgical removal was determined by examining follow-up clinic charts. A patient was deemed to have a persistent perforation if the eardrum had not adequately healed within 3 months after surgery. Data on 201 patients were gathered. These patients had 273 tube removals. Eleven percent of ears (29/273) had persistent perforations. According to tube type, no perforations (0/48) occurred with Collar Bobbin tubes, 6% (3/50) with Tytan tubes, 7% (3/44) with Duravent tubes, and 22% (16/74) with Paparella II tubes. Three percent (3/101) of tubes in place for <3 years and 15% (26/172) of tubes in place for >3 years showed persistent perforations after removal. Ears with granulation polyps had a 9% (18/203) rate of perforations, whereas those without granulation polyps had a 16% (11/70) rate of perforations. Forty percent (4/10) of ears were treated with paper patches at the time of tube removal showed persistent perforations. Our data indicate that the rate of persistent perforation (11%) after elective tympanostomy tube removal is high. The factors associated with higher rates of persistent perforation (P<0.05) include duration of intubation >3 years prior to removal and the use of long-term Paparella II tubes.

Timing of insemination relative to ovulation in pigs: effects on sex ratio of offspring.

The objective of the present study was to identify effects of the interval between insemination and ovulation in pigs on the sex ratio and sex ratio dispersion of offspring. Crossbred sows that had farrowed 2 to 9 litters were weaned (Day 0) and came into estrus between Days 3 and 7 after weaning. Ultrasonography was performed every 6 h, from 12 h after the onset of estrus until ovulation had been observed. The sows were inseminated once at various intervals from the onset of estrus. At farrowing, the numbers of viable piglets and dead piglets were recorded per sow. In four 12-h intervals between insemination and ovulation (36 to 24 h before ovulation, 24 to 12 h before ovulation, 12 to 0 h before ovulation and 0 to 12 h after ovulation), the total number of piglets was (mean+/-SEM) 10.8+/-1.2 (n=15); 13.4+/-0.7 (n=23); 13.2+/-0.9 (n=21); and 12.1+/-1.0 (n=16), respectively (P>0.05). The percentage of male piglets per litter in the four 12-h intervals was 52.1+/-3.6, 50.5+/-2.7, 54.9+/-2.8 and 47.8+/-4.5, respectively (P>0.05). Sex ratio was not influenced by litter size (P>0.05), and its distribution was normally dispersed (i.e., as expected under a binomial distribution) in all 4 intervals between insemination and ovulation (P>0.05).

Ovulation and embryonic developmental rate following hCG-stimulation in sows.

The hCG induced ovulation in sows was studied by use of ultrasonography, and an investigation of the development and diversity of the zygotes/embryos was performed at 24 h after ovulation. Crossbred sows (N = 48) were weaned (day 0) and checked for heat twice daily from day 3 onwards. From day 4, the ovaries were transrectally scanned twice daily. On day 4, the sows were given an injection of 750 iu hCG i.m. and inseminated 27 +/- 2 h (X +/- SD) and 38 +/- 1 h later. From 38 to 48 h after the hCG injection, the ovaries were scanned at 60 to 90 min intervals. At 24 h after ovulation the oviducts were surgically flushed in 18 sows. Out of the 48 sows, 34 showed heat at 12-36 h after the hCG-treatment and 14 showed heat before the hCG treatment. In the former group of sows, 20 (59%) ovulated within the interval of 38 to 48 h after the hCG treatment, and the follicular size immediately before ovulation was 7.8 +/- 0.6 mm. Among the sows which showed heat before hCG treatment only 7 (50%) ovulated within the above interval and the preovulatory follicle size was larger (8.3 +/- 0.5, p < 0.05) than in the former group of sows, which showed heat after the hCG treatment. The flushing of 18 sows yielded a total of 243 ova, 70 (29%) 1-cell stages, 160 (66%) 2-cell stages and 13 (5%) 4-cell stages. A pronounced difference in the degree of variation in embryonic development was seen between sows: 4 animals yielded 1- to 4-cell stages, one exclusively 2-cell stage. In conclusion, the control of ovulation in sows by hCG treatment will affect the follicular growth and the exact timing of ovulation can not always be relied on. It is strongly recommended to use ultrasonography to monitor the time of ovulation if this parameter is important. Ova recovered at 24 +/- 1 h after the median time of ovulation revealed a pronounced diversity (1- to 4-cell stage) within sows. No obvious relation with this embryonic diversity and the follicular size at ovulation was seen in these data.

