Integrated dementia care in The Netherlands: a multiple case study of case management programmes

The number of dementia patients is growing, and they require a variety of services, making integrated care essential for the ability to continue living in the community. Many healthcare systems in developed countries are exploring new approaches for delivering health and social care. The purpose of this study was to describe and analyse a new approach in extensive case management programmes concerned with long‐term dementia care in The Netherlands. The focus is on the characteristics, and success and failure factors of these programmes. A multiple case study was conducted in eight regional dementia care provider networks in The Netherlands. Based on a literature study, a questionnaire was developed for the responsible managers and case managers of the eight case management programmes. During 16 semistructured face‐to‐face interviews with both respondent groups, a deeper insight into the dementia care programmes was provided. Project documentation for all the cases was studied. The eight programmes were developed independently to improve the quality and continuity of long‐term dementia care. The programmes show overlap in terms of their vision, tasks of case managers, case management process and the participating partners in the local dementia care networks. Differences concern the targeted dementia patient groups as well as the background of the case managers and their position in the local dementia care provider network. Factors for success concern the expert knowledge of case managers, investment in a strong provider network and coherent conditions for effective inter‐organizational cooperation to deliver integrated care. When explored, caregiver and patient satisfaction was high. Further research into the effects on client outcomes, service use and costs is recommended in order to further analyse the impact of this approach in long‐term care. To facilitate implementation, with a focus on joint responsibilities of the involved care providers, policy recommendations are to develop incentives for collaborative financial contracts between insurers and providers.     

Small Bowel Ultrasound beyond Inflammatory Bowel Disease: An Updated Review of the Recent Literature

The use of bowel ultrasonography (US) for the evaluation of gut diseases has increased in recent years and has been proven to provide a widely available, non-invasive and inexpensive method for the initial work-up and follow-up of different intestinal diseases, limited mostly by technical challenges posed by the patient's anatomy. The present review aims to provide an extensive overview of the main pathologic features at US examination of intestinal diseases other than inflammatory bowel disease, both acute (e.g., acute appendicitis, colonic diverticulitis, infectious diseases and ischemic conditions) and chronic (e.g., celiac disease, cystic fibrosis and other enterocolites). The identification of typical US features may help in the diagnostic process and guide the treatment approach. Therefore, the application of knowledge of the US appearance of gastrointestinal diseases is of relevance in enabling greater diagnostic performance and better patient management.     

Cx26 gene mutations in idiopathic progressive hearing loss

OBJECTIVE: The present study evaluated the frequency and type of mutations throughout the entire GJB2 region in a population of 39 patients affected with sporadic progressive "idiopathic" hearing loss. MATERIAL: A large series of patients suffering from progressive hearing loss underwent a systematic screening program to identify the etiology of the hearing loss. Of these patients, 39 presented with sporadic idiopathic progressive hearing loss and were included in this study. METHOD: We performed molecular analysis of GJB2 in each patient sequencing the genomic deoxyribonucleic acid (DNA) in both directions for detection of GJB2 mutations. Furthermore, in all patients bearing a Cx26 mutation, a search was also conducted for mutations or deletions of GJB6 (Cx30 gene) and for the A1555G mutation of the mitochondrial DNA. A control group was also considered to evaluate the frequency of Cx26 mutations in the normal population. RESULTS: A Cx26 gene mutation was detected in nine cases. One subject was found to bear a homozygous genotype for the 35delG mutation, another subject was compound heterozygous for 35delG and E47X, and the remaining patients showed heterozygous genotypes (35delG, L90P, R127H, M34T, V153I, V37I). No mutation or delection of the Cx30 gene was observed in these nine patients, and none of them presented with the A1555G mutation in the mitochondrial DNA. In the control group (40 individuals), a Cx26 mutation was detected in two cases (5%). CONCLUSIONS: About 23% of our patients (nine subjects) presented with mutations in GJB2, and 18% (seven subjects) were heterozygous. However, most of the described mutations are recessive, so a monogenic model of inheritance cannot explain the deafness phenotype. On the basis of these findings, we can speculate that the heterozygote Cx26 genotype could be a cause of progressive hearing loss, probably in association with mutations in other alleles. Thus, we recommend carefully following all hearing-impaired subjects with GJB2 mutations, even if they present with only mild hearing loss, because the hearing deficit could worsen. Furthermore, molecular analysis of the Cx26 gene should also be performed in adult patients affected with idiopathic progressive hearing loss.     

