MR imaging features for improved diagnosis of hepatocellular carcinoma in the non-cirrhotic liver: Multi-center evaluation.

PURPOSE: To determine MR-imaging features for the differentiation between hepatocellular carcinoma (HCC) and benign hepatocellular tumors in the non-cirrhotic liver. MATERIAL AND METHODS: 107 consecutive patients without liver cirrhosis (46 male; 45 ± 14 years) who underwent liver resection due to suspicion of HCC were included in this multi-center study. The following imaging features were assessed: lesion diameter and demarcation, satellite-lesions, central-scar, capsule, fat-content, hemorrhage, vein-infiltration and signal-intensity (SI) on native T1-, T2- and dynamic-enhanced T1-weighted images (center versus periphery). In addition, contrast-media (CM) uptake in the liver specific phase was analyzed in a sub-group of 42 patients. RESULTS: Significant differences between HCC (n=55) and benign lesions (n=52) were shown for native T1-, T2- and dynamic-enhanced T1-SI, fat-content, and satellite-lesions (all, P<.05). Independent predictors for HCC were T1-hypointensity (odds-ratio, 4.81), T2-hypo-/hyperintensity (5.07), lack of central tumor-enhancement (3.36), and satellite-lesions (5.78; all P<0.05). Sensitivity and specificity of HCC was 91% and 75% respectively for two out-of four independent predictors, whereas specificity reached 98% for all four predictors. Sub-analysis, showed significant differences in liver specific CM uptake between HCC (n=18) and benign lesions (n=24; P<0.001) and revealed lack of liver specific CM uptake (odds-ratio, 2.7) as additional independent feature for diagnosis of HCC. CONCLUSION: Independent MRI features indicating HCC are T1-hypointensity, T2-hypo- or hyperintensity, lack of central tumor-enhancement, presence of satellite-lesions and lack of liver specific CM-uptake. These features may have the potential to improve the diagnosis of HCC in the non-cirrhotic liver.

Risk of depression in patients with chronic obstructive pulmonary disease and its determinants.

BACKGROUND: Although it has been repeatedly suggested that chronic obstructive pulmonary disease (COPD) is associated with depression, no conclusion has so far been reached. A study was undertaken to investigate whether depression occurs more often in patients with COPD than in controls. The demographic and clinical variables associated with depression were also determined. METHODS: Patients with a registered diagnosis of obstructive airway disease in general practice, aged > or=40 years, forced expiratory volume in 1 second (FEV(1)) <80% predicted, FEV(1) reversibility

Added value of co-morbidity in predicting health-related quality of life in COPD patients.

The extent to which a chronic obstructive pulmonary disease (COPD) patient is impaired in health-related quality of life (HRQoL) is only to a small extent reflected in clinical and demographical measures. As the influence of comorbidity on HRQoL is less clear, we investigated the added value of 23 common diseases in predicting HRQoL in COPD patients with mild to severe airways obstruction. COPD patients from general practice who appeared to have an forced expiratory volume in 1 sec/inspiratory vital capacity (FEV1/IVC) < predicted -1.64 SD, FEV1 <80% predicted, FEV1 reversibility < 12% and a smoking history, were included (n=163). HRQoL was assessed with the short-form-36 (SF-36) and the presence of comorbidity was determined by a questionnaire, which asked for 23 common diseases. All domains of the SF-36 were best predicted by the presence of three or more co-morbid diseases. FEV1 % predicted, dyspnoea and the presence of one or two diseases were second-best predictors. Co-morbidity explained an additional part of the variance in HRQoL, particularly for emotional functioning (delta R2=0.11). When individual diseases were investigated, only insomnia appeared to be related to HRQoL. As HRQoL is still only partly explained, co-morbidity and other patient characteristics do not clearly distinguish between COPD patients with severe impairments in HRQoL and COPD patients with minor or no impairments in HRQoL. Therefore, it remains important to ask for problems in daily functioning and well-being, rather than to rely on patient characteristics alone.

Prevalence of comorbidity in patients with a chronic airway obstruction and controls over the age of 40.

The goal of this study is to determine the prevalence of 23 common diseases in subjects with a chronic airway obstruction and in controls. All subjects with a known diagnosis by their general practitioner of asthma or chronic obstructive pulmonary disease (COPD), and who were 40 years and older were selected (n = 1145). Subjects who were willing to participate (n = 591) and who appeared to have an irreversible airway obstruction (n = 290) were included. To recruit controls, a random sample was taken of 676 individuals who were 40 years and older and who were not diagnosed as having asthma or COPD by their general practitioner. Of these 676 individuals 421 were willing to participate. The presence of diseases was determined by using a questionnaire. One hundred and ninety-four subjects (73%) and 229 controls (63%) were shown to be suffering from one or more (other) diseases. In both groups, locomotive diseases, high blood pressure, insomnia and heart disease were most common. Locomotive diseases, insomnia, sinusitis, migraine, depression, stomach or duodenal ulcers and cancer were significantly more common in the subject group than in the control group. For both clinical and research purposes, it is important to consider the presence of diseases in patients with a chronic airway obstruction.

