Empowering patients: how to implement a diabetes passport in hospital care

The purpose was to ascertain the views of patients with diabetes and patient care teams on the introduction of a recently developed diabetes passport in order to plan effective implementation. A semi-qualitative study by eight semi-structured focus group discussions with patient care teams and patients in four Dutch hospitals was organised. In total 29 patients participated (range five to nine per hospital). Patient care teams ranged from four to six participants. Each team included at least one specialised diabetic nurse and an internist. Taped views were transcribed and coded on the basis of a structured checklist. Various potential barriers to the implementation of the diabetes passport were found. Although patients recognized the diabetes passport as a handy tool, most of them expected starting problems and little co-operation from the internists; in this respect they rely more on the diabetes specialist nurse (DSN). Internists had mixed feelings about the diabetes passport. Lack of motivation and lack of time were important perceived barriers. The specialised diabetes nurses had the highest expectations of the diabetes passport and perceived themselves as those who would effectuate implementation. The main potential barriers to effective implementation of the diabetes passport were found in setting the agenda of the passport and fitting it into the organization of diabetes care. These barriers need to be considered when implementing the passport. The DSN could play an important part in its implementation.     

Readiness to adopt the self-management approach to cope with chronic pain in fibromyalgic patients

The effectiveness of cognitive-behavior therapy aimed at helping patients with the acquisition of self-management skills to cope with pain, is thought to depend partly on the patients' willingness to adopt a self-management approach. Some patients may not believe that self-management will be helpful while others have decided to adopt it and others already apply the self-management skills in their daily lives. The present study explored the concept of 'Readiness to change' in a population of Dutch fibromyalgic patients. A self-report questionnaire was completed by 321 patients. Factor analysis revealed three scales, each assessing the characteristic of one stage of readiness to change, the Precontemplation, Contemplation and Action scale. Firstly, the reliabilities of these scales were 0.61, 0.86 and 0.61, respectively, and only the latter two scales correlated significantly (r=0.14). Secondly, the scales were validated using subscales from the Multidimensional Pain Inventory, beliefs on the credibility of the self-management approach and subscales from the Illness Perception Questionnaire. These subscales explained 5, 22 and 8% of the variance of the scores on the Precontemplation, Contemplation and the Action scales, respectively. Thirdly, on the basis of the three scale scores, over 80% of the fibromialgia patients could be classified into one of five potentially psychological relevant subgroups: Precontemplation, Contemplation, Preparation, Action and Relapse. The data suggest that improvements in operationalizations of the Precontemplation and Action dimensions of readiness to change are needed and that the theoretical foundation of readiness to change needs further development.     

Value of sentinel node biopsy in the management of breast cancer

Aims  

To determine the rate of detection of the sentinel node using both blue dye and radioisotope, and the accuracy with which the sentinel node histology reflects the nodal status of the axilla in a series of patients with clinically node-negative breast cancer.     

Vaccination of melanoma patients with an allogeneic, genetically modified interleukin 2-producing melanoma cell line

Thirty-three metastatic melanoma patients were vaccinated according to a phase I-II study with an allogeneic melanoma cell line that was genetically modified by transfection with a plasmid containing the gene encoding human interleukin 2 (IL-2). The cell line expresses the major melanoma-associated antigens and the HLA class I alleles HLA-A1, -A2, -B8, and Cw7. All patients shared one or more HLA class I alleles with this cell line vaccine. Patients were immunized by three vaccinations, each consisting of 60 x 106 irradiated (100 Gy) melanoma cells (secreting 120 ng of IL-2/10(6) cells/24 hr) administered subcutaneously at weekly intervals for 3 consecutive weeks. Side effects of treatment consisted of swelling of locoregional lymph nodes and induration at the site of injection, i.e., a delayed-type hypersensitivity (DTH) reaction. In three patients, vaccination induced inflammatory responses in distant metastases containing necrosis or apoptosis along with T cell infiltration. Apoptosis occurred only in Bcl-2-negative areas, not in Bcl-2-expressing parts of the metastases. Two other patients experienced complete or partial regression of subcutaneous metastases. Seven patients had protracted stabilization (4 to >46 months) of soft tissue metastases, including one patient who developed vitiligo after vaccination. Immune responses to the vaccine could be detected in 67% of the 27 patients measured. Vaccination was shown to induce a variable change in the number of anti-vaccine cytotoxic T lymphocytes (CTLs) in peripheral blood, which did not correlate with response to treatment. However, in two of five patients the frequency of anti-autologous tumor CTLs measured was significantly higher than before vaccination. This study demonstrates the feasibility, safety, and therapeutic potential of vaccination of humans with allogeneic, gene-modified tumor cells, and that frequencies of vaccine-specific CTLs among patient lymphocytes can be determined by using a modified limited dilution analysis (LDA).     

