[Avoidable visual impairment among residents in care institutions: lessons from an intervention project in the Den Bosch region]. / Onnodige slechtziendheid onder ouderen in zorginstellingen: lessen uit een interventieproject in de regio Den Bosch.

INTRODUCTION: Many elderly in care institutions in The Netherlands are visually impaired (visual acuity < 0.3). They fall more frequently, are more depressed and require more care. In this project visually impaired residents were identified and referred for adequate eye care. The aim of this study is to evaluate the intervention, including validation of the screening, assessment of the prevalence and causes of visual impairment as well as the outcome of the treatment. The effectiveness of the care chain is also evaluated. MATERIALS AND METHODS: 640 residents were offered a basic eye examination and 210 of them were referred, via their general practitioner, to an optometrist (10), ophthalmologist (98), or centre for visually impaired persons (1). RESULTS: Compliance in this study was poor. The prevalence of visual impairment (24%) was lower than in comparable studies. Cataract was the main cause in 51%. Overall 17 (8.1%) residents were treated by ophthalmologists and nine (4.3%) were referred to optical shops. Constraints in the care chain are identified. DISCUSSION: Vision screening in care institutions for elderly is feasible and useful. The care chain should be shorter and simpler. That will increase the effectiveness of this intervention, and thereby the quality of life for many residents.

Road Blocks or Building Blocks? A Qualitative Study on Challenges and Resilience in Romantic Relationships of Youth Exposed to Family Violence.

Romantic relationships are an important part of many people's lives and at least partly shaped by experiences during childhood. Youth exposed to family violence during childhood are more likely to experience difficulties in their later romantic relationships. However, a more holistic perspective on the romantic relationships of youth with a history of family violence is lacking. Using both theoretical and inductive thematic analysis, this qualitative study explored challenges as well as positive experiences within romantic relationships of youth exposed to family violence during childhood. In-depth individual interviews were conducted with 18 youth aged between 16 and 20 years, who were reported to child protection services. The narratives reflected that youth experienced challenges related to support, connection, trust, boundary setting, emotion regulation and conflict resolution. Furthermore, family violence during childhood seemed to be important in the emergence of these challenges, consistent with theoretical mechanisms described in observational learning theory and attachment theory. However, youth also described positive experiences in their romantic relationships and demonstrated an ability to learn from others (e.g., their current romantic partner) how to communicate effectively or solve problems. Therefore, with the right social or professional support, at-risk youth may be able to overcome these challenges.

Determinants of increased angiotensin II levels in severe chronic heart failure patients despite ACE inhibition.

INTRODUCTION: The beneficial effects of ACE inhibitors are generally ascribed to blockade of neurohormonal activation. However, especially in chronic heart failure (CHF) patients plasma angiotensin II and aldosterone levels can be elevated despite ACE inhibition, the so-called ACE escape. In the present study, we aimed to identify the frequency and determinants of ACE escape in CHF patients. METHODS: We studied 99 stable chronic heart failure patients (NYHA class III and IV, 66% ischemic etiology) receiving long-term therapy with ACE inhibitors. In all patients, cardiac, renal, and neurohormonal parameters were measured. ACE escape was defined as plasma angiotensin level > or = 16 pmol/L. RESULTS: Mean (+/- SD) left ventricular ejection fraction of our 99 patients (79 men and 20 women, age 69 +/- 12 years) was 28 +/- 10%. In addition to an ACE inhibitor, 93% of patients received diuretics, 71% a beta-blocker, and 49% spironolactone. None of the patients used an angiotensin receptor blocker. In our population, 45% of the patients had an angiotensin II plasma concentration higher than 16 pmol/L (median concentration was 14.1 pmol/L). Spironolactone use was an independent predictor of elevated plasma angiotensin II levels. Furthermore, spironolactone users had significantly higher plasma active renin protein and aldosterone levels. Plasma angiotensin II concentration was positively correlated to active renin, plasma angiotensin I and plasma aldosterone. No correlation was found between plasma angiotensin II levels and serum ACE activity, dose of ACE inhibitor, or duration of use. CONCLUSION: In a group of severe chronic heart failure patients, 45% had elevated plasma angiotensin II levels independent of serum ACE activity despite long-term ACE inhibitor use. Although a causal link could not be proven, an association was found between spironolactone use and active renin protein, angiotensin II and aldosterone levels, suggesting that escape from ACE is mainly caused by a feedback mechanism.

