Development of a patient decision aid for discharge planning of hospitalized patients with stroke.

BACKGROUND: Patient involvement in discharge planning of patients with stroke can be accomplished by providing personalized outcome information and promoting shared decision-making. The aim of this study was to develop a patient decision aid (PtDA) for discharge planning of hospitalized patients with stroke. METHODS: A convergent mixed methods design was used, starting with needs assessments among patients with stroke and health care professionals (HCPs). Results of these assessments were used to develop the PtDA with integrated outcome information in several co-creation sessions. Subsequently, acceptability and usability were tested to optimize the PtDA. Development was guided by the International Patient Decision Aids Standards (IPDAS) criteria. RESULTS: In total, 74 patients and 111 HCPs participated in this study. A three-component PtDA was developed, consisting of: 1) a printed consultation sheet to introduce the options for discharge destinations, containing information that can be specified for each individual patient; 2) an online information and deliberation tool to support patient education and clarification of patient values, containing an integrated "patients-like-me" model with outcome information about discharge destinations; 3) a summary sheet to support actual decision-making during consultation, containing the patient's values and preferences concerning discharge planning. In the acceptability test, all qualifying and certifying IPDAS criteria were fulfilled. The usability test showed that patients and HCPs highly appreciated the PtDA with integrated outcome information. CONCLUSIONS: The developed PtDA was found acceptable and usable by patients and HCPs and is currently under investigation in a clinical trial to determine its effectiveness.

Skin testing for immediate hypersensitivity to corticosteroids: a case series and literature review.

BACKGROUND: Immediate hypersensitivity to corticosteroids is reported to occur with an incidence of 0.1%. The largest previous case series reporting corticosteroid skin testing has seven patients. METHODS AND PATIENTS: We identified 23 patients (mean age 50 years, 65% female) from Auckland City Hospital who underwent skin testing (ST) for suspected corticosteroid hypersensitivity between July 2005 and April 2012. We performed a retrospective clinical case note review detailing clinical history of reaction, skin test results and subsequent management. Most patients (21/23) had a standard panel of testing with prednisolone, triamcinolone, methylprednisolone, hydrocortisone and dexamethasone. Skin tests used a 10% steroid stock concentration for skin prick tests (SPT) and dilutions of 1 : 1000, 1 : 100 and 1 : 10 for subsequent intradermal testing. A weal 3 mm greater than the negative control was considered positive. RESULTS: A total of 23 patients were identified who had skin testing for suspected acute hypersensitivity to corticosteroids, eight of which had a history of anaphylaxis. From 28 reactions (in 23 patients), the most common route of administration was intra-articular (13), followed by oral (7), intravenous (3) and other (5). Skin tests were positive in 8/23 patients, and 7/8 of these patients had a history of corticosteroid-associated anaphylaxis. Skin tests were positive at either the skin prick test or intradermal stages. There was evidence suggesting clinical and skin test cross-reactivity between corticosteroids in one patient. One patient had a positive skin test, but negative oral challenge suggesting the skin test was false positive. Skin tests were negative in 15/23 patients. One patient had a negative prednisolone skin test and positive unblinded oral challenge, suggesting a false-negative skin test. CONCLUSIONS: Skin testing can provide sufficient evidence to diagnose allergy in patients with a clear history of immediate hypersensitivity to corticosteroids such as anaphylaxis. Both skin prick and intradermal tests should be used. There is evidence of cross-reactivity between steroids, so a panel is recommended. False-positive and false-negative reactions do occur; however, the frequency is unknown. Challenge remains the only definitive way to demonstrate a safe alternative to use. CLINICAL RELEVANCE: As the largest case series described, this article provides new evidence for the interpretation of skin tests when investigating possible immediate hypersensitivity to corticosteroids.

[Four patients with aneurysm of the hepatic artery]. / Vier patiënten met een aneurysma van de A. hepatica.