The prognosis and outcome of patients referred to an outpatient clinic for rheumatic diseases characterized by the presence of antinuclear antibodies (ANA)

To evaluate if patients with symptoms related to the musculoskeletal system, characterized by the presence of ANA, are prone to develop SLE or other specific rheumatic diseases, a follow-up study was started to investigate all patients who for the first time visited the outpatient clinic of the Department of Rheumatology in the period from 1983 to 1986 and who had detectable ANA. Patients with anti-dsDNA antibodies were excluded from evaluation. In total 65 patients could be included in the study, with a mean duration of follow-up of 9.3 years (range 2-16 years). During follow-up a specific rheumatic diagnosis could be established in 38 patients, on 75% of the patients within 2 years of follow-up, and in 90% within 5 years. Five patients developed a non-rheumatic disease. For the remaining 22 patients, diagnosis was not conclusive. These patients without a conclusive diagnosis had a mild clinical picture, which remained stable during follow-up. In conclusion 58% of patients presented with rheumatic symptoms and detectable ANA developed an overt rheumatic disease, usually within the first 5 years of follow-up.     

The role of topical corticosteroids after functional endoscopic sinus surgery for chronic sinusitis and/or nasal polyps

Introduction. The objective was determination of the influence of Fluticasone propionate nasal spray on the recurrence rate of chronic sinusitis and/or nasal polyps after functional endoscopic sinus surgery (FESS) using a randomized double‐blind placebo‐controlled trial. Methods. From 1994 to 1997, 162 patients were included in this trial after FESS for chronic sinusitis and/or nasal polyps. Postoperatively they were treated for 1 year with study medication (double‐blind). Study medication contained Fluticasone propionate nasal spray 400 μg bid, or Fluticasone propionate nasal spray 800 μg bid, or placebo bid. Symptoms (using visual analogue scales) and nasendoscopy findings were scored preoperatively and postoperatively for 1 year. Results. No reduction of the recurrence rate of chronic sinusitis or nasal polyps was found in the patient‐groups using Fluticasone propionate nasal spray. No reduction was found when separate groups were analysed (such as nasal polyps, chronic sinusitis, allergy, no history of FESS or use of topical corticosteroids, or high score at FESS). Conclusion. In this trial no positive influence of Fluticasone propionate nasal spray could be found on the recurrence rate of chronic sinusitis and/or nasal polyps.     

Glutathione-S-epoxide transferase in human hair follicles

A fluorometric assay for determination of glutathione-S-epoxide transferase (GSH-T) activity in freshly isolated human hair follicles or cultured cells is described. With this assay, basal levels of the enzyme in hair follicles have been compared between smokers and non-smokers. No significant difference between both groups could be detected. GSH-T was not elevated after treatment of cultured hair follicle keratinocytes with benz[a]anthracene or clotrimazole. The same result was obtained with cultured skin fibroblasts from Ah-responsive and Ah-non-responsive mice. The possible significance of basal GSH-T levels for assessment of the risk of individuals for the carcinogenic action of polycyclic aromatic hydrocarbons is discussed.     

A method for the selective depletion of perivascular and meningeal macrophages in the central nervous system.

The perivascular (PVM) and meningeal (MM) macrophages form a distinct population of resident CNS cells, selectively expressing the mature macrophage marker ED2 in the rat. In order to elucidate the role of the PVM and MM in rats during normal functioning of the brain and pathology, we have developed a strategy employing a single intraventricular injection of clodronate liposomes. This resulted in a complete depletion of the PVM and MM. Clodronate liposomes did not deplete the microglial cells. In other parts of the body, a temporal and mild depletion effect was observed, which was restored within 1 week. Detailed analysis of the elimination and repopulation kinetics of the PVM and MM revealed a slow repopulation of the CNS, starting at 14 days post depletion. This selective depletion method of the PVM and MM will enable us to get direct insight in their functions during normal and pathologic conditions of the CNS.