Drug resistance-associated factors in primary and secondary glioblastomas and their precursor tumors.

Malignant gliomas are largely resistant to current chemotherapeutic strategies often displaying a multidrug-resistant phenotype. Mechanisms involved in drug resistance are reduced cellular drug accumulation through membrane efflux pumps, drug detoxification as well as alterations in drug target specificity. In 27 primary and 17 secondary glioblastomas and their astrocytic precursor tumors, we studied the immunohistochemical expression profile of P-glycoprotein (P-gp), multidrug resistance-associated protein (MRP), lung resistance-related protein (LRP), metallothionein, and topoisomerase II alpha. Glial tumor cells in all glioblastomas showed constant up-regulation of LRP, MRP, and topoisomerase II alpha. P-gp was found in 90% of the primary and 60% of the secondary glioblastomas. In precursor tumors, these drug resistance-related factors were expressed in varying proportions. Metallothionein, also found in normal and activated astrocytes, was retained in all neoplastic phenotypes. Furthermore, metallothionein, P-gp, LRP, and topoisomerase II alpha were strongly expressed by normal and neoplastic vessels which may confer to impaired penetration of therapeutic agents through the blood-brain and blood-tumor barrier. However, the expression profiles of drug resistance-related proteins neither differed between primary and secondary glioblastomas nor revealed any correlation to precursor or recurrent tumors. Nevertheless, inhibition of these factors may be promising approaches to the management of malignant gliomas.

[National surveillance of Helicobacter pylori eradication in Denmark. Results based on registration of 34.582 drug prescriptions]. / National overvågning af Helicobacter pylori-eradikationsterapi i Danmark. Resultater fra registreringen af 34.582 receptudskrivninger.

We wanted to characterize the use of H. pylori eradication therapy in Denmark (inhabitants 5,227,862). All H. pylori eradication treatments from a nation wide database covering all drug prescriptions in the period January 1994-June 1996 were identified. We found 28,784 out-patients having a prescription with drugs for H. pylori eradication, accounting for 34,582 prescriptions in total. The incidence of new consumers was 220 per 10(5) inhabitants per year, with a maximum at 70-79 years of age. Eighty-six percent of the patients had only one treatment course. Forty-five percent had an anti-ulcer drug prescribed 1-12 months after the H. pylori eradication therapy. Consumption of antibiotics used for H. pylori eradication accounted for 1.4% of the total consumption of antibiotics. In conclusion, the incidence of H. pylori eradication therapy was fairly stable but with changes in the pattern of drug regimens used. Anti-ulcer drugs were often given after H. pylori eradication therapy, suggesting an inappropriate use of eradication treatment.

National surveillance of Helicobacter pylori eradication therapy in Denmark. Results from registration of 34,582 prescriptions.

BACKGROUND: We wanted to characterize the use of Helicobacter pylori eradication therapy in Denmark (5,227,862 inhabitants). METHODS: All H. pylori eradication treatments from a nationwide database including all redeemed drug prescriptions in the period January 1994 to June 1996 were identified. So were all outpatients receiving a drug prescription for H. pylori eradication. RESULTS: We recorded 34,582 prescriptions for H. pylori eradication therapy given to 28,784 patients. The incidence of new consumers was 220 per 10(5) inhabitants per year, with a maximum at 70-79 years of age. Eighty-six per cent of the patients had only one treatment course. In 16% of the eradication therapies, nonsteroid anti-inflammatory drugs had been prescribed within the previous 3 months, and 45% had an anti-ulcer drug prescribed 1-12 months after the H. pylori eradication therapy. Consumption of antibiotics used for H. pylori eradication accounted for 1.4% of the total consumption of antibiotics. CONCLUSIONS: The incidence of H. pylori eradication therapy was fairly stable but with changes in the pattern of drug regimens used. Anti-ulcer drugs were often given after H. pylori eradication therapy, suggesting an inappropriate use of treatment.

Expression of adhesion factors and degrading proteins in primary and secondary glioblastomas and their precursor tumors.