Decrease of memory T helper cells (CD4+ CD45R0+) in hairy cell leukemia.

Patients with hairy cell leukemia (HCL) are prone to opportunistic infections, which suggests an impaired T-cell functioning. To investigate a possible mechanism of such an impairment, we determined the numbers of naive and memory T cells by measuring the expression of CD45R0 on CD4+ and CD8+ T cells in 23 HCL patients. As control, 13 healthy subjects and 13 patients with other chronic B-cell leukemias were studied. In HCL patients with active disease, the percentage of CD4+ CD45R0+ T cells was significantly lower compared to healthy subjects (41% versus 57%, p = 0.01). Also the absolute numbers of CD4+ CD45R0+ T cells were reduced (396 x 10(6)/l versus 615 x 10(6)/l, p = 0.02) compared to healthy subjects, whereas within the CD8+ subset no differences were found. A contrasting elevation of percentages and numbers of CD45R0-expressing T cells (p < 0.0001) was seen in patients with chronic lymphocytic leukemia or leukemic non-Hodgkin's lymphoma. No relationship between CD4+ CD45R0+ and splenectomy, treatment with alpha-interferon or monocyte numbers was found in the HCL population. Despite the fact that the underlying mechanism of the reduced expression of CD45R0 in CD4+ T cells remains unclear, our observations may contribute to the understanding of an impaired T-cell functioning in HCL.

Three novel mutations at serine 314 in the thyroid hormone beta receptor differentially impair ligand binding in the syndrome of resistance to thyroid hormone.

The syndrome of resistance to thyroid hormone is associated with diverse mutations in the ligand-binding domain of the thyroid hormone beta receptor, localizing to three clusters around the hormone binding cavity. Here, we report three novel resistance to thyroid hormone mutations (S314C, S314F, and S314Y), due to different nucleotide substitutions in the same codon, occurring in six separate families. Functional characterization of these mutant receptors showed marked differences in their properties. S314F and S314Y receptor mutants exhibited significant transcriptional impairment in keeping with negligible ligand binding and were potent dominant negative inhibitors of wild-type receptor action. In contrast, the S314C mutant bound ligand with reduced affinity, such that its functional impairment and dominant negative activity manifest at low concentrations of thyroid hormone, but are more reversible at higher T3 concentrations. The degree of functional impairment of mutant receptors in vitro may correlate with the magnitude of thyroid dysfunction in vivo. Modelling these mutations using the crystal structure of thyroid hormone receptor beta shows why ligand binding is perturbed and why the phenylalanine/tyrosine mutations are more deleterious than cysteine.

The usefulness of five D-dimer assays in the exclusion of deep venous thrombosis.

D-Dimer measurement is a promising tool in the exclusion of venous thrombosis. New d-dimer assays have been introduced, but need clinical validation. Our objective was to evaluate the clinical usefulness of four relatively new d-dimer assays and a classical ELISA in outpatients suspected for deep venous thrombosis. In 537 patients, participants in a large prospective management study using a clinical probability score and a d-dimer measurement (Tina-quant), additional samples were taken for d-dimer measurement using the Asserachrom ELISA, the VIDAS New, the STA-LIA and the Miniquant assay. Performances of each test were calculated using clinical data during a 3-month follow-up. Thrombosis was detected in 224 patients (42%). The area under the ROC curve was significantly higher for the Tina-quant as compared to the other assays. Using standard cut-off values, sensitivity, negative predictive value (NPV) and specificity of the Asserachrom were 97, 94 and 33%, respectively. For the VIDAS New, values were 100, 96 and 8%, respectively. The Tina-quant showed values of 99, 98 and 41%, respectively, and the STA-LIA 98, 95 and 32%. Values for the Miniquant were 95, 94 and 52%. The d-dimer assays in our study all show a high sensitivity and negative predictive value, but none of the assays reached an NPV of > 98% at standard cut-off values. d-Dimer assays with a low specificity still necessitate additional diagnostic tests in the majority of the patients.

