How do GPs identify a need for palliative care in their patients? An interview study

Contains fulltext : 118548.pdf (publisher's version ) (Open Access)BACKGROUND: Little is known about how GPs determine whether and when patients need palliative care. Little research has been done regarding the assumption underpinning Lynn and Adamson's model that palliative care may start early in the course of the disease. This study was conducted to explore how GPs identify a need for palliative care in patients. METHODS: A qualitative interview study was performed among 20 GPs in the Netherlands. RESULTS: GPs reported that a combination of several signals, often subtle and not explicit, made them identify a need for palliative care: signals from patients (increasing care dependency and not recuperating after intercurrent diseases) and signals from relatives or reports from medical specialists. GPs reported differences in how they identified a need for palliative care in cancer patients versus those with other diseases. In cancer patients, the need for palliative care was often relatively clear because of a relatively strict demarcation between the curative and palliative phase. However, in patients with e.g. COPD or in the very old, GPs' awareness of palliative care needs often arises gradually, relatively late in the disease trajectory.GPs consider the diagnosis of a life-threatening illness as a key point in the disease trajectory. However, this does not automatically mean that a patient needs palliative care at that point. CONCLUSIONS: GPs recognize a need for palliative care on the basis of various signals. They do not support the idea underlying Lynn and Adamson's model that palliative care always starts early in the course of the disease

How do GPs recognize needs for palliative care in their patients?

Aim: The aim of this study was to explore how GPs in the Netherlands recognize patients’ needs for palliative care. Methods: We conducted qualitative semi-structured interviews with about 25 GPs. These GPs were interviewed about recognition of the needs for palliative care in their patients and how GPs anticipate on these needs. All interview data were analysed qualitatively, with support of the programme Atlas.ti. Results: Signals on the basis of which GPs recognized a need for palliative care were: a strong increase of care dependency, lost of interest of patients in usual activities or hobbies, depressed mood or other mental changes and / or the message from the medical specialist that cure is no option anymore. GPs act proactively when having recognized a need for palliative care in their patients; they plan telephone appointments or visits at the patient’s home regularly. GPs also look forward with the patient and the family what kind of care wishes the patient and the family have, for example with regard to which place and by whom they wish to be cared for in the last phase of life. This pro-active approach in the palliative phase contrasts with the more reactive attitude of the GP in previous phases of the disease trajectory. Conclusion: This study shows that GPs recognize needs for palliative care by several often subtle signals in the disease trajectory. GPs have a pro-active attitude after signalling needs for palliative care in their patients. Main source of funding: ZonMw-Netherlands Organisation for Health Research and Development. (aut. ref.

Phenotyping of Nod1/2 double deficient mice and characterization of Nod1/2 in systemic inflammation and associated renal disease

Contains fulltext : 109047.pdf (publisher's version ) (Open Access)It is indispensable to thoroughly characterize each animal model in order to distinguish between primary and secondary effects of genetic changes. The present study analyzed Nod1 and Nod2 double deficient (Nod1/2 DKO) mice under physiological and inflammatory conditions. Nod1 and Nod2 are members of the Nucleotide-binding domain and Leucine-rich repeat containing Receptor (NLR) family. Several inflammatory disorders, such as Crohn's disease and asthma, are linked to genetic changes in either Nod1 or Nod2. These associations suggest that Nod1 and Nod2 play important roles in regulating the immune system.Three-month-old wildtype (Wt) and Nod1/2 DKO mice were sacrificed, body and organ weight were determined, and blood was drawn. Except for lower liver weight in Nod1/2 DKO mice, no differences were found in body/organ weight between both strains. Leukocyte count and composition was comparable. No significant changes in analyzed plasma biochemical markers were found. Additionally, intestinal and vascular permeability was determined. Nod1/2 DKO mice show increased susceptibility for intestinal permeability while vascular permeability was not affected. Next we induced septic shock and organ damage by administering LPS+PGN intraperitoneally to Wt and Nod1/2 DKO mice and sacrificed animals after 2 and 24 hours. The systemic inflammatory and metabolic response was comparable between both strains. However, renal response was different as indicated by partly preserved kidney function and tubular epithelial cell damage in Nod1/2 DKO at 24 hours. Remarkably, renal inflammatory mediators Tnfalpha, KC and Il-10 were significantly increased in Nod1/2 DKO compared with Wt mice at 2 hours.Systematic analysis of Nod1/2 DKO mice revealed a possible role of Nod1/2 in the development of renal disease during systemic inflammation

Immune restoration does not invariably occur following long term HIV-1 suppression during antiretroviral therapy.