In tumor tissue specimens of 27 primary and 17 secondary glioblastomas and the precursor lesions, the immunohistochemical expression patterns of the membrane protein CD44s, the basal lamina proteins laminin, collagen IV, and fibronectin, the lectin galectin-3 recognizing tenascin and N-CAM as well as of the matrix-degrading enzymes matrix metalloproteinase MMP-2 and MMP-9, and cathepsin D were studied. Besides expression of basal lamina proteins in vessels, all glioblastomas and the precursor lesions showed strong immunoreactivity of CD44s, tenascin, galectin-3, and N-CAM which were restricted to solid tumor masses. Present in solid tumor areas, MMP-2, MMP-9 and cathepsin D were also strongly expressed by single tumors cells invading adjacent brain tissue at the infiltrative margin. Neither the expression pattern in primary and secondary glioblastomas nor in the precursor tumors revealed significant differences. There was also no intraindividual constant expression pattern during glioma progression or correlation with malignancy. Restricted expression of CD44s, galectin-3, tenascin and N-CAM in solid tumor masses seems to contribute to homotypic tumor cell adhesion while single tumor cells abolish this expression profile and acquire invasive activities by expression of cathepsin D, MMP-2 and MMP-9.

The influence of time of insemination relative to time of ovulation on farrowing frequency and litter size in sows, as investigated by ultrasonography.

The objective of this experiment was to identify the optimal time of insemination relative to the time of ovulation, based on ultrasonographic detection of embryonic survival at 10 days after ovulation, number of sows farrowing, and litter size. Furthermore, the possible value of the interval from weaning to onset of estrus for prediction of the time of ovulation was examined. Crossbred sows (n = 143) that had farrowed 2 to 9 litters were weaned (Day 0) and observed for estrus every 8 h from Day 3 until end of estrus. Ultrasonography was performed every 6 h, from 12 h after onset of estrus until ovulation had been observed. The sows were inseminated once at various time intervals from ovulation. At Day 16, 25 of the sows were slaughtered and their uteri were flushed for embryos. In the remaining sows, the number of viable and dead piglets and mummified fetuses per sow was recorded at farrowing, with the sum of the 3 constituting the total number of piglets born per sow. The highest number of embryos recovered per sow was found after insemination during the interval from 24 h before to 4 h after ovulation. The lowest frequency of non-pregnant sows and the highest total number of piglets born per sow were found after insemination from 28 h before to 4 h after ovulation. Consequently, the optimal time for insemination was found to be in the interval 28 h before to 4 h after ovulation. The interval from weaning to onset of estrus and from onset of estrus to ovulation were negatively correlated, allowing a rough prediction of the time of ovulation from the interval from weaning to onset of estrus.

Value of intraoperative threshold stimulus in predicting postoperative facial nerve function after acoustic tumor resection.

OBJECTIVE: The objective of this study was to determine the predictive value of intraoperative threshold stimulus and postoperative facial nerve outcome in acoustic neuroma surgery. This is a retrospective case review of 116 consecutive procedures to remove acoustic neuromas using either a retrosigmoid or translabyrinthine approach. STUDY DESIGN: Retrospective study. SETTINGS: The Tertiary Referral Center at The California Ear Institute in Palo Alto, California. PATIENTS: These were consecutive presenting patients with acoustic neuroma in the senior author's practice. Patients were not categorized into age, sex, race, or other demographic features. INTERVENTION: All patients had acoustic neuromas detected via magnetic resonance imaging, and they underwent surgery at the hands of the same neurootologic team, Drs. Nissen and Welsh. MAIN OUTCOME MEASURE: The electrophysiological monitoring reports of 81 cases of acoustic tumors. Measures in which intraoperative facial nerve monitoring was performed provided the data for this article. RESULTS: The patients were categorized by postoperative facial nerve function evaluated a minimum of 6 months after surgical removal. Group I was composed of those patients with facial nerve grades of I or II. The median threshold stimulus voltage required to produce measurable facial nerve activity at the root entry zone (REZ) immediately after tumor removal in this group was 0.100 V. Patients in group II had postoperative facial nerve grades of III to VI. Median threshold stimulus in this group was 0.7250 V. The difference in median threshold stimulus voltage at the REZ after tumor removal between these two groups was found to be statistically significant in using the nonparametric Mann-Whitney U test. CONCLUSIONS: The results of this study strongly support the continued use of intraoperative facial monitoring as a predictor of postoperative facial nerve outcome after acoustic tumor surgery.

A multifactorial analysis of facial nerve results in surgery for cerebellopontine angle tumors.

