Operationalization of biopsychosocial case complexity in general health care: the INTERMED project

OBJECTIVE: Lack of operationalization of the biopsychosocial model hinders its effective application to the increasingly prevalent problems of comorbidities in clinical presentations. Here, we describe the INTERMED, an instrument to assess biopsychosocial case complexity in general health care, and provide an overview of its psychometric evaluation. METHOD: Review and summary of our publications to date, and re-analysis of findings. RESULTS: The INTERMED has face-validity, is brief and easy to use, and several research reports support its reliability and validity. It has the capacity to detect patients at risk for poor clinical outcome and quality of life. CONCLUSIONS: The INTERMED project is relevant to various agents involved in the care process. It provides a basis for effective multidisciplinary treatment of patients with a high case complexity.     

Birthing positions. A qualitative study into the views of women about various birthing positions

The aim of this study was to gain insight into the influences on women's use of birthing positions, and into the labor experiences of women in relation to the birthing positions they used. Quantitative studies have shown some medical advantages of non-supine birthing positions. They also suggested some psychological benefits but these are difficult to interpret. In this study in-depth interviews were conducted to gain a deeper understanding of the relationship between birthing positions and the labor experience. We found that the advice given by midwives was the most important factor influencing the choice of birthing positions. If medically possible, women benefited from having the autonomy to find the positions that were most useful to them. Their choices varied greatly, as did their experience of pain in relation to the type of position. Women, regardless of ethnicity, were most familiar with the supine position but valued practical information on other options. In conclusion, because the supine position is dominant in westernized societies, midwives have an important role to play in widening the range of women's choices. Midwives should empower women to find the positions that are most suitable for them, by giving practical advice during pregnancy and labor.     

Single-step maternal serum screening for trisomy 21 in the era of combined or integrated screening

Single-step maternal serum screening (MSS) in the first (1MSS) or second (2MSS) trimester at maternal age > or =35 years was evaluated in the North Belgian region Flanders, where difficulties are encountered in the general introduction of combined or integrated screening algorithms. The fetal aneuploidy screening database of General Medical Laboratory AML in Antwerp was searched for 2MSS tests between 1992 and 1999 (alpha-fetoprotein, beta-human chorionic gonadotropin (beta-HCG) and unconjugated estriol, cut-off 1:300) and for 1MSS tests between 1999 and 2003 (free beta-HCG and pregnancy-associated plasma protein A, cut-off 1:85). At > or =35 years, the detection rate for trisomy 21 (DR) was 93.8% (15/16) for 2MSS and the screen-positive rate (SPR) was 24.5% (504/2061). For 1MSS, these figures were 85.7% (6/7) and 17.7% (109/615) respectively. To detect one trisomy 21, missed by MSS at > or =35 years of age, an additional number of 1,557 and 506 primary invasive procedures would be needed for 2MMS and 1MSS respectively. We conclude that the performance of both single-step 1MSS and 2MSS at maternal age > or =35 years in Flanders is excellent, even without the combination with ultrasound parameters or integration of first and second trimester parameters. The simplicity of both methods allows to consider them valuable options for fetal aneuploidy screening at advanced maternal age, until high quality combined or integrated screening is accessible to all pregnant women in Belgium.     

Mycobacterium marinum causing tenosynovitis. 'Fish tank finger'

Mycobacterium marinum is an unusual atypical mycobacterium with low pathogenicity for humans in comparison with Mycobacterium tuberculosis. Among the non-tuberculous mycobacterial pathogens, Mycobacterium marinum is the most common pathogen to cause skin infections. Mycobacterium marinum infection causes chronic cutaneous lesions and in some cases deeper infections such as tenosynovitis, septic arthritis and rarely osteomyelitis. We report the case of a male patient presenting with tenosynovitis of the distal upper extremity secondary to Mycobacterium marinum infection.     

Expression of the cystic fibrosis gene in the lungs

Cystic fibrosis (CF) is one of the most common hereditary diseases with a potentially lethal outcome. CF is caused by mutations in a gene on chromosome 7 that encodes for a polypeptide called 'cystic fibrosis transmembrane conductance regulator' (CFTR). Pulmonary complications in CF are a direct consequence of a fault in the production or function of CFTR. The consequences of these faults are a change in the viscosity and volume of the air-surface liquid in the airways and possible malfunctioning of the immunological defence system. The result is stasis of mucus and obstruction of the smaller airways. Secondary to this process, a (chronic) infection with an uncontrolled inflammatory response, leads to destruction of lung tissue and a reduction in lung function. Mutations in CFTR can be classified in five types, which reflect the level of production or the function of CFTR. This classification permits discrimination between mild and severe mutations. The clinical image and the course of CF are often related to the combination of mutations present. This may explain, in part, why some CF patients are diagnosed at a later age with a normal sweat test and a clinical image that is predominantly limited to respiratory symptoms.     