Two men aged 73 and 71 years and 2 women aged 76 and 80 years were referred for a false aneurysm (the 3rd patient) or true aneurysm (the other 3 patients) of an extrahepatic portion of the hepatic artery. The first patient was asymptomatic, the third patient had a rupture in the biliary duct and the remaining 2 patients had upper abdominal pain. In the first 2 patients, the aneurysm was removed surgically and replaced with a venous interposition graft. The 3rd patient received a coated stent. In the 4th patient, the artery was occluded, after which hepatic circulation recovered spontaneously. Treatment was successful in all 4 patients. Aneurysm of the hepatic artery is identified increasingly more often due to the current capabilities of diagnostic imaging. Elective treatment is indicated if the diameter is > 2 cm due to the increased risk of rupture, which has been associated with mortality rates of up to 40%. Primarily, endovascular treatment should be considered by means of a coated stent or aneurysm coiling. For patients with compromised intestinal circulation, surgical elimination with venous reconstruction is the treatment of choice.

[Cystic adventitial degeneration of the popliteal artery; an unexpected cause of intermittent claudication]. / Cysteuze adventitiadegeneratie van de A. poplitea; een onverwachte oorzaak van claudicatio intermittens.

Three men, aged 48, 44 and 51 years, were referred to the vascular surgery outpatient clinic because of acute intermittent claudication in one leg. The first patient had no medical history and no vascular risk factors, the second patient was receiving drug treatment for hypercholesterolaemia and diabetes mellitus and the third patient smoked. After additional radiological diagnostics, cystic adventitial degeneration of the popliteal artery was diagnosed in all patients. All 3 patients were operated. Only circumferential resection of the cystic adventitia and the outer layer of the media, so-called exarteriectomy, was performed in the second patient. The other 2 patients underwent resection of the affected popliteal artery followed by an autologous vein graft. The post-operative course was uncomplicated. The diagnosis of cystic adventitial degeneration was confirmed histopathologically. Cystic adventitial degeneration is localised only in the popliteal artery in 85-90% of cases. It is probably caused by incorporation of mesenchymal cells in the wall of the popliteal artery during embryogenesis. The disease is often progressive and, if left untreated, may lead to critical ischaemia due to arterial occlusion. Surgical intervention is therefore necessary, with exarteriectomy as the preferred technique, especially because the patients are often young.

Lack of association between baseline plasma homocysteine concentrations and restenosis rates after a first elective percutaneous coronary intervention without stenting.

OBJECTIVE: To evaluate the association between baseline homocysteine concentrations and restenosis rates in patients electively undergoing their first percutaneous coronary intervention (PCI) without stenting. DESIGN: Prospective, single centre, observational study. SETTING AND PATIENTS: Patients electively undergoing their first PCI without stenting at a tertiary referral centre between 1990 and 1998. METHODS: Blood samples were collected from all patients at baseline and assayed to determine the patients' homocysteine concentrations. Patients whose PCI was successful underwent repeat angiography at a median of 6.4 (interquartile range 6-6.8) months. Their baseline and follow up angiograms were compared by quantitative coronary angiography to assess the incidence of restenosis. For the analysis, the patients were divided into two groups based on whether their baseline homocysteine concentrations were above or below the median value. These two groups were compared to determine whether there was any association between their baseline homocysteine concentrations and the incidence of restenosis at six months. RESULTS: 134 patients had a successful first PCI without stenting (involving 200 lesions). At six month angiography, restenosis was observed in 33 patients (49.3%) with baseline homocysteine concentrations above the median value and in 31 patients (46.3%) with concentrations below the median value (p = 0.74). There was no difference in the percentage of lesions developing restenosis (38 (39.6%) v 40 (38.5%), respectively, p = 0.87) or late lumen loss (0.40 mm v 0.31 mm, respectively, p = 0.24). On multivariable analysis, there was no association between homocysteine concentrations and late lumen loss (r = -0.11, p = 0.11) or the percentage diameter stenosis at follow up (r = -0.07, p = 0.32). CONCLUSION: Baseline homocysteine concentrations were not associated with six month restenosis rates in patients electively undergoing their first PCI without stenting.

Neurological complications in children with supracondylar fractures of the humerus.