The relationship between findings on pre-treatment mammograms and local recurrence after breast-conserving therapy for invasive breast cancer.

AIMS: This study was planned (a) to determine the correlation between findings on the pre-treatment mammogram and local recurrence after breast-conserving therapy (BCT), and (b) to analyse the relationship between mammographical features, specific pathological characteristics and the need for re-excision. METHOD: The size and outline of the lesion, the presence of suspect microcalcifications and signs of multifocality on pre-treatment mammograms of 39 patients with local recurrence after BCT and 126 randomly selected control patients without local recurrence were compared. Tissue slides of the primary tumour were reviewed to confirm the histological type and grade, the aspect of the margins, microscopic margin involvement, presence of vascular invasion and the presence and extent of an intraductal component. RESULTS: Among patients /=50 years, 67% of the patients with local recurrence had a non-circumscribed lesion compared to 9% of the control group (P<0.001). Suspect microcalcifications on the mammogram were associated with the finding of an extensive intraductal component, vascular invasion and a higher histological grade by the pathologist. Patients with a non-circumscribed density or a scirrhous lesion needed re-excision more often (30 and 33%, respectively) than those with a well-circumscribed density (9%). CONCLUSIONS: Although the number of patients was small, this study indicates that some mammographical features are associated with a higher risk of local recurrence after BCT and the need for re-excision. This was supported by the findings of the pathological review.

Determinants of patient satisfaction after cataract surgery in 3 settings.

PURPOSE: To analyze the determinants of satisfaction and postoperative visual function after cataract surgery in 3 settings in The Netherlands. SETTING: University Hospital Maastricht (outpatient care), Atrium Medical Center Heerlen (inpatient care), and Medical Center Maastricht Annadal (outpatient care), Maastricht, The Netherlands. METHODS: This cross-sectional study consisted of 150 patients of 50 years and older who had first-eye phacoemulsification with intraocular lens implantation. Data were collected by a written questionnaire. The following parameters were measured: medical outcome, postoperative function, patient satisfaction with medical outcome and hospital care, and overall patient satisfaction. RESULTS: In general, patients were very satisfied (mean score 8.43 on a 10-point scale ranging from 1 = very bad to 10 = excellent). The 3 centers did not differ regarding the patient satisfaction (P =.092). However, postoperative visual function (P =.012), counseling (P =.010), and waiting time (P <.001) were different among the settings. Patient satisfaction with hospital care had a stronger correlation with overall satisfaction than patient satisfaction with the medical outcome (r = 0.669 versus r = 0.543, respectively). CONCLUSIONS: A causal model of patient satisfaction was tested, indicating that satisfaction was related to the patient's preoperative expectations and the quality of care given during the hospital stay and follow-up at the outpatient clinic. This emphasizes the relevance of patient education (to set realistic expectations) and counseling (need for care) by hospital staff in a cataract surgery setting.

Patient satisfaction after corneal transplantation.