Assessment of the need for palliative care as perceived by individual cancer patients and their families: a review of instruments for improving patient participation in palliative care.

BACKGROUND: Palliative care should fit the needs of individual cancer patients and their families. Instruments can help to improve needs assessment. This review evaluates questionnaires for the systematic assessment of needs experienced by individual cancer patients for help, care, or support, as well as the needs of their family members. METHODS: The MEDLINE and PsycLIT data bases were searched systematically. Questionnaires were evaluated by reviewing their contents and estimating their validity, reliability, and feasibility for use in caregiving practice. RESULTS: Analysis of the 471 articles identified from the searches yielded 9 questionnaires for the assessment of patients' needs and 6 questionnaires for the assessment of family members' needs. Most of these instruments were carefully constructed; their validity and reliability were satisfactory and well documented. However, in most questionnaires the needs for care were confounded by satisfaction with care, and the problems experienced by patients. Only one questionnaire for patients specifically addressed the need for help; none for family members was so specific. Data on the feasibility of questionnaires for use in regular care were scarce. Issues frequently omitted were spiritual issues, the personal needs of family members, and the continuity of care. CONCLUSIONS: None of the instruments the authors found was complete for all dimensions of palliative care. Most instruments were constructed for research purposes and had not been tested for use in practical care. Further development of practical instruments based on a theoretical concept of needs assessment seems necessary. The feasibility of instruments for use in practical caregiving and their effects on the quality of care needs further research.

Methodologic issues in effectiveness research on palliative cancer care: a systematic review.

BACKGROUND: The objective of this report is to explore methodologic issues on the basis of a systematic review of the literature of effectiveness research on palliative cancer care with regard to selection and characteristics of a study population, interventions, and outcome assessment. METHODS: A systematic review was performed of randomized clinical trials on comprehensive palliative care with quality assessment of the studies by three independent observers, using predefined quality criteria. RESULTS: In the literature search, 11 relevant studies were identified. Without exception, methodologic problems were experienced. In two studies, the problems were so severe that no results were reported. Problems were associated with the recruitment of a study population in 10 studies, its homogeneity in six, patient attrition in four, defining and maintaining the contrast between the strategies in six, and selection of the outcome variables in four. CONCLUSION: Effectiveness research in palliative care is complex and has many pitfalls. To enhance the quality of future palliative care trials and the validity of their results, we particularly stress the importance of careful case finding, strict eligibility criteria, precise documentation of the process of care, and comprehensive outcome measurement. The relation of structure, process, and outcome variables in comprehensive palliative care should be further explored. It is a challenge for future research to link patient outcomes to the quality of care, independent from the autonomous course of the disease and from personal characteristics.

[Intra- and extramural workshop for care, teaching, and research]. / Intra- en extramurale werkplaats voor zorg, onderwijs en onderzoek.

Medical care and its development, education, training and research are closely linked in academic medical centres. Traditionally, hospital-based disciplines can make use of the university hospital as a 'workshop' for the combination of these activities. In the Netherlands, however, there is no structurally financed workshop for the non-hospital based medical disciplines, such as family medicine, public health medicine, and nursing home medicine. In the Academic Medical Centre, University of Amsterdam, an integrated hospital and primary health care oriented academic workshop is being developed, for all medical disciplines, including social medicine (e.g. preventive care) and general practice.

Home care and the general practitioner.

In the future more patients will be treated at home rather than in hospital. Proposed health-care systems have been developed into four scenarios. These have been termed the primary care network, primary care centre, transmural network and deconstruction. Whatever form it takes, home care must involve cooperation between patient, family and health service. A clear description of the duties of health professionals is needed, with clear documentation of who is responsible for specific care. The general practitioner's involvement should be based on specific care programmes to satisfy the patient's care needs.

Role of the general practitioner in breast cancer screening in The Netherlands.

Following the advice of the Dutch National Health Council, a national screening program for breast cancer was started in 1990 in the Netherlands. All women aged 50-70 will be invited for screening by mammography in fixed or (semi)mobile screening units every 2 years. The role of the general practitioner in screening for breast cancer is described in the Dutch protocol (Standard) published in 1990 by the Dutch College of General Practitioners. Because of the role of the general practitioner/family doctor as a gatekeeper and because of the list system, every Dutch woman is known by her own general practitioner. In any given year the general practitioner will see 70% of his population. So the general practitioner is in the position to play an important role in practice and patient-centered support of breast cancer screening. The general practitioner also has an important role in the support of women with positive results. The general practitioner receives the "abnormal" results and has to explain to the woman what this means and what further investigations are necessary. There are teaching programs on screening for breast cancer for the vocational training of general practitioners and for postgraduate training.