OBJECTIVE: To study the incidence of primary and secondary nerve injury in supracondylar fractures of the humerus, and to find out which factors may be responsible for iatrogenic nerve injuries. DESIGN: Retrospective study. SETTING: University Hospital, The Netherlands. SUBJECTS: 32 children admitted with type II or type III supracondylar fracture of the humerus. MAIN OUTCOME MEASURES: Incidence of primary and secondary nerve injury and their relation to type of fracture and treatment. RESULTS: 3 patients developed primary nerve injuries (9%). 4 further children developed nerve injury during treatment. All these children had several closed reductions attempted before definitive treatment was given (either pinning with a Kirschner wire or overhead traction). CONCLUSION: Several attempts at closed reduction may cause iatrogenic nerve injury in unstable supracondylar fractures of the humerus.

Alveolar and skeletal dimensions associated with overbite.

The aim of this study was to investigate whether in the maxilla and in the mandible the structure of the anterior medial sagittal alveolar and basal bone is related to the overbite. A total of 460 untreated adult subjects were divided into four groups with either deep bite, normal overbite, end-to-end bite, or open bite and were compared. The overbite, lower face height, and anterior alveolar and basal midsagittal cross-sectional areas from the maxilla and the mandible were assessed on lateral cephalometric radiographs. An index was calculated, dividing the sagittal by the vertical dimension of the midsagittal cross-sectional area. A deeper bite coincided with smaller lower face height, larger alveolar and basal areas, and a more widened shape of the symphysis. If the lower face height was introduced as a covariable, the open bite group showed significantly smaller maxillary and mandibular alveolar and basal cross-sectional areas compared with the end-to-end group, the normal overbite group, or the deep bite group. Vertical variation of the overbite probably coincides with a relative hyperdevelopment or hypodevelopment of the symphysis.

Alveolar and skeletal dimensions associated with lower face height.

In this study, the relationships between the lower face height and the structure of the frontal alveolar and basal bone were investigated. The areas and the dimensions of the anterior alveolar and basal midsagittal cross-sectional bone from the maxilla and the mandible were recorded on lateral cephalograms from 460 untreated adults. An index was calculated dividing the sagittal by the vertical dimension of the midsagittal cross-sectional area. The subjects with a normal overbite between 0.5 and 4 mm (N=165) were divided into three groups according to the lower face height. A larger lower face height coincided with a larger maxillary alveolar and basal area and with a smaller mandibular alveolar index. Correlations between the lower face height and the maxillary alveolar index and the mandibular alveolar and basal area were low. It is concluded that long-faced subjects have a large mandibular alveolar height, which is more associated with a narrowed shape than with a large volume of the symphysis.

A multicentre comparison of treatment regimens for unilateral cleft lip and palate using a multiple regression model.

The European Cleft Lip and Palate Research Group consists of specialists in orthodontics from six centres for the treatment of cleft palate in northern Europe. The purpose of this part of the multicentre study was to investigate whether differences in outcomes could be explained by specific treatment regimens. Three regimens that were assumed to influence the outcome of treatment were selected: Presurgical orthopaedics, closure of the palate, and primary bone grafting. The sample comprised 151 children with complete unilateral cleft lip and palate from the six centres. The result of multiple regression analysis showed that within that sample it was not possible to reach definite conclusions as to which factors exerted the most favourable influence on facial growth, but primary bone grafting was associated with reduced maxillary inclination and presurgical orthopedics with increased mandibular inclination.

A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 1. Principles and study design.

This article describes the design of an intercenter comparative study of treatment outcome in the treatment of children with a unilateral complete cleft of the lip and palate. The rationale and aims of this study are defined and treatment schemes of the participating centers are described. The findings are presented in a series of three papers (Parts 2, 3, and 4) dealing with the comparison of craniofacial form, dental arch relationships, and nasolabial appearance. In Part 5, conclusions and general recommendations regarding future research are discussed.

A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 4. Assessment of nasolabial appearance.

One hundred and fifteen frontal and profile photographs of the nasolabial area of subjects with complete unilateral clefts of the lip and palate from six European centers were assessed. Four components of the nasolabial area were rated separately by a panel of judges using a five-point scale of attractiveness. The Tukey multiple comparison test showed significant differences between the centers. The relative position of the six centers in this study followed a similar pattern to their respective positions in the cephalometric and dental cast studies.

Synthetic monoacylphospholipids as reactivators of the calcium-dependent ATPase of enzymatically delipidated sarcoplasmic membranes.