Effects of adherence to treatment on short-term outcomes in children with juvenile idiopathic arthritis

OBJECTIVE: To determine the impact of adherence to treatment (medication and prescribed exercise) on outcomes in children with juvenile idiopathic arthritis (JIA). METHODS: In this longitudinal study, we studied parents of patients with JIA at the Montreal Children's Hospital and British Columbia Children's Hospital in Vancouver. Adherence was evaluated on a visual analog scale in the Parent Adherence Report Questionnaire. Outcomes of interest were active joint count, pain, child functional score on the Child Health Assessment Questionnaire, quality of life score on the Juvenile Arthritis Quality of Life Questionnaire, and parental global impression of overall well-being. The association between adherence to treatment and subsequent outcomes was evaluated using generalized estimating equations and logistic regression. RESULTS: Mean age and disease duration of our sample of 175 children were 10.2 and 4.1 years, respectively. Moderate adherence to medication was associated with lower active joint count (odds ratio [OR] 0.47, 95% confidence interval [95% CI] 0.22-0.99). Moderate adherence to exercise was associated with better functional score (OR 0.13, 95% CI 0.03-0.54), and lower pain during the last week (OR 0.14, 95% CI 0.04-0.50). Both high and moderate adherence to exercise were associated with parental perception of global improvement. CONCLUSION: Improved outcomes in patients who adhered to treatment underscores the need for clinicians to address adherence issues with their patients. Sustaining adherence, particularly to the more time-consuming treatment of exercise, is a challenge.     

Role of Bowel Ultrasound in the Diagnosis and Follow-up of Patients with Crohn's Disease

Crohn's disease (CD) is an inflammatory chronic bowel disorder; it can involve the whole gastrointestinal tract, but its localization in the ileum or colon is most common. The reference standard for the diagnosis of CD is ileocolonoscopy with histologic assessment. The reference standard for the detection of any complications is surgery. However, imaging techniques have an important role both in the detection/localization of CD and in the follow-up of CD patients. In the last few years, the technical development of ultrasound equipment, the advent of new technologies such as elastography and mostly the increased expertise of sonographers have boosted the role of bowel ultrasound in assessment of the gastrointestinal tract. In fact, bowel ultrasound is particularly attractive thanks to its widespread availability, non-invasiveness, low cost and good reproducibility, as it can be easily repeated during follow-up. The aim of this article is to provide an extensive overview of the actual role of bowel ultrasound in the detection and follow-up of patients with CD.     

Sulfated K5 Escherichia coli polysaccharide derivatives as wide-range inhibitors of genital types of human papillomavirus

Genital human papillomaviruses (HPV) represent the most common sexually transmitted agents and are classified into low or high risk by their propensity to cause genital warts or cervical cancer, respectively. Topical microbicides against HPV may be a useful adjunct to the newly licensed HPV vaccine. A main objective in the development of novel microbicides is to block HPV entry into epithelial cells through cell surface heparan sulfate proteoglycans. In this study, selective chemical modification of the Escherichia coli K5 capsular polysaccharide was integrated with innovative biochemical and biological assays to prepare a collection of sulfated K5 derivatives with a backbone structure resembling the heparin/heparan biosynthetic precursor and to test them for their anti-HPV activity. Surface plasmon resonance assays revealed that O-sulfated K5 with a high degree of sulfation [K5-OS(H)] and N,O-sulfated K5 with a high [K5-N,OS(H)] or low [K5-N,OS(L)] sulfation degree, but not unmodified K5, N-sulfated K5, and O-sulfated K5 with low levels of sulfation, prevented the interaction between HPV-16 pseudovirions and immobilized heparin. In cell-based assays, K5-OS(H), K5-N,OS(H), and K5-N,OS(L) inhibited HPV-16, HPV-18, and HPV-6 pseudovirion infection. Their 50% inhibitory concentration was between 0.1 and 0.9 mug/ml, without evidence of cytotoxicity. These findings provide insights into the design of novel, safe, and broad-spectrum microbicides against genital HPV infections.     