Background: Current antiretroviral treatment can induce significant and sustained virological and immunological responses in HIV-1-infected persons over at least the short- to mid-term. Objectives: In this study, long-term immune reconstitution was investigated during highly active antiretroviral therapy. Methods: Patients enrolled in the INCAS study in The Netherlands were treated for 102 weeks (range 52-144 weeks) with nevirapine (NVP) + zidovudine (ZDV) (n = 9), didanosine (ddl) + ZDV (n 10), or NVP + ddl + ZDV (n = 10). Memory and naive CD4+ and CD8+ T cells were measured using CD45RA and CD27 monoclonal antibodies (mAb), T-cell function was assayed by CD3 + CD28 mAb stimulation, and plasma HIV-1 RNA load was measured by ultra-direct assay (cut-off <20 copies/ml). Results: Compared to both double combination regimens the triple combination regimen resulted in the most sustained increase in CD4+ T cells (change in CD4+ + 253 x 10(6) cells/l; standard error, 79 x 10(6) cells/l) and reduction of plasma HIV-1 RNA. In nine patients (31%) (ddl + ZDV, n = 2; NVP + ddl + ZDV, n = 7) plasma HIV-1 RNA levels remained below cut-off for at least 2 years. On average, these long-term virological responders demonstrated a significantly higher increase of naive and memory CD4+ T cells (P = 0.01 and 0.02, respectively) as compared with patients with a virological failure, and showed improved T-cell function and normalization of the naive: memory CD8+ T-cell ratio. However, individual virological success or failure did not predict the degree of immunological response. T-cell patterns were independent of baseline CD4+ T-cell count, T-cell Function, HIV-1 RNA load or age. Low numbers of naive CD4+ T cells at baseline resulted in modest long-term naive T-cell recovery Conclusions: Patients with prolonged undetectable plasma HIV-1 RNA levels during antiretroviral therapy do not invariably show immune restoration. Naive T-cell recovery in the setting of complete viral suppression is a gradual process, similar to that reported for immune recovery in adults after chemotherapy and bone marrow transplantation. (C) 1999 Lippincott WiiIiams & Wilkins

Indicadores fisiológicos da interação entre deficit hídrico e acidez do solo em cana-de-açúcar Physiological indicators of the interaction between water deficit and soil acidity in sugarcane

O objetivo deste trabalho foi avaliar os indicadores fisiológicos da interação entre deficit hídrico e acidez do solo em plantas jovens de cana-de-açúcar. As plantas foram submetidas a três tratamentos de disponibilidade hídrica, medidos em percentagem de capacidade de campo (CC) - sem estresse (70% CC), estresse moderado (55% CC) e estresse severo (40% CC); e três tratamentos de acidez no solo, medidos em termos de saturação por bases (V) - baixa acidez (V = 55%), média acidez (V = 33%) e alta acidez (V = 23%). O experimento foi realizado em casa de vegetação a 29,7±4,3ºC e 75±10% UR. O delineamento experimental utilizado foi o de blocos ao acaso, em esquema fatorial 3x3, com quatro repetições. Após 60 dias, foram determinados os teores de solutos compatíveis - trealose, glicina betaína e prolina - na folha diagnóstico e o crescimento inicial da parte aérea. Os solutos compatíveis trealose, glicina betaína e prolina são indicadores do efeito da interação dos estresses hídrico e ácido no solo. O acúmulo dos solutos compatíveis nos tecidos foliares das plantas não é capaz de impedir a redução na produção de matéria seca da cana-de-açúcar, resultante do agravamento nas condições de disponibilidade hídrica e de acidez no solo.<br>The aim of this work was to assess the physiological indicators of the interaction between water deficit and soil acidity, in sugarcane. The plants were submitted to three treatments of water availability - no stress (70% of field capacity, FC), moderate stress (55% FC), and extreme stress (40% FC); and three acidity treatments - no acidity [base saturation (V) = 55%], average acidity (V = 33%), and high acidity (V = 23%). The experiment was carried out in greenhouse, with 29.7±4.3ºC and 75±10% RH. The experimental design was in randomized blocks, in 3x3 factorial arrangement, with four replicates. After 60 days, the contents of compatible solutes - trehalose, glycine betaine and proline - in the diagnostic leaf and the initial growth of shoots were determined. The compatible solutes trehalose, glycine betaine, and proline are indicators of the interaction of water and acidity stresses in the soil. The accumulation of compatible solutes in plant foliar tissues can not prevent sugarcane losses in dry matter production, caused by increasing water deficit and soil acidity