INTERMED: a measure of biopsychosocial case complexity: one year stability in Multiple Sclerosis patients

The 1-year temporal stability of the INTERMED in a sample of patients with relatively stable care needs, patients with established Multiple Sclerosis (MS) was analyzed. Seventy MS patients underwent an interview to assess the INTERMED by a trained nurse, and two examinations of disability, EDSS and GNDS by medical doctors. At the following appointment with the nurse, approximately 1 year later, a second INTERMED assessment was done. Spearman correlations and change scores between the INTERMED assessments were calculated. Correlations between the two assessments were considerable: 0.75 for the total score and 0.55-0.74 for the domain scores (all P <.05). Median change of all four INTERMED domain scores and total score were 0. Changes in INTERMED total scores tended to be associated with changes in EDSS scores over time (P = 0.09), but not with changes in GNDS scores (P = 0.67). Patients with INTERMED scores above 20 on at least one of the two assessments had longer disease duration (P < 0.01), were more frequently suffering from a chronic form of MS (P < 0.01), and had more disability on EDSS (P < 0.01) and GNDS (P < 0.01) assessments. In a sample of patients with an established diagnosis of MS, INTERMED scores remained fairly stable over the period of a year. Implementing the INTERMED in routine care of patients with chronic conditions may help the clinician to structure interdisciplinary care.     

Detecting mental disorders in general hospitals by the SCL-8 scale

OBJECTIVE: The objective of this study is to validate the eight-item dichotomised version of the Symptoms Check List (SCL-8d) as a screening tool for psychiatric disorders. METHODS: The study population included 198 consecutive new neurological inpatients and outpatients and 294 consecutive internal medical inpatients, aged 18 or older. All patients received the SCL-8d questionnaire, and a stratified subsample was interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) interview. We tested the external SCL-8d validity using the SCAN interview as gold standard. The test was performed based on weighted data to correct for the skewness introduced by stratification. RESULTS: The diagnostic performance of the SCL-8d was excellent in the internal medical setting but not quite as good in the neurological sample. It performed better among the older compared with the younger patients, whereas the scale was not affected by gender. In the combined sample at the cut point 0/1, the sensitivity (SE) of the SCL-8d was 0.73 (confidence interval [CI](95%): 0.60-0.82), the specificity (SP) 0.61 (CI(95%): 0.53-0.68) and the positive predictive value (PPV) 0.42 (CI(95%): 0.34-0.50), using any International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) psychiatric disorder, excluding somatoform and substance abuse disorders, as gold standard. The risk of a patient having a mental disorder (except phobia, substance abuse or somatoform disorder) was less than 6% in case of a negative screening test. In patients with a current depressive disorder, 87.1% (27/31) were screening positive, and all except 1 (93.0%) of the 14 patients with a modest to severe depression scored 1 or higher on the SCL-8d. All 17 patients with an anxiety disorder, excluding phobias, were screening positive. CONCLUSION: The study suggests that the SCL-8d is a valid, brief screening tool for use in nonpsychiatric medical settings, especially to detect emotional psychiatric disorders (EPDs).     

Phase II study on 9-nitrocamptothecin (RFS 2000) in patients with advanced or metastatic urothelial tract tumors

OBJECTIVE: To investigate the antitumor activity and the safety of RFS2000, an oral topoisomerase I inhibitor, in patients with advanced or metastatic urothelial tract tumors refractory to one prior chemotherapy regimen. PATIENTS AND METHODS: Eligible patients were to have failed first line treatment for advanced or metastatic disease. Patients received RFS2000 as one daily oral intake at the dose of 1.5 mg/m(2)/day according to a "5 days on/2 days" off schedule continuously. One cycle was arbitrarily defined as a 3 week period. Sufficient oral fluid intake to prevent cystitis previously described in phase I trials with RFS2000 was recommended. Gehan design was used for sample size determination. Anti-tumor activity was evaluated according to the RECIST criteria and toxicity according to CTC version 2. RESULTS: Twenty patients received a total of 57 cycles (range 1-8). Grade 3-4 toxicity was observed in 10 patients requiring dose or schedule modifications. Hematological grade 3-4 toxicity was observed in 16% of the cycles. Only one patient experienced a partial response. CONCLUSIONS: RFS2000 could be administered orally as a "5 days on/2 days off" schedule continuously with a median dose intensity of 90.6% with an acceptable toxicity profile. However, RFS2000 did not exert significant activity in patients with advanced/metastatic urothelial tract tumors failing prior chemotherapy. The results of this study do not suggest further investigation of RFS2000 at the present dose and schedule for the treatment of urothelial tract tumors in this refractory population.