PURPOSE: To determine the relationship between objective and subjective outcome measures and patient satisfaction after corneal transplantation. METHODS: Data were collected for 184 patients who underwent a corneal transplantation between 1 and 5 years ago. Only patients with the diagnosis of bullous keratopathy, endothelial decompensation (or Fuchs dystrophy), nonherpetic keratitis, and keratoconus were included. Objective treatment outcome measures, such as clarity of the graft and visual acuity in the grafted eye, were collected prospectively. Visual acuity of the other eye was collected retrospectively by chart review. Subjective outcome measures were derived from a retrospective survey. In addition to assessment of patient satisfaction, the survey provided information regarding subjective outcome measures, such as visual functioning and quality of life. RESULTS: The response rate was 86%. Generally, patients indicated that they were satisfied with the results of the transplantation. Age was negatively related to satisfaction, with older patients being less satisfied. On average, patients with keratoconus were most satisfied. Subjective outcome measures explained 57% of the variance in patient satisfaction, whereas objective factors explained 12%. Receipt of patient education during treatment was the best predictor. Other important variables were quality of life and visual functioning. CONCLUSION: In general, corneal transplantation had a positive effect on objective and subjective outcome measures. Patient satisfaction was better predicted by subjective outcomes than by objective outcomes. Patient education, in particular, proved to be a crucial factor. Objective outcome measures appeared to have a more indirect influence on patient satisfaction.

Employment careers of young type I diabetic patients in The Netherlands.

The factors that influence the employment careers of diabetic patients aged 20 to 34 years were studied using a mail questionnaire. The study included all members of the Dutch diabetics association (Diabetes Vereniging Nederland) in that age group. A total of 5987 questionnaires were mailed; 4300 completed questionnaires were returned, giving a response rate of about 72%. The aim of the study was to provide a better insight into the problems type I diabetic patients face in the labor market: entry into the labor market, conditions at work, and (premature) exit from the labor market owing to health reasons. This study carefully distinguished between employability and employment. Results showed that having diabetes did not decrease the chances of entry into the labor market for the subjects, although some types of jobs are still unavailable for diabetic patients. There was no higher unemployment in the study population than in the general population. Although there were problems faced by patients in the work situation, they were generally limited to a small group.

Anticipatory care and the role of Dutch general practice in health promotion--a critical reflection.

The Dutch GP is in a unique (potential) position within the health care system with regard to clinical health promotion. An essential feature is the integration in the regular consultation. The concept of anticipatory care seems fit to understand this integration. Because of the GP's (anticipatory) knowledge of the patient's medical history, lifestyle, risk factors, living conditions, health perceptions and family context, he has the opportunity to include during the consultation, aspects of health promotion and disease prevention. The production of evidence-based guidelines by the Dutch College of General Practitioners greatly enhances the integration of health promotion within the consultation. Strategies for the implementation are needed on three different levels: encouragement of the patient to ask questions, training of the GP and organization of the practice. An important aspect of the last strategy concerns systematic delegation of health promotion tasks, usually related to the guidelines, to the practice assistant or practice nurse. Recent legislation in the Netherlands underlines and advances the above mentioned trends.

Membership of a patients' association and well-being. A study into the relationship between membership of a patients' association, fellow-patient contact, information received, and psychosocial well-being of people with a neuromuscular disease.

This article presents the results of a study into the relationship between membership of a patients' association, information received, fellow-patient contact and psychosocial well-being. Data were collected from a group of people with myotonic dystrophy and spinal muscular atrophy (n = 349). About 60% of this group are members of a patients' association for people with a neuromuscular disease. No direct relationship was found between membership of the patients' association and well-being. Membership, however, was positively related to the number of fellow-patients with whom one has had personal contact and also to the amount of information received about the disease and related factors. Having personal contact with more fellow-patients was related to a better well-being in the group of patients who had a relatively low level of physical functioning. There were no indications that receiving information leads to better well-being. The results of this study indicate that membership of a patients' association, through promoting fellow-patients contacts, can be beneficial to people with a chronic disease, especially to people who are relatively severely ill.

Morbidity among unemployed and work-incapacitated men in The Netherlands.

As yet, the relationship between unemployment and physical health has not sufficiently been clarified. With a longitudinal approach a representative Dutch panel study and a study on a health center population were carried out. They involved work-incapacitated and unemployed men between 21 and 65 years of age. Men incapacitated for work were in poorer health than matched working men; the same was true in a three-year follow-up. Unemployed and working men were shown to be equally healthy. The physical health of the incapacitated men decreased with time but that of the unemployed men did not. This finding implies that unemployment per se does not lead to poorer health. Differences in social security systems seem to interfere with an international comparison of the consequences of unemployment on health. International research should distinguish more explicitly between those who are unemployed for economic reasons or incapacitated for work for medical reasons.

