Effects of an Integrated Palliative Care Pathway: More Proactive GPs,Well Timed,and Less Acute Care: A Clustered,Partially Controlled Before-After Study

ObjectivesThis study presents the design of an integrated, proactive palliative care pathway covering the full care cycle and evaluates its effects using 3 types of outcomes: (1) physician-reported outcomes, (2) outcomes reported by family, and (3) (utilization of) health care outcomes.DesignA clustered, partially controlled before-after study with a multidisciplinary integrated palliative care pathway as its main intervention.Setting and Participantsafter assessment in hospital departments of oncology, and geriatrics, and in 13 primary care facilities, terminally ill patients were proactively included into the pathway. Patients' relatives and patients’ general practitioners (GPs) participated in a before/after survey and in interviews and focus groups.InterventionA multidisciplinary, integrated palliative care pathway encompassing (among others) early identification of the palliative phase, multidisciplinary consultation and coordination, and continuous monitoring of outcomes.MeasuresMeasures included GP questionnaire: perceived quality of palliative care; questionnaires by family members: FAMCARE, QOD-LTC, EDIZ; and 3 types of health care outcomes: (1) utilization of primary care: consultations, intensive care, communication, palliative home visits, consultations and home visits during weekends and out-of-office-hours, ambulance, admission to hospital; (2) utilization of hospital care: outpatient ward consultations, day care, emergency room visits, inpatient care, (radio) diagnostics, surgical procedures, other therapeutic activities, intensive care unit activities; (3) pharmaceutical care utilization.ResultsGPs reported that palliative patients die more often at their preferred place of death, and that they now act more proactively toward palliative patients. Relatives of included, deceased patients reported clinically relevant improved quality of dying, and more timely palliative care. Patients in the pathway received more (intensive) primary care, less unexpected care during out-of-office hours, and more often received hospital care in the form of day care.Conclusions and ImplicationsAn integrated palliative care pathway improves a variety of clinical outcomes important to patients, their families, physicians, and the health care system. The integration of palliative care into multidisciplinary, proactive palliative care pathways, is therefore a desirable future development.     

Early imaging biomarkers of lung cancer,COPD and coronary artery disease in the general population: rationale and design of the ImaLife (Imaging in Lifelines) Study

Lung cancer, chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD) are expected to cause most deaths by 2050. State-of-the-art computed tomography (CT) allows early detection of lung cancer and simultaneous evaluation of imaging biomarkers for the early stages of COPD, based on pulmonary density and bronchial wall thickness, and of CAD, based on the coronary artery calcium score (CACS), at low radiation dose. To determine cut-off values for positive tests for elevated risk and presence of disease is one of the major tasks before considering implementation of CT screening in a general population. The ImaLife (Imaging in Lifelines) study, embedded in the Lifelines study, is designed to establish the reference values of the imaging biomarkers for the big three diseases in a well-defined general population aged 45 years and older. In total, 12,000 participants will undergo CACS and chest acquisitions with latest CT technology. The estimated percentage of individuals with lung nodules needing further workup is around 1–2%. Given the around 10% prevalence of COPD and CAD in the general population, the expected number of COPD and CAD is around 1000 each. So far, nearly 4000 participants have been included. The ImaLife study will allow differentiation between normal aging of the pulmonary and cardiovascular system and early stages of the big three diseases based on low-dose CT imaging. This information can be finally integrated into personalized precision health strategies in the general population.     

Long-term effectiveness of computer-generated tailored feedback in smoking cessation

Although tailored interventions consisting of only a few pages of information lead to more quitting than no intervention in the short term, the long-term efficacy of a single tailored intervention still has to be proven. In the present study smokers were reactively recruited and randomly allocated to one of four intervention conditions: (1) outcome information, (2) self-efficacy enhancing information, (3) both sorts of information or (4) no information. Smokers in the three experimental groups received computer-generated tailored feedback containing the condition-specific information, by mail. The results from the 14 months follow-up can be summarized as follows. Compared to the no information condition, all three experimental conditions led to significantly more smokers who had engaged in 24-h quit attempts. However, no experimental condition led to more 7-day quitting than the no information condition. With regard to continuous abstinence, the experimental condition offering a combination of outcome information and self-efficacy enhancing information had a significant effect, compared to the no information condition. It is concluded that a minimal six-page tailored intervention can be beneficial in supporting smokers to quit smoking, even after 14 months.     