1. The reactivating effect of synthetic analogues of natural lysophosphatidylcholines, acyldeoxyglycerophosphocholines, with acyl chain lengths between C10-C18 on enzymatically delipidated sarcoplasmic membranes has been analyzed. 2. The calcium-dependent ATPase is fully restored by myristoyldeoxyglycerophosphocholine. The restoring effect of deoxyglycerophosphocholines declines when the length of the saturated acyl chain becomes shorter or longer. 3. In contrast to the weakly effective palmitoyldeoxyglycerphosphocholine, its cis-9-mono unsaturated analogue oleyldeoxyglycerophosphocholine proved to be a highly effective reactivating compound. 4. The transfer of the terminal phosphate residue of ATP to the transport protein and the phosphate exchange between ADP and ATP displays the same dependence on the acyl chain length of the deoxyglycerophos-phocholines. In contrast to the ATPase activity the ATP-supported phosphoryltransfer reactions can only partially be restored. 5. A significant restoration of the phosphorylation of the protein by inorganic phosphate could be achieved with none of the deoxyglycerophosphocholines. 6. Below 23 degrees C the apparent activation energy of the calcium-dependent ATPase increases with increasing chain length of the deoxyglycerophosphoclines while above 23 degrees C the activation energies were identical for all restituted preparations.

Stimulatory and inhibitory effects of dimethyl sulfoxide and ethylene glycol on ATPase activity and calcium transport of sarcoplasmic membranes.

1. The effect of dimethyl sulfoxide (Me2SO) and ethylene glycol on two different preparations of the sarcoplasmic reticulum, i.e. native membranes and membranes whose phospholipids were hydrolyzed by phospholipase A, were investigated using ATP and p-nitrophenylphosphate as substrates. 2. Me2SO and ethylene glycol inhibit both calcium-dependent ATP hydrolysis and ATP-supported calcium transport by native vesicles. 3. In contrast, calcium-dependent p-nitrophenylphosphatase activity as well as p-nitrophenyl-phosphate-supported calcium transport are activated by both agents at concentrations lower than 30% (v/v). 4. Me2SO strongly stimulates p-nitrophenylphosphate activity of vesicles treated with phospholipase A, but has relatively little effect on p-nitrophenylphosphatase activity of native vesicles. 5. Up to a concentration of approximately 40% Me2SO (v/v) the inhibiting effect on the calcium-dependent ATPase is fully reversible, but only partially reversible on calcium transport. 6. In the concentration range where Me2SO inhibits ATP hydrolysis and calcium transport, it does not affect ATP binding to the membranes nor calcium-dependent formation of phospho-protein. 7. The rate of dephosphorylation as well as the rate of Pi exchange between ATP and ADP are markedly reduced by the presence of 30% Me2SO (v/v). 8. While Me2SO inhibits passive calcium efflux, ethylene glycol produces a considerable activation. 9. ADP-dependent calcium efflux and ATP synthesis are activated by 15% Me2SO (v/v). Ethylene glycol reduces both activities. 10. The results suggest that the respective substrate-enzyme complexes are differently affected by the agents, resulting either in inhibition or stimulation

The effect of ethylene glycol and DMSO on fusion of isolated sarcoplasmic reticulum membranes.

Fragmented sarcoplasmic reticulum (FSR) vesicles from rabbit skeletal muscle were suspended in 5-10% ethylene glycol (EG) or in 5, 10, or 15% dimethylsulfoxide (DMSO) and were pelleted onto flat aluminum foil disks. No vesicle fusion o-curs with either 5 or 10% EG treatment and 2-21/2 hours drying. After 4-5 hours drying, 5% EG-treated vesicles have established more areas of close contact and individual vesicles have begun to flatten when compared with the 10% EG vesicles remained round as in the 2-21/2 hour samples of all treatments. Overnight drying also causes extended sheets of bilayer pairs to form in the 5% DMSO-treated samples but, with 10 and 25% treated vesicles, destroys the double bilayers and only occasional dense regions of membrane whorls remain. Both EG and DMSO promote morerapid fusion of FSR vesicles than does glycerol but overnight drying after treatment with 10 or 25% DMSO DESTROYS THE FUSED MEMBRANE.