Preserving the function of the facial nerve remains a paramount objective in acoustic neuroma surgery. This study was undertaken to determine the influence of four independent variables on facial nerve outcome by means of a retrospective review of 111 surgical cases: 1) tumor size; 2) use of intraoperative facial nerve monitoring (IFNM); 3) completeness of tumor resection; and 4) surgical approach used. Partial tumor resection appeared to result in improved facial nerve outcome for patients with large tumors. Results indicated that tumor size did not correlate with facial nerve functional outcome, with no statistically significant differences observed among the three size categories. Facial nerve function was not found to depend on selection of either a translabyrinthine (n = 47) or a suboccipital (n = 55) surgical approach in that results were similar for both groups. Outcome data showed a trend in support of the use of IFNM, especially for large tumors, even though the differences between monitored and unmonitored groups were not statistically significant. This study describes the independent impact of the four factors generally thought to affect facial nerve outcome and, in addition, recommends the use of data stratification in reporting facial nerve function results.

Use of the KTP-532 laser in acoustic neuroma surgery.

The potassium titanyl phosphate (KTP-532) laser has been applied to otologic surgery with a proven record of both safety and efficacy. The aim of this study was to demonstrate the use, safety, and advantages of laser dissection in the surgical treatment of acoustic neuromas. The authors' experience with 111 patients in whom laser surgery was used in acoustic neuroma is presented, with emphasis on surgical technique employed and facial nerve functional outcome. The method of laser dissection did not result in deleterious neurologic sequelae or laser-specific complications. In addition, laser dissection afforded certain advantages to traditional techniques, especially in larger tumors. The facial nerve functional outcome as assessed by the House-Brackmann grading system revealed that 90.2% of small tumors, 72.2% of medium tumors, and 75.0% of large tumors achieved satisfactory (grades I and II) functional results. These results compare favorably with the literature describing nonlaser dissection techniques. The observations and results reported in this article demonstrate the safety of the KTP-532 laser in the posterior cranial fossa, and specific advantages that this technology may offer to the surgical armamentarium of the neuro-otologist are outlined.

Complications of chronic otitis media.

In summary, recent literature indicates that the complications of chronic otitis media have been decreasing. However, even with the advent of modern and more powerful antimicrobials and aggressive surgical eradication of disease, the morbidity and mortality are still high. Some complications may initially be quite obvious and some complications may be quite subtle. Therefore, the most important tools in making early diagnosis are careful history and physical examination, and a high index of suspicion for impending complications.

[Individual-based statistics on drug utilization]. / Individbaseret laegemiddelforbrugsstatistik.

The Danish retail pharmacies' drug subsidy system is completely computerised. The data are person-identifiable, making it possible to chart the population's drug use from the perspective of the individual users. We undertook an analysis to explore the potential of this data source and to analyse the heavy drug users specifically. The analysis encompassed all 890,352 prescriptions presented by Odense citizens in 1991. There was a total sales volume of 32 million defined daily doses, consumed by 113,468 adult drug users, corresponding to 65.1% percent of the adult population. We found 2388 heavy drug users defined by an annual purchase of more than 2000 defined daily doses. Heavy drug users accounted for 1.4% of the adult population and 22.9% of drug sales. Heavy drug users were remarkably well characterised by their main therapeutic class which constituted a median of 47% of their drug use. A median of 97% of each heavy user's drugs were issued by one main prescriber. We conclude that heavy drug use generally can be ascribed to severe disease rather than to irresponsible prescribing. For the most important drug classes, we present various epidemiological measures of drug use, including one-year prevalence, incidence, duration of therapy and some measures of skewness in utilization. If analysed regularly these measures can disclose subtle trends in clinical drug use that would not be evident from the wholesale figures.

Long-range air pollution and its impact on heavy metal accumulation in dippers Cinclus cinclus in Norway.

Heavy metals such as cadmium, lead and zinc are deposited in Norway as long-range transported air pollution, while copper deposition is of mainly local origin. This study examined whether the deposition influences the metal concentrations in dippers Cinclus cinclus. The lead concentration in dippers reflected the deposition pattern of long-range air pollution, with higher concentrations in Southern Norway than Central Norway and a significant decrease (>/=40%) between 1987 and 1994. For cadmium, copper and zinc there were no geographical or temporal variations in metal concentrations. For zinc, this lack of geographic and temporal variation probably reflects the fact that it is a homeostatically regulated metal. For both cadmium and copper, local sources are probably more important than long-range sources. Zinc and copper was at higher level in livers of females than in males during the egg laying period. The concentrations of zinc and copper in livers were positively correlated.