Further in vitro and in vivo studies with the putative presynaptic dopamine agonist N,N-dipropyl-7-hydroxy-2-aminotetralin

Summary The in vitro binding of the putative dopamine autoreceptor agonist [³H]DP-7-ATN to rat striatal membrane homogenates was investigated. The maximum number of binding sites B _max was 497.5 ± 50.2 fmol/mg protein and the affinity constant K _D was 8.3 ± 1.5 nM using 10 M (+) butaclamol to define non-specific binding. Lesion of the left medium forebrain bundle by 6-hydroxydopamine resulted in an almost complete loss of dopamine in the striatum but did not affect the binding of [³H]DP-7-ATN. The binding of [³H]DP-7-ATN to the homogenates of the dopaminergic cell bodies in the substantia nigra revealed a B _max of 542.4 ± 40.1 fmol/mg protein and a K _D of 11.1 ± 1.3 nM. The pharmacological profile of the binding was characterized as being to D-2 receptors. No direct in vitro evidence could be found for a selective binding to DA autoreceptors. The dopamine uptake inhibitor GBR 12909 interacted in a noncompetitive manner with the in vitro binding of [³H]DP-7-ATN and the latter compounds uptake into isolated synaptosomes was not through the specific dopamine uptake system but rather through diffusion. GBR 12909 failed to reveal any agonistic or antagonistic activity in the GBL model but was able to antagonize the hypomotility in rats induced by 0.25 mg/kg DP-7-ATN. The inhibitory effect of DP-7-ATN on DA release was also demonstrated using in vivo brain dialysis in conscious rats. Based on the above results, the possibility is discussed that the release regulating DA autoreceptors, which might be coupled to the reuptake complex, and the DA biosynthesis regulating autoreceptors, are different entities. Send offprint requests to A. S. Horn     

Psychiatric diagnosis in an outpatient population. A comparative study of PSE-Catego and DSM-III

Two diagnostic systems are compared in a psychiatric outpatient population of 175 patients. The Present State Examination (PSE)-Catego system identified 121 patients (69%) as "cases," whereas DSM-III identified 152 patients (87%) as cases. The two systems converged in 115 patients, yielding a kappa coefficient of only .32. Approximately one third of the DSM-III cases that were not detected by the PSE-Catego system was due to the restricted coverage of the latter system; the remaining two thirds could be attributed to differences in threshold and time framing. Compared with DSM-III, the PSE-Catego system showed a strong bias toward depression, and the system was extremely insensitive to the detection of social phobias and obsessive-compulsive disorders. Only 58% of cases of depression and 46% of cases of anxiety were diagnosed by both systems. The results are compared with other studies, and some consequences are discussed.     

Adherence to Adjuvant Endocrine Therapy in Christchurch Women with Early Breast Cancer

Aims

To assess adherence to adjuvant endocrine therapy by a real-world cohort of women in Christchurch and to determine any associated factors.

Shoulder complaints after neck dissection; is the spinal accessory nerve involved?

The purpose of the current study was to investigate the relation between shoulder morbidity (pain and range of motion), and the function of the spinal accessory nerve after neck dissection. Identifying dysfunction of the nerve gives insight in the mechanisms of post-operative shoulder complaints. In total 112 patients after neck dissection (73 males/39 females), mean (SD) age 61 (13) years, participated in the study. The mean duration of follow up was 3 (2) years. Five patients had radical, 43 modified radical, 48 supraomohyoid, and 16 posterolateral neck dissection. Thirty-nine complained of shoulder pain of whom 20 (51%) had dysfunction of the spinal accessory nerve, and 19 (49%) did not. In total 29 patients (26%) had dysfunction of the spinal accessory nerve of whom 20 (69%) had shoulder pain. Shoulder pain was significantly related to dysfunction of the nerve (P < 0.001). Twenty-three patients had a difference in active range of motion in shoulder abduction of > or =40 degrees, of whom 22 (96%) had dysfunction of the nerve. A difference in active shoulder abduction of > or =40 degrees was significantly related to loss of function of the spinal accessory nerve (P < 0.001). CONCLUSION: Shoulder pain after neck dissection can only be attributed to dysfunction of the spinal accessory nerve in about 50%. If patients experience shoulder pain after neck dissection examination of the trapezius muscle and active bilateral abduction of the shoulder should be made to find out if the spinal accessory nerve is involved.     

Targeting smokers with low readiness to change with tailored and nontailored self-help materials

BACKGROUND: Few smoking cessation self-help materials are available for smokers who are not planning to quit. However, computer-tailored interventions can be designed specifically for these smokers. METHODS: In a large randomized field trial (N = 843), two different tailored smoking cessation self-help interventions (multiple tailoring and single tailoring) and one standardized smoking cessation self-help guide were compared with a no-information control group and with each other. The contents of the tailored interventions were adapted to individuals' self-reported stage of change, outcome expectations, self-efficacy levels, and smoking behavior. RESULTS: The primary outcome measure was forward stage transition. The standardized self-help guide had no effect. Among smokers who were not planning to quit within the next 5 years the multiple-tailored intervention was more effective than the single-tailored intervention. This pattern was supported by the cognitive changes caused by the interventions. Among smokers who were planning to quit within the next 5 years but not within the next 6 months, none of the self-help materials had any effect. CONCLUSION: The present results show that the self-help material currently available in the Netherlands, the standardized self-help guide, was not effective among smokers with low readiness to change. However, computer-generated tailored interventions seem a promising means of communicating information on smoking and smoking cessation to these smokers.