High-performance liquid chromatographic determination of amantadine in urine after micelle-mediated pre-column derivatization with 1-fluoro-2,4-dinitrobenzene.

Cationic micelles have been used for the derivatization of the anti-Parkinson drug amantadine with the chromophore 1-fluoro-2,4-dinitrobenzene in urine. In the presence of 90 mM cetyltrimethylammonium bromide (CTAB), the conversion of amantadine into its derivative is complete within 4 min at 60 degrees C and pH 11. Such a short reaction time allows a fully automated pre-column derivatization of amantadine in an on-line combination with reversed-phase high-performance liquid chromatography. This cannot be attained when using purely aqueous derivatization mixtures because then the reaction takes some 20 min at the same temperature. Without the use of an internal standard, the repeatability of the automated determination at the 0.5 microgram ml-1 level is ca. 6%, whilst the detection limit is 75 ng ml-1 (S/N = 3). The present study clearly demonstrates that micellar systems can be beneficially used for the on-line precolumn derivatization of amines in urine.

[Unexplained vague abdominal complaints in adults: indication for CT in case of suspected intussusception]. / Onbegrepen vage buikklachten bij volwassenen: bij vermoeden van een invaginatie CT verrichten.

In two adult patients, a 74-year-old woman and a 84-year-old man, who suffered from vague abdominal complaints, an intussusception was diagnosed by CT. Surgical resection of the affected bowel parts was successful. Intussusception is usually seen in children; in adults it is a rare condition. Adult patients mostly complain about vague abdominal pain only. Physical examination, laboratory investigations and plain abdominal X-rays often don't give any additional information. In such patients it is advised to perform CT of the abdomen at an early stage. CT may show a so-called 'target sign' which is characteristic of an intussusception. In addition it can provide information about the possible causes of the intussusception, most commonly a malignant tumour in adults. During laparotomy one should not attempt to reduce the intussusception because of the risk of tumour spill. In this clinical review, we present two adult patients with unexplained abdominal complaints due to intussusception, caused by malignancy.

[Home visits by community health nurses can contribute to the family practitioner's knowledge of elderly patients]. / Huisbezoek door de wijkverpleegkundige kan bijdragen aan de kennis van de huisarts over oudere patiënten.

OBJECTIVE: To determine to what extent the general practitioner (GP) is aware of the health status and functioning of his elderly patients and in which areas this knowledge can be completed with the aid of community nurses. DESIGN: Cross-sectional, descriptive. SETTING: Department of General Practice. State University Limburg, Maastricht, the Netherlands. METHODS: A random sample of 59 patients aged 79 years and over, belonging to the population of a primary health care centre, were visited by community nurses. One patient was lost. The nurses inventoried the patients health complaints and their daily functioning by means of a structured questionnaire. Data from these home visits were compared with data from the same questionnaire, regarding the same patients, which the three GPs of the health centre had filled in on the basis of their medical records. RESULTS: Of the complaints recorded by the community nurses. 34% were not known to the general practitioners. This concerned mainly symptoms of depression, urinary incontinence, disabilities and handicaps of the musculoskeletal system. sleep disturbances, daily functioning and ability to cope. The main determinants of the ability to cope were impaired walking and to a lesser degree symptoms of depression. CONCLUSION: A structured interview of elderly patients by a community nurse yields substantial information about health problems.

[Breast cancer in southeast North Brabant and in North Limburg; trends in incidence and earlier diagnosis in an unscreened female population, 1975-1986]. / Borstkanker in Zuidoost-Noord-Brabant en in Noord-Limburg; beloop van incidentie en vervroeging van de diagnose in een niet-gescreende vrouwelijke bevolking, 1975-1986.