A prognostic algorithm including a modified version of MD Anderson Cancer Center (MDACC) score predicts time to first treatment of patients with clinical monoclonal lymphocytosis (cMBL)/Rai stage 0 chronic lymphocytic leukemia (CLL)

We propose an algorithm based on a slightly modified version of MD Anderson Cancer Center (MDACC) score (i.e., mutational status of IgVH, LDH, presence of high-risk FISH abnormalities), β₂-microglobulin and separation of clinical monoclonal B-cell lymphocytosis (cMBL) from chronic lymphocytic leukemia (CLL) to predict time to first treatment (TTFT) of a prospective multicentre cohort including 83 cMBL and 136 CLL Rai stage 0 patients. Patients with MDACC score point ≥38, at any level of β₂-microglobulin and irrespective of whether they fulfilled 2008 International Workshop on CLL (IWCLL) criteria for CLL Rai stage 0 or cMBL, experienced the worst clinical outcome (5-year TTFT, 24 %) and formed the high-risk group. In contrast, subjects with a diagnosis of cMBL, MDACC score point <38 and β₂-microglobulin ≤ UNL had the best clinical outcome (5-year TTFT, 100 %) and constituted the low-risk group. The intermediate group included patients in Rai stage 0, MDACC score point <38, and any level of β₂-microglobulin, and patients with cMBL, MDACC score point <38, and β₂-microglobulin ≥ UNL. Cases showing these features can be grouped together to form the intermediate-risk group (5-year TTFT, 65 %). Although the separation between cMBL and Rai stage 0, as proposed by the 2008 IWCLL guidelines, has clinical implications, the model we propose may help to classify patients with cMBL and Rai stage 0 into more precise subgroups suggesting that a prognostic separation of these entities based solely on clonal B-cell threshold may be unsatisfactory.     

Optimal care for rheumatoid arthritis: a focus group study

Our study sought to identify barriers to optimal care for individuals with rheumatoid arthritis (RA). Our study was set in a population with universal access to comprehensive health care in the context of a university hospital health network. Using purposive sampling, we invited RA patients, health professionals, and decision makers from urban and rural regions to participate in structured focus group interviews. Content analysis was performed to determine themes emerging from the data. We identified four general themes. First, initial barriers to optimal care for people begin before primary care contact, at the level of the general population and/or related to primary care access. Second, many factors (at the patient, physician, and system level) influenced how quickly a patient is referred from primary to specialty care. Third, after referral, multiple comanagement issues influence patient outcomes. Fourth, optimizing RA care requires adequate resources. Participants emphasized the need for more education (of patients, of health care providers, and within the general community), better communication between and among patients and health care providers, and more efficient use of existing resources. Our work provides insights regarding barriers to and facilitators of optimal care in RA. Further work with these stakeholder groups in our health care region will examine potential solutions and the feasibility of their implementation. Our work provides an example of how research can assist stakeholder leaders in creating structured and incremental plans to improve health care delivery for persons with chronic diseases like RA.     

The role of functional social support in treatment retention and outcomes among outpatient adult substance abusers

Aims The goals of this study were: (1) to compare patients with high and low functional social support at intake and 6 months later on various risk factors; (2) to test the stress‐buffering role of functional social support on treatment outcomes, and (3) to determine whether levels of functional social support at intake predicted treatment retention. Design Consecutive admissions to an outpatient treatment program were assessed at intake (n = 206) and at 6 month follow‐up (n = 172) using the Addition Severity Index (ASI). Patients completed questionnaires pertaining to social support, stress and psychological functioning both at intake and at 6 months. Findings Both high and low social support groups experienced marked declines in negative affect and in the severity of substance abuse over time. There were some group differences: for example, symptoms of depression and psychological distress were higher among patients with low social support at intake and at 6 months. Patients with low social support at intake reported higher severity of alcohol and drug abuse at 6 months. Hierarchical regression analyses showed that functional social support was a modest predictor of reductions in the severity of alcohol abuse at follow‐up, after controlling for the number of days in treatment. Higher levels of social support explained a modest (6%) proportion of the variance in alcohol‐related outcomes, but did not predict reductions in drug abuse. Survival analysis demonstrated that the rate of dropping out of treatment was significantly higher for patients with low social support. Conclusions Higher functional social support at intake is a positive predictor of retention in treatment, and a modest predictor of reductions in alcohol intake, but not in drug use. Overall, social support accounts for a small percentage of the variance in drug/alcohol‐related outcomes, underscoring the need for further research into variables accounting for treatment success and failure.