Data on incidence, tumour size at diagnosis and mortality from breast cancer in the southeast of the Netherlands, collected by means of the SOOZ-cancer registry were studied in combination with data on patient management, collected through the regional tumour work group. Age-adjusted incidence increased by approx. 1% per year, especially in women less than 50 years and mortality showed a slight decrease in women less than 60 years. The proportion of patients with a tumour greater than 5 cm and with extension to chest wall or skin decreased from more than 40 to 15%. The proportion of tumours of 2.1-5 cm rose from 30 to 35% and that of less than or equal to 2 cm from 20 to almost 45%, in particular in younger women. The process of patient management changed by the shift to smaller tumours and the introduction of mammography, cytology and breast sparing treatment. These 'spontaneous' changes may have implications for the effectiveness of future breast cancer screening programs, which would only cover 35% of women with invasive breast cancer in this population.

[Screening for breast cancer on basis of individual risk assessment for women ineligible for the national population screening program]. / Screening op mammacarcinoom buiten het landelijke bevolkingsonderzoek, op grond van individuele risico-inschatting.

For healthy women, without malignancies in their personal histories, a positive family history for breast cancer is the single indication for individual breast surveillance outside the population screening. Management of women is based on individual risk assessment. A cumulative risk of 20% and more, as a result of a positive family history, will in practice be an indication for breast surveillance. This threshold is not evidence-based yet, nor are data available on the benefits of this surveillance efficacy. When a personal cumulative risk of more than 30% exists to develop breast cancer, a consultation with a clinical geneticist involved in a family cancer clinic should be offered. Surveillance of women with a high-risk cumulative risk should preferably be included in a prospective study design. Only in this way will data about compliance and the estimates of different ways of surveillance become available. There is no convincing evidence that population screening for women aged 40-49 years does lead to important mortality reduction in combination with a good balance between pros and cons for the women involved. Women in the age category 50-75 years, with breast cancer in their personal histories, who are not followed anymore, should be informed by their specialist about participating (again) in the population breast screening. There is no evidence of mortality reduction as a result of breast self-examination nor of palpation performed by a physician. However, awareness of the own body can be useful for early recognition of breast abnormalities; it may reduce the delay between the first recognizable symptom and the subsequently initiated therapy.

Vitamin K1 in oral solution or tablets: a crossover trial and two randomized controlled trials to compare effects.

BACKGROUND: Vitamin K1 (VK1) reverses the effects of vitamin K antagonists (VKAs). The literature shows that the bioavailability from solutions might be higher than that from tablets, possibly resulting in different effects. OBJECTIVES: To compare the bioavailability and effect on the International Normalized Ratio (INR) of 5-mg VK1 tablets and solution in three randomized clinical trials. METHODS AND RESULTS: The bioavailability was determined in a crossover trial with 25 healthy volunteers. VK1 plasma concentrations were assessed at 0, 2, 4, 5, 6, 8, 10 and 24 h, and the area under the curve was higher in the solution group than in the tablet group (mean difference 365 µg L(-1) h, 95% confidence interval [CI] 230-501, P < 0.0001). In the other two trials, the effects of both formulations on the INR were measured at 0, 24 and 48 h. In the second trial, on 72 patients on phenprocoumon with planned invasive procedures, both formulations were similarly effective, because all patients reached an INR of < 2.0, which was the primary endpoint. In the last trial, on 72 patients on phenprocoumon with an INR of 7.0-11.0, the INR decreased slightly more in the solution group (4.7, 95% CI 4.3-5.1) than in the tablet group (4.2, 95% CI 3.8-4.6). The solution group had a 3.3-fold increased likelihood (95% CI 0.7-15.1) of reaching an INR of < 2.0 at 48 h. Additionally, the increases in VK1 concentrations were similar (tablets, 3.2 µg L(-1) ; solution, 3.4 µg L(-1) ; P = 0.99) after 24 h. CONCLUSIONS: VK1 tablets are at least as clinically effective as the solution